Predictors of diabetic foot ulcers & infections

NewsBot · May 27, 2006

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Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information - The Seattle Diabetic Foot Study
Diabetes Care 29:1202-1207, 2006

OBJECTIVE—The ability of readily available clinical information to predict the occurrence of diabetic foot ulcer has not been extensively studied. We conducted a prospective study of the individual and combined effects of commonly available clinical information in the prediction of diabetic foot ulcer occurrence.

RESEARCH DESIGN AND METHODS—We followed 1,285 diabetic veterans without foot ulcer for this outcome with annual clinical evaluations and quarterly mailed questionnaires to identify foot problems. At baseline we assessed age; race; weight; current smoking; diabetes duration and treatment; HbA1c (A1C); visual acuity; history of laser photocoagulation treatment, foot ulcer, and amputation; foot shape; claudication; foot insensitivity to the 10-g monofilament; foot callus; pedal edema; hallux limitus; tinea pedis; and onychomycosis. Cox proportional hazards modeling was used with backwards stepwise elimination to develop a prediction model for the first foot ulcer occurrence after the baseline examination.

RESULTS—At baseline, subjects were 62.4 years of age on average and 98% male. Mean follow-up duration was 3.38 years, during which time 216 foot ulcers occurred, for an incidence of 5.0/100 person-years. Significant predictors (P 0.05) of foot ulcer in the final model (hazard ratio, 95% CI) included A1C (1.10, 1.06–1.15), impaired vision (1.48, 1.00–2.18), prior foot ulcer (2.18, 1.61–2.95), prior amputation (2.57, 1.60–4.12), monofilament insensitivity (2.03, 1.50–2.76), tinea pedis (0.73, 0.54–0.98), and onychomycosis (1.58, 1.16–2.16). Area under the receiver operating characteristic curve was 0.81 at 1 year and 0.76 at 5 years.

CONCLUSIONS—Readily available clinical information has substantial predictive power for the development of diabetic foot ulcer and may help in accurately targeting persons at high risk of this outcome for preventive interventions.
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NewsBot · May 27, 2006

Risk Factors for Foot Infections in Individuals With Diabetes

Risk Factors for Foot Infections in Individuals With Diabetes
Diabetes Care 29:1288-1293, 2006

OBJECTIVE—To prospectively determine risk factors for foot infection in a cohort of people with diabetes.

RESEARCH DESIGN AND METHODS—We evaluated then followed 1,666 consecutive diabetic patients enrolled in a managed care–based outpatient clinic in a 2-year longitudinal outcomes study. At enrollment, patients underwent a standardized general medical examination and detailed foot assessment and were educated about proper foot care. They were then rescreened at scheduled intervals and also seen promptly if they developed any foot problem.

RESULTS—During the evaluation period, 151 (9.1%) patients developed 199 foot infections, all but one involving a wound or penetrating injury. Most patients had infections involving only the soft tissue, but 19.9% had bone culture–proven osteomyelitis. For those who developed a foot infection, compared with those who did not, the risk of hospitalization was 55.7 times greater (95% CI 30.3–102.2; P < 0.001) and the risk of amputation was 154.5 times greater (58.5–468.5; P < 0.001). Foot wounds preceded all but one infection. Significant (P < 0.05) independent risk factors for foot infection from a multivariate analysis included wounds that penetrated to bone (odds ratio 6.7), wounds with a duration >30 days (4.7), recurrent wounds (2.4), wounds with a traumatic etiology (2.4), and presence of peripheral vascular disease (1.9).

CONCLUSIONS—Foot infections occur relatively frequently in individuals with diabetes, almost always follow trauma, and dramatically increase the risk of hospitalization and amputation. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially those that are chronic, deep, recurrent, or associated with peripheral vascular disease.
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NewsBot · Jun 3, 2006

The second abstract above, has this press release associated with it:
Landmark Study On Diabetic Foot Infection Published - Renowned Researchers At 3 Universities Unveil Startling Data About Infection-induced Amputation
02 Jun 2006 - 14:00pm (PDT)

Persons with diabetes who develop an infection are at a 55-fold greater risk for hospitalization, and an alarming 154-fold greater risk for amputation. These are some of the startling figures emanating from the first population-based study on diabetic foot infection. Researchers from Texas A&M University, Rosalind Franklin University of Medicine and Science, and the University of Washington collected data on nearly 1,700 patients over a two-year period.

"The results strongly suggested that foot infections are common and complex. They are also costly in terms of morbidity," noted Dr. Lawrence A. Lavery of Texas A&M, the lead author on the study.

The study also found that nearly 9 in 10 amputations performed are instigated by an infection. "This was perhaps the most interesting figure in the study," noted David G. Armstrong, DPM, PhD, Professor of Surgery and Director of Scholl's Center for Lower Extremity Ambulatory Research at Rosalind Franklin University and one of the study's principal investigators.

"It is infection that is the spark that led to nearly all amputations in this study," said Armstrong. "Poor circulation, while critically important, did not necessarily cause amputation. It determined the level of amputation. This subtlety makes a significant difference when designing strategies for prevention."

The study is published in the June issue of the journal Diabetes Care.
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From Medical News Today

NewsBot · Jun 3, 2006

Numerous media outlets are picking up on this story:
Foot Infections Raise Hospitalizations, Amputations, in Diabetics (FOX News)
Diabetic Feet Pose High Risks (WebMD)

NewsBot · Aug 1, 2006

Risk factors for primary major amputation in diabetic patients.
Sao Paulo Med J. 2006 00;124(2):66-70

CONTEXT AND OBJECTIVE: Diabetic patients present high risk of having to undergo minor or major amputation during their lifetimes, because of ischemia or infection. The aim of this study was to identify and quantify risk factors for major amputation in diabetic patients with foot infections.

DESIGN AND SETTING: Retrospective clinical-surgical trial at the Vascular Surgery Service of Santa Casa de São Paulo.

METHODS: Ninety-nine patients with diabetic foot infections who underwent 129 hospitalizations in the Vascular Surgery Unit were analyzed in accordance with a pre-established protocol to compare two groups of diabetic patients: one that underwent major amputations and the other that underwent minor amputations or debridements. The patients were predominantly male, in their sixth decade of life, and had type 2 diabetes mellitus. Chronic arterial insufficiency, age, diabetes mellitus duration, ascending lymphangitis, calcaneal lesions, Wagner's classification, laboratory tests and different microorganisms in deep tissue cultures were the risk factors evaluated in all patients.

RESULTS: The statistically significant risk factors for major amputation included age, ascending lymphangitis (odds ratio, OR: 2.5), calcaneal lesions (OR: 10.5), Wagner grade 5 lesions (OR: 3.4), chronic arterial insufficiency without possibility of revascularization (OR: 5.4) and diabetes duration. Presence of Gram-positive microorganisms was associated with the need of major amputation. The serum urea, creatinine, glucose and white blood cell levels were not significant risk factors for major amputation.

CONCLUSIONS: The risk factors for major amputation were: age, ascending lymphangitis, calcaneal lesions, Wagner grade 5 lesions, arterial insufficiency, diabetes duration and Gram-positive microorganisms in cultures.
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NewsBot · Jul 18, 2008

Risk factors and healing impact of multidrug-resistant bacteria in diabetic foot ulcers.
Richard JL, Sotto A, Jourdan N, Combescure C, Vannereau D, Rodier M, Lavigne JP; on behalf of the Nîmes University Hospital Working Group on the Diabetic Foot (GP30).
Diabetes Metab. 2008 Jul 14. [Epub ahead of print]

AIM: To determine the risk factors for acquiring multidrug-resistant organisms (MDRO) and their impact on outcome in infected diabetic foot ulcers.

METHODS: Patients hospitalized in our diabetic foot unit for an episode of infected foot ulcer were prospectively included. Diagnosis of infection was based on clinical findings using the International Working Group on the Diabetic Foot-Infectious Diseases Society of America (IWGDF-ISDA) system, and wound specimens were obtained for bacterial cultures. Each patient was followed-up for 1 year. Univariate analysis was performed to compare infected ulcers according to the presence or absence of MDRO; logistic regression was used to identify explanatory variables for MDRO presence. Factors related to healing time were evaluated by univariate and multivariate survival analyses.

RESULTS: MDRO were isolated in 45 (23.9%) of the 188 patients studied. Deep and recurrent ulcer, previous hospitalization, HbA(1c) level, nephropathy and retinopathy were significantly associated with MDRO-infected ulceration. By multivariate analysis, previous hospitalization (OR=99.6, 95% CI=[19.9-499.0]) and proliferative retinopathy (OR=7.4, 95% CI=[1.6-33.7]) significantly increased the risk of MDRO infection. Superficial ulcers were associated with a significant decrease in healing time, whereas neuroischaemic ulcer, proliferative retinopathy and high HbA(1c) level were associated with an increased healing time. In the multivariate analysis, presence of MDRO had no significant influence on healing time.

CONCLUSION: MDRO are pathogens frequently isolated from diabetic foot infection in our foot clinic. Nevertheless, their presence appears to have no significant impact on healing time if early aggressive treatment, as in the present study, is given, including empirical broad-spectrum antibiotic treatment, later adjusted according to microbiological findings.
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NewsBot · Oct 3, 2008

Foot ulcer risk and location in relation to prospective clinical assessment of foot shape and mobility among persons with diabetes.
Cowley MS, Boyko EJ, Shofer JB, Ahroni JH, Ledoux WR.
Diabetes Res Clin Pract. 2008 Sep 29. [Epub ahead of print]

AIMS: We assessed baseline clinical foot shape for 2939 feet of diabetic subjects who were monitored prospectively for foot ulceration.

METHODS: Assessments included hammer/claw toes, hallux valgus, hallux limitus, prominent metatarsal heads, bony prominences, Charcot deformity, plantar callus, foot type, muscle atrophy, ankle and hallux mobility, and neuropathy. Risk factors were linked to ulcer occurrence and location via a Cox proportional hazards model.

RESULTS: Hammer/claw toes (hazard ratio [HR] (95% confidence interval [CI])=1.43 (1.06, 1.94) p=0.02), marked hammer/claw toes (HR=1.77 (1.18, 2.66) p=0.006), bony prominences (HR=1.38 (1.02, 1.88), p=0.04), and foot type (Charcot or drop foot vs. neutrally aligned) (HR=2.34 (1.33, 4.10), p=0.003) were significant risk factors for ulceration adjusting for age, body mass index, insulin medication, ulcer history and amputation history. With adjustment for neuropathy only hammer/claw toes (HR=1.40 (1.03, 1.90), p=0.03) and foot type (HR=1.76 (1.04, 3.04), p=0.05) were significantly related to ulceration. However, there was no relationship between ulcer location and foot deformity.

CONCLUSIONS: Certain foot deformities were predictive of ulceration, although there was no relationship between clinical foot deformity and ulcer location.
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NewsBot · Sep 29, 2009

Assessment of risk factors in diabetic foot ulceration and their impact on the outcome of the disease.
Hokkam EN.
Prim Care Diabetes. 2009 Sep 22. [Epub ahead of print]

AIMS: The current study aims to identify risk factors for diabetic foot ulcer and their impact on the outcome of the disease.

METHODS: Three hundred diabetic patients were enrolled in the study. One hundred eighty subjects with diabetic foot ulcer and 120 diabetic controls without foot lesions. All expected risk factors were studied in all patients and after a follow up period, patients with diabetic foot ulcer were classified into group A (patients with healed ulcers) and group B (patients with persistent ulcer or ended by amputation). The risk factors were reanalyzed in both groups to find out their impact on the outcome of the disease.

RESULTS: The following variables were significant factors for foot ulceration: Male gender (P=0.009), previous foot ulcer (P=0.003), peripheral vascular disease (P=0.004), and peripheral neuropathy (P=0.006). Also lack of frequent foot self-examination was independently related to foot ulcer risk. The outcome was related to longer diabetes duration (P=0.004), poor glycaemic control (P=0.006) and anaemia (P=0.003) and presence of infection (P<0.001).

CONCLUSIONS: Peripheral vascular disease and peripheral neuropathy together with lack of foot self-examination, poor glycaemic control and anaemia are main significant risk factors for diabetic foot ulceration.
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NewsBot · Apr 7, 2010

External validation and optimisation of a model for predicting foot ulcers in patients with diabetes.
Monteiro-Soares M, Dinis-Ribeiro M.
Diabetologia. 2010 Apr 6. [Epub ahead of print]

AIMS/HYPOTHESIS: In 2006 a risk stratification model was developed by Boyko et al. to predict foot ulceration in patients with diabetes, using seven commonly available clinical variables. We sought to validate and optimise this clinical prediction rule in a different setting.

METHODS: A retrospective cohort study was conducted on all patients with diabetes attending the podiatry section of a diabetic foot clinic at a tertiary hospital in Portugal (n = 360). Assessment at baseline included variables evaluated in the previous study and other relevant variables.

RESULTS: Type 2 diabetes was present in 98% of patients, 45% were men and (at baseline) the median age was 65 years. Median follow-up was 25 months (range 3-86), during which 94 patients (26%) developed a foot ulcer. Boyko's model had an area under the receiver operating curve of 0.83 (95% CI 0.78-0.88). The corresponding value for the optimised model, which included the footwear risk variable, was 0.88 (95% CI 0.84-0.91). Both models had high classification accuracy for prediction of foot ulceration. However, the optimised model tended to produce higher specificity and positive likelihood ratio values at all levels.

CONCLUSIONS/INTERPRETATION: This study confirmed that Boyko's proposed model has a high capacity to predict foot ulceration in diabetes patients of both sexes. Our results suggest that the inclusion of a further footwear variable could improve the model. Nevertheless, prospective validation in a larger population is still necessary.
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NewsBot · Dec 28, 2010

The risk of foot ulceration in people with diabetes screened in community settings: findings from a cohort study.
Crawford F, McCowan C, Dimitrov BD, Woodburn J, Wylie GH, Booth E, Leese GP, Bekker HL, Kleijnen J, Fahey T.
QJM. 2010 Dec 23. [Epub ahead of print]

BACKGROUND: Annual foot checks are recommended in patients with diabetes mellitus (DM) to identify those at risk of foot ulceration. Systematic reviews have found few studies evaluating the predictive value of tests in community-based diabetic populations.

AIM: To quantify the predictive value of clinical risk factors in relation to foot ulceration in a community population.

METHODS: A cohort of 1192 people with diabetes receiving care in community settings was recruited and a screening procedure, covering symptoms, signs and diagnostic tests was conducted at baseline. At an average 1-year follow-up patients who developed a foot ulcer were identified by an independent blind assessor. Multivariable analysis was performed to identify clinical predictors of foot ulceration.

Findings: The incidence of foot ulceration was 1.93% [95% confidence interval (CI) 1.27-2.89). Three time-independent clinical predictors with five factors were selected: previous amputation [odds ratio (OR) 14.7, 95% CI 3.1-69.5), use of insulin before 3 months with inability to distinguish between cool and cold temperatures (OR 2.97, 95% CI 1.9-4.5) and failure to obtain at least one blood pressure reading for the calculation of ankle-brachial index with the failure to feel touch with a 10-g monofilament (OR 1.7, 95% CI 1.3-2.2).

Interpretation: Recommendations for annual diabetic foot check in low-risk, community-based patients should be reviewed as absolute events of ulceration are low. The accuracy of foot risk assessment tools to predict ulceration requires evaluation in randomized controlled trials with concurrent economic evaluations.
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NewsBot · Oct 25, 2011

Clinical and bacteriological survey of diabetic foot infections in Lisbon.
Mendes JJ, Marques-Costa A, Vilela C, Neves J, Candeias N, Cavaco-Silva P, Melo-Cristino J.
Diabetes Res Clin Pract. 2011 Oct 20. [Epub ahead of print]

AIMS:
An epidemiological survey of diabetic foot infections (DFIs) in Lisbon, stratifying the bacterial profile based on patient demographical data, diabetic foot characteristics (PEDIS classification), ulcer duration and antibiotic therapy.

METHODS:
A transversal observational multicenter study, with clinical data collection using a structured questionnaire and microbiological products (aspirates, biopsies or swabs collected using the Levine method) of clinically infected foot ulcers of patients with diabetes mellitus (DM).

RESULTS:
Forty-nine hospitalized and ambulatory patients were enrolled in this study, and 147 microbial isolates were cultured. Staphylococcus was the main genus identified, and methicillin-resistant Staphylococcus aureus (MRSA) was present in 24.5% of total cases. In the clinical samples collected from patients undergoing antibiotic therapy, 93% of the antibiotic regimens were considered inadequate based on the antibiotic susceptibility test results. The average duration of an ulcer with any isolated multi-drug resistant (MDR) organism was 29 days, and previous treatment with fluoroquinolones was statistically associated with multi-drug resistance.

CONCLUSIONS:
Staphylococcus aureus was the most common cause of DFIs in our area. Prevalence and precocity of MDR organisms, namely MRSA, were high and were probably related to previous indiscriminate antibiotic use. Clinicians should avoid fluoroquinolones and more frequently consider the use of empirical anti-MRSA therapy.
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MyFootCrisis · Oct 27, 2011

Wow this is really important information. Thanks for posting. Was there any information on preventative treatments and their affect?

Greg Fyfe · May 30, 2012

The risk of foot ulceration in people with diabetes screened in community settings: findings from a cohort study.
Crawford F, McCowan C, Dimitrov BD, Woodburn J, Wylie GH, Booth E, Leese GP, Bekker HL, Kleijnen J, Fahey T.
QJM. 2010 Dec 23. [Epub ahead of printFindings: The incidence of foot ulceration was 1.93% [95% confidence interval (CI) 1.27-2.89). Three time-independent clinical predictors with five factors were selected: previous amputation [odds ratio (OR) 14.7, 95% CI 3.1-69.5), use of insulin before 3 months with inability to distinguish between cool and cold temperatures (OR 2.97, 95% CI 1.9-4.5) and failure to obtain at least one blood pressure reading for the calculation of ankle-brachial index with the failure to feel touch with a 10-g monofilament (OR 1.7, 95% CI 1.3-2.2).

Interpretation: Recommendations for annual diabetic foot check in low-risk, community-based patients should be reviewed as absolute events of ulceration are low. The accuracy of foot risk assessment tools to predict ulceration requires evaluation in randomized controlled trials with concurrent economic evaluations.
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Intersting thread, even if it goes back a bit.
Having screened quite a lot of diabetic feet in the community setting, and seen a few people both high and low risk have an injury develop infections and end up in hospital +/- amputation

I've wondered if I can improve on what I do.
I check for the usual suspects, loss of protective sensation, peripheral arterial supply, previous Hx of diabetic wound/amputation, foot deformity, inadequate footwear.
If available I'll have a look at their glycaemic control.

This establishes if the patient is at the high or low risk for diabetic foot wound, although as the quoted study suggests may not be "predictive"

I wonder we would get a more predictive result ( and indication of risk) from an assessment of patients susceptabiliy for "risk taking behaviour" or "lifestyle" .Hopefully something more in enlightening than being male and a smoker.

My current assessment for diabetic foot risk only covers the currently accepted objective "medical" risk factors , which when found will determine my advice and management of the patient.

However I'm thinking that my risk assessment may not really account for the actual ( predictive?) risk and that my assessment of the client may not account for the clients state of readiness to recieve some of my advice/care.

Interested to hear what others see as risk/predictive factors and if any have a structured approach to assesssing clients state of engagement in consultation.

or if someones already researched it !

Thanks

Greg

NewsBot · Jun 21, 2012

Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis of a Eurodiale subgroup.
Dubský M, Jirkovská A, Bem R, Fejfarová V, Skibová J, Schaper NC, Lipsky BA.
Int Wound J. 2012 Jun 19.

Few studies have examined factors associated with diabetic foot ulcer (DFU) recurrence. Using data from patients enrolled in the prospective Eurodiale DFU study, we investigated the frequency of, and risk factors for, DFU recurrence after healing during 3-year follow-up period. At our site, 93 Eurodiale enrolled patients had a healed DFU. Among these, 14 died; of the remaining 79 patients we enrolled 73 in this study. On entry to the Eurodiale study we assessed: demographic factors (age, sex, distance from hospital); diabetes-related factors (duration, HbA1c levels); comorbidities (obesity, renal failure, smoking, alcohol abuse); and DFU-related factors (peripheral arterial disease, ulcer infection, c-reactive protein [CRP]; foot deformities). During the 3-year follow-up, a DFU recurred in 42 patients (57·5%). By stepwise logistic regression of findings at initial DFU presentation, the significant independent predictors for recurrence were plantar ulcer location (odds ratio [OR] 8·62, 95% CI 2·2-33·2); presence of osteomyelitis (OR 5·17, 95% CI 1·4-18·7); HbA1c > 7·5% ([DCCT], OR 4·07, 95% CI 1·1-15·6); and CRP > 5 mg/l (OR 4·27, 95% CI 1·2-15·7). In these patients with a healed DFU, the majority had a recurrence of DFU during a 3-year follow-up, despite intensive foot care. The findings present at diagnosis of the initial DFU that were independent risk factors associated with ulcer recurrence (plantar location, bone infection, poor diabetes control and elevated CRP) appear to define those at high risk for recurrence, but may be amenable to targeted interventions.
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NewsBot · Jun 26, 2012

Predictive factors for diabetic foot ulceration: a systematic review.
Monteiro-Soares M, Boyko E, Ribeiro J, Ribeiro I, Dinis-Ribeiro M.
Diabetes Metab Res Rev. 2012 Jun 22.

BACKGROUND AND AIM:
Improving ability to predict and prevent diabetic foot ulcer (DFU) is imperative due to the high personal and financial costs of this complication. We therefore conducted a systematic review in order to identify all studies of factors associated with DFU and assess whether available DFU risk stratification systems incorporate those factors of highest potential value.

MATERIAL AND METHODS:
We performed a search in PubMed for studies published until April 2011 that analysed the association between independent variables and DFU. Articles were selected by 2 investigators independent and blind to each other. Divergence was solved by a third investigator.

RESULTS:
A total of 71 studies were included and evaluated the association between DFU and more than 100 independent variables. The variables most frequently assessed were age, gender, diabetes duration, body mass index, HbA1C and neuropathy diagnostic tests. DFU prevalence varied greatly among studies. The majority of the identified variables were assessed by only 2 or fewer studies. Diabetic neuropathy, peripheral vascular disease, foot deformity and previous DFU or lower extremity amputation - which are the most common variables included in risk stratification systems - were consistently associated with DFU development.

CONCLUSION:
Existing DFU risk stratification systems often include variables shown repeatedly in the literature to be strongly predictive of this outcome. Improvement of these risk classification systems though is impaired due to deficiencies noted including a great lack of standardization in outcome definition and variable selection and measurement
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NewsBot · Jun 29, 2012

NewsBot said: ↑

Risk factors for recurrence of diabetic foot ulcers: prospective follow-up analysis of a Eurodiale subgroup.
Dubský M, Jirkovská A, Bem R, Fejfarová V, Skibová J, Schaper NC, Lipsky BA.
Int Wound J. 2012 Jun 19.
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Press Release on this study:
Recurring diabetic foot ulcers ‘predictable’

The risk for recurring diabetic foot ulcers (DFUs) is predicted by clinical characteristics, such as existing ulcer location, bone infection, and diabetes control, demonstrates research published in International Wound Journal.

"Knowing these risk factors may allow clinicians and health-care systems to target heightened efforts at prevention of re-ulceration after healing to selected high-risk patients," say Michal Dubský (Institute for Clinical and Experimental Medicine, Prague, Czech Republic) and co-workers.

The team followed up 73 patients for 3 years after successful healing of a DFU, defined as full skin recovery for at least 6 weeks. Overall, 57.5% developed a further DFU.

In multivariate analysis, accounting for demographics, diabetes factors, comorbidity, and DFU-related factors, patients were a significant 8.62 times more likely to experience recurrent DFU if their original ulcer was located on the plantar surface of the forefoot, mid-foot, or heel than if positioned on the dorsum foot, toes, or heel.

Recurrent DFU was also significantly associated with osteomyelitis (odds ratio [OR]=5.17), poor diabetes control, defined as a glycated hemoglobin level above 7.5% (OR=4.07), and a C-reactive protein level above 5 mg/ml (OR=4.27).

Further analysis of the 30 patients with osteomyelitis showed that the risk for recurring DFU did not differ significantly between patients treated with antibiotics alone or with surgery. Nor was there a significant difference in recurrence between patients with bone infection in their toes and those affected in other parts of the foot.

"In light of the high risk of a recurrent ulceration, we believe it would be appropriate to develop prevention programmes that focus on patients identified as being in the highest risk groups," Dubský et al conclude.

"This might also include efforts to educate the patients and their health-care providers on methods that have been shown to be effective in preventing DFU."
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NewsBot · Jul 1, 2012

Indexing Severity of Diabetic Foot Infection With 99mTc-White Blood Cell Single Photon Emission Computed Tomography/Computed Tomography Hybrid Imaging.
Erdman WA, Buethe J, Bhore R, Ghayee HK, Thompson C, Maewal P, Anderson J, Klemow S, Oz OK.
Diabetes Care. 2012 Jun 20.

OBJECTIVEManagement of diabetic foot infection (DFI) has been hampered by limited means of accurately classifying disease severity. New hybrid nuclear/computed tomography (CT) imaging techniques elucidate a combination of wound infection parameters not previously evaluated as outcome prognosticators. Our aim is to determine if a novel standardized hybrid image-based scoring system, Composite Severity Index (CSI), has prognostic value in DFI.

RESEARCH DESIGN AND METHODSMasked retrospective (99m)Tc-white blood cell (WBC) single photon emission CT (SPECT)/CT image interpretation and independent chart review of 77 patients (101 feet) suspected of DFI-associated osteomyelitis at a large municipal hospital between January 2007 and July 2009. CSI scores were correlated with probability of favorable outcome (no subsequent amputation/readmission after therapeutic intervention) during median 342-day follow-up.RESULTSCSI ranged from 0-13. Receiver operating characteristic accuracy for predicting favorable outcome was 0.79 (optimal cutoff CSI, ≤2; odds ratio of therapeutic failure for CSI >2, 15.1 [95% CI 4.4-51.5]). CSI of 0 had a 92% chance of favorable outcome, which fell progressively to 25% as indices rose to ≥7. Image-based osteomyelitis versus no osteomyelitis assessment was less accurate than CSI at predicting outcome (P = 0.016). In patients with intermediate severity (CSI 3-6), treatment failure decreased from 68 to 36% when antibiotic duration was extended to ≥42 days (P = 0.026).

CONCLUSIONS(99m)Tc-WBC SPECT/CT hybrid image-derived wound infection parameters incorporated into a standardized scoring system, CSI, has prognostic value in DFI.
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NewsBot · Sep 28, 2013

A prospective study of risk factors for foot ulceration: The West of Ireland Diabetes Foot Study.
Hurley L, Kelly L, Garrow A, Glynn L, McIntosh C, Alvarez-Iglesias A, Avalos G, Dinneen S.
QJM. 2013 Sep 25

BackgroundThis is the first study to examine risk factors for diabetic foot ulceration in Irish general practice.

AimTo determine the prevalence of established risk factors for foot ulceration in a community-based cohort, and to explore the potential for estimated glomerular filtration rate (eGFR) to act as a novel risk factor.

DesignA prospective observational study.

MethodsPatients with diabetes attending 12 (of 17) invited general practices were invited for foot screening. Validated clinical tests were carried out at baseline to assess for vascular and sensory impairment and foot deformity. Ulcer incidence was ascertained by patient self-report and medical record. Patients were re-assessed 18 months later.

ResultsOf 828 invitees, 563 (68%) attended screening. On examination 23-25% had sensory dysfunction and 18-39% had evidence of vascular impairment. Using the Scottish Intercollegiate Guidelines Network risk stratification system we found the proportion at moderate and high risk of future ulceration to be 25% and 11% respectively. At follow-up 16/383 patients (4.2%) developed a new foot ulcer (annual incidence rate of 2.6%). We observed an increasing probability of abnormal vascular and sensory test results (pedal pulse palpation, doppler waveform assessment, 10g monofilament, vibration perception and neuropathy disability score) with declining eGFR levels. We were unable to show an independent association between new ulceration and reduced eGFR [Odds ratio 1.01; p=0.64].

ConclusionsOur data show the extent of foot complications in a representative sample of diabetes patients in Ireland. Use of eGFR did not improve identification of patients at risk of foot ulceration.
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NewsBot · Nov 5, 2013

Diabetes-related foot ulcers and associated factors: results from the Nord-Trøndelag Health Survey (HUNT3) (2006–2008)
Anne Karin Molvær et al
Journal of Diabetes and its Complications; Available online 31 October 2013

Aim
To determine the proportion of people with diabetes reporting a history of foot ulcer and investigate associated factors and healing time in the Nord-Trøndelag Health Survey (HUNT3), Norway.

Methods
In 2006–2008, all inhabitants in Nord-Trøndelag County aged ≥ 20 years were invited to take part in this population-based study; 54% (n = 50,807) attended. In participants reporting to have diabetes we examined the relationships between foot ulcers requiring more than 3 weeks to heal (DFU) and sociodemographic, lifestyle and clinical variables using logistic regression analysis.

Results
Among participants with diabetes, 7.4% (95% confidence interval (CI) 6.2–8.6%) reported a DFU. The median healing time was 6.0 weeks. In the final model, factors associated with a DFU were age ≥ 75 years (odds ratio (OR) 2.3, 95% CI 1.4–3.7), male sex (OR 2.0, 95% CI 1.3–3.1), waist circumference ≥ 102 cm (men) or 88 cm (women) (OR 1.95, 95% CI 1.2–3.2), insulin use (OR 2.1, 95% CI 1.3–3.4) and any macrovascular complication (OR 1.8, 95% CI 1.1–2.8).

Conclusions
The proportion of people with diabetes reporting a DFU was 7.4%, associated factors were age ≥ 75 years, male sex, waist circumference ≥ 102 cm (men) or 88 cm (women), insulin use and any macrovascular complication. The median healing time was 6 weeks.
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NewsBot · Nov 7, 2013

Predictors of Diabetic Foot and Leg Ulcers in a Developing Country with a Rapid Increase in the Prevalence of Diabetes Mellitus.
Sriyani KA, Wasalathanthri S, Hettiarachchi P, Prathapan S
PLoS ONE 8(11): 2013 e80856. doi:10.1371/journal.pone.0080856

Objective
To identify the socio demographic, life style and foot examination related predictors of diabetic foot and leg ulcers with a view to develop a screening tool appropriate for the use in an outpatient setting.

Research design and methods
This cross sectional study included type 2 diabetes mellitus (DM) patients; 88 subjects with leg and foot ulcers and 80 non ulcer controls. Socio demographic data and life style factors were documented. Foot was examined for skin changes and structural abnormalities. Distal peripheral neuropathy was assessed by pressure sense, vibration sense and joint position sense. Multivariate analysis by logistic regression was used to determine the significant predictors in screening for foot ulcers.

Results
Education of grade 6 and below (OR - 1.41, 95% CI; 1.03 - 4.68), low income (OR - 23.3, 95% CI; 1.5 - 34.0), impaired vibration sense (OR - 24.79, 95% CI; 9.3 - 66.2), abnormal monofilament test on first (OR - 1.69, 95% CI; 1.36 - 16.6), third (OR - 3.4, 95% CI; 1.1 - 10.6) and fifth (OR - 1.8, 95% CI; 1.61- 12.6) toes are found to be predictors of increased risk whereas incidental diagnosis of DM (OR - 0.03, 95% CI; 0.003 - 0.28), wearing covered shoes (OR - 0.003, 95% CI; 0.00 - 0.28), presence of normal skin color (OR - 0.01, 95% CI; 0.001 - 0.14) and normal monofilament test on first metatarsal head (OR - 0.10, 95% CI; 0.00 - 0.67) are protective factors for ulcers.

Conclusions
Ten independent risk and protective factors identified in this study are proposed as a simple screening tool to predict the risk of developing leg and foot ulcers in patients with DM.
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NewsBot · Dec 24, 2013

Diabetes-related foot ulcers and associated factors: Results from the Nord-Trøndelag Health Survey (HUNT3) (2006-2008).
Molvær AK, Graue M, Espehaug B, Ostbye T, Midthjell K, Iversen MM.
J Diabetes Complications. 2013 Oct 31

AIM:
To determine the proportion of people with diabetes reporting a history of foot ulcer and investigate associated factors and healing time in the Nord-Trøndelag Health Survey (HUNT3), Norway.
METHODS:
In 2006-2008, all inhabitants in Nord-Trøndelag County aged ≥20years were invited to take part in this population-based study; 54% (n=50,807) attended. In participants reporting to have diabetes we examined the relationships between foot ulcers requiring more than 3weeks to heal (DFU) and sociodemographic, lifestyle and clinical variables using logistic regression analysis.
RESULTS:
Among participants with diabetes, 7.4% (95% confidence interval (CI) 6.2%-8.6%) reported a DFU. The median healing time was 6.0weeks. In the final model, factors associated with a DFU were age ≥75years (odds ratio (OR) 2.3, 95% CI 1.4-3.7), male sex (OR 2.0, 95% CI 1.3-3.1), waist circumference ≥102cm (men) or 88cm (women) (OR 1.95, 95% CI 1.2-3.2), insulin use (OR 2.1, 95% CI 1.3-3.4) and any macrovascular complication (OR 1.8, 95% CI 1.1-2.8).
CONCLUSIONS:
The proportion of people with diabetes reporting a DFU was 7.4%, associated factors were age ≥75years, male sex, waist circumference ≥102cm (men) or 88cm (women), insulin use and any macrovascular complication. The median healing time was 6weeks.
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NewsBot · Feb 14, 2014

Classification systems for lower extremity amputation prediction in subjects with active diabetic foot ulcer: a systematic review and meta-analysis.
Monteiro-Soares M, Martins-Mendes D, Vaz-Carneiro A, Sampaio S, Dinis-Ribeiro M.
Diabetes Metab Res Rev. 2014 Feb 12.

AIM:
We aimed to systematically review the available systems used to classify diabetic foot ulcers (DFU) in order to synthetize their methodological qualitative issues and accuracy to predict lower extremity amputation (LEA), as this may represent a critical point in these patients' care.
MATERIAL AND METHODS:
Two investigators searched, in EBSCO, ISI, PubMed and SCOPUS databases, and independently selected studies published until May 2013 and reporting prognostic accuracy and/or reliability of specific systems for patients with DFU in order to predict LEA.
RESULTS:
We included 25 studies reporting a prevalence of LEA between 6 to 78%. Eight different DFU descriptions and 7 prognostic stratification classification systems were addressed with a variable (1-9) number of factors included, being the presence of peripheral arterial disease (n = 12) or infection at the ulcer site (n = 10) or its (ulcer) depth (n = 10) the most frequently included. The Meggit-Wagner, S(AD)SAD and Texas University Classification systems were the most extensively validated, whereas 10 classifications were derived or validated only once. Reliability was reported in a single study and accuracy measures reported in 5 studies with another 8 allowing their calculation. Meta-analysis was only possible for the composing variables` accuracy. Pooled accuracy ranged from 0.65 (for gangrene) to 0.74 (for infection).
CONCLUSION:
There are numerous classification systems for DFU outcome prediction but only few studies evaluated their reliability or external validity. Also only rarely studies validated several systems' simultaneously and reported accuracy measures. Further studies assessing reliability and accuracy of the available systems and their composing variables are needed. This article is protected by copyright. All rights reserved.
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NewsBot · Mar 12, 2014

A study of Prognostic factors of Chinese patients with diabetic foot ulcers
Aiping Wang, Xinjuan Sun, Wei Wang, Kechun Jiang
Diabetic Foot & Ankle 2014, 5: 22936

Objective: Few studies have identified factors as predictors of clinical prognosis of patients with diabetic foot ulcers (DFUs), especially of Chinese patients. In this study, we assessed the prognostic factors of Chinese patients with DFUs.

Methods and materials: This was a retrospective study (January 2009 - January 2011) of 194 DFUs conducted in an inpatient population at PLA 454 Hospital in Nanjing, China, to determine the prognostic influential factors of DFUs in Chinese patients. All of the studied patients were grouped into an amputation group, a non-healing group, and a cured group, according to the clinical prognosis. Patient parameters, including gender, age, smoking habits, education level, family history of diabetes mellitus, medical history, duration of foot lesions and complications, ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), urinary albumin/creatinine ratio (Alb/Cr), fundus oculi, electrocardiogram, DFU characteristics, bacterial nature, and neuropathy, were cross-studied among the three groups.

Results: Compared with the other two groups, the amputation group showed a higher number of males, older in age, lower ABI and TcPO2 levels, higher Wagner wound grading and size, and significantly higher urinary Alb/Cr ratio, blood urea nitrogen, serum creatinine, white blood cell count, and erythrocyte sedimentation rate. Compared to the cured group (162 patients), more patients with an older age, smoking, family history of diabetes mellitus, medical history of foot ulcerations, lower ABI and TcPO2 levels, higher urine Alb/Cr ratio, and serum creatinine were found in the non-healing group. Regression analysis was used to study the correlation between various factors and clinical prognosis, and the results were as follows: age,Wagner wound classification, and heel ulcerations were negatively correlated to the DFU prognosis, whereas the female population, ABI, and TcPO2 were positively correlated with DFU prognosis.

Conclusion: In this retrospective study, we conclude that the DFU prognosis may be related to age, gender, wound location (heel), Wagner wound classification, ABI, and TcPO2 levels in the Chinese population.
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NewsBot · Apr 9, 2014

Risk Factors for Plantar Foot Ulcer Recurrence in Neuropathic Diabetic Patients.
Waaijman R, de Haart M, Arts ML, Wever D, Verlouw AJ, Nollet F, Bus SA.
Diabetes Care. 2014 Apr 4

OBJECTIVERecurrence of plantar foot ulcers is a common and major problem in diabetes but not well understood. Foot biomechanics and patient behavior may be important. The aim was to identify risk factors for ulcer recurrence and to establish targets for ulcer prevention.

RESEARCH DESIGN AND METHODSAs part of a footwear trial, 171 neuropathic diabetic patients with a recently healed plantar foot ulcer and custom-made footwear were followed for 18 months or until ulceration. Demographic data, disease-related parameters, presence of minor lesions, barefoot and in-shoe plantar peak pressures, footwear adherence, and daily stride count were entered in a multivariate multilevel logistic regression model of plantar foot ulcer recurrence.

RESULTSA total of 71 patients had a recurrent ulcer. Significant independent predictors were presence of minor lesions (odds ratio 9.06 [95% CI 2.98-27.57]), day-to-day variation in stride count (0.93 [0.89-0.99]), and cumulative duration of past foot ulcers (1.03 [1.00-1.06]). Significant independent predictors for those 41 recurrences suggested to be the result of unrecognized repetitive trauma were presence of minor lesions (10.95 [5.01-23.96]), in-shoe peak pressure <200 kPa with footwear adherence >80% (0.43 [0.20-0.94]), barefoot peak pressure (1.11 [1.00-1.22]), and day-to-day variation in stride count (0.91 [0.86-0.96]).

CONCLUSIONSThe presence of a minor lesion was clearly the strongest predictor, while recommended use of adequately offloading footwear was a strong protector against ulcer recurrence from unrecognized repetitive trauma. These outcomes define clear targets for diabetic foot screening and ulcer prevention.
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NewsBot · May 3, 2014

Characteristics of a large cohort of patients with diabetes having at-risk feet and outcomes in patients with foot ulceration referred to a tertiary care diabetes unit.
Riaz M, Miyan Z, Zaidi SI, Alvi SF, Fawwad A, Ahmadani MY, Zafar AB, Malik RA, Basit A.
Int Wound J. 2014 May 2.

To identify in a large population cohort the clinical and biochemical characteristics of patients with diabetes at risk of foot ulceration and outcomes in those with foot ulcers. All patients with diabetes attending Baqai Institute of Diabetology and Endocrinology from January 2004 to April 2012 included in the study. Clinical, biochemical and socio-demographic data were collected and patients were categorised into those at no risk of ulceration, at risk of ulceration and those with foot ulcer, according to the University of Texas classification. Patients with foot ulceration followed for their final outcome, that is complete healing, persisted non-healed ulcer, lower extremity amputation, lost to follow-up or death. A total of 18 119 patients with diabetes underwent assessment, 3576 (19·7%) patients defined as at high risk for foot ulceration and 3731 (20·6%) presented with foot ulcer. Age, male gender, hypertension, higher glycated haemoglobin (HbA1c), history of smoking and presence of neuropathy were risk factors (P < 0·000) for foot ulceration. Amputation rate in patients with foot ulceration was significantly related to severity of ulceration at presentation. Preventive foot care practices were followed by 19·02% patients. One thousand eight hundred seventy three (50·2%) patients completely healed, 293 (11%) patients underwent amputation and 397 (10·1%) patients continued to be treated in the foot clinic. All patients with diabetes should be screened for neuropathy to identify those at risk of foot ulceration, as it is the major contributory factor for foot ulceration. The final outcome of foot ulceration was determined by the severity and grade of ulcer at presentation.
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NewsBot · May 27, 2014

Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice
Almoutaz Alkhier Ahmed et al
Diabetes & Metabolic Syndrome: Clinical Research & Reviews; Available online 22 May 2014

Introduction
Diabetes mellitus is a global health problem with rising prevalence worldwide. Diabetes mellitus is a multisystem disease affects many systems and tissues. Foot problems are not uncommon with diabetes and foot ulceration is one of theses problems. Risk factors for foot ulcerations may differ from community to community based on many factors.
Objectives
To determine the risk factors for diabetic foot ulceration among Saudi diabetic patients with type 2 diabetes attending primary care center.
Methodology
Cross sectional study was designed. Four hundred subjects were selected randomly. Inclusion criteria were settled. Three hundred and fifty subjects (350) were participated. Especial assessment form was designed. Data was collected and analyzed using SPPS ver 14.
Results
Three hundred and fifty subjects were participated (57% male and 43% female). The prevalence of peripheral vascular disease was 15%, hulux vulgus 22.5%, inappropriate foot wear 41%, peripheral neuropathy 47.5%. Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration.
Conclusion
Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration.
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NewsBot · Aug 21, 2014

Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia.
Hu Y, Bakhotmah BA, Alzahrani OH, Wang D, Hu FB, Alzahrani HA.
Diabetes Res Clin Pract. 2014 Aug 7.

AIMS:
To identify risk factors and clinical biomarkers of prevalent diabetes foot complications, including foot ulcers, gangrene and amputations among patients with diabetes in Jeddah, Saudi Arabia.
METHODS:
598 diabetes patients from Jeddah participated in the current study. Patients were considered to have diabetes foot complications if they reported diagnosis of foot ulcers or gangrene or amputations in a questionnaire administered by a physician and confirmed by clinical exams. Information on socio-demographic and lifestyle variables was self-reported by patients, and several clinical markers were assessed following standard procedures.
RESULTS:
The prevalence of diabetes foot complications in this population was 11.4%. In the multivariable model without adjustment for PAD (peripheral artery disease) and DPN (diabetes peripheral neuropathy), non-Saudi nationality, longer diabetes duration and insulin use was significantly associated with higher diabetes foot complications prevalence. Each 1g/L increase of hemoglobin was associated with 2.8% lower prevalence of diabetes foot complications. In the multivariable model adjusting for PAD and DPN, the previously observed associations except for nationality were no longer significant. Patients with both DPN and PAD had 9.73 times the odds of diabetes foot complications compared to the patients with neither condition.
CONCLUSION:
In this population, longer diabetes duration, insulin use, lower hemoglobin levels and non-Saudi nationality were associated with higher prevalence of foot complications. These associations were largely explained by the presence of DPN and PAD except for non-Saudi nationality. Diabetes patients with both DPN and PAD had nearly 10-fold increased risk of foot complications than those with neither condition.
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NewsBot · Oct 9, 2014

Prevalence rates of foot complications in subacute inpatient rehabilitation facilities. A cross-sectional prevalence study
Brenton J Earl, Peter A Lazzarini, Ewan M Kinnear and Petrea L Cornwell
Journal of Foot and Ankle Research 2014, 7:41 doi:10.1186/s13047-014-0041-x

BackgroundAustralian subacute inpatient rehabilitation facilities face significant challenges from the ageing population and the increasing burden of chronic disease. Foot disease complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute rehabilitation inpatient services, it seems imperative to investigate the prevalence of foot disease and foot disease risk factors in this population. The primary aim of this cross-sectional study was to determine the prevalence of active foot disease and foot disease risk factors in a subacute inpatient rehabilitation facility.

MethodsEligible participants were all adults admitted at least overnight into a large Australian subacute inpatient rehabilitation facility over two different four week periods. Consenting participants underwent a short non-invasive foot examination by a podiatrist utilising the validated Queensland Health High Risk Foot Form to collect data on age, sex, medical co-morbidity history, foot disease risk factor history and clinically diagnosed foot disease complications and foot disease risk factors. Descriptive statistics were used to determine the prevalence of clinically diagnosed foot disease complications, foot disease risk factors and groups of foot disease risk factors. Logistic regression analyses were used to investigate any associations between defined explanatory variables and appropriate foot disease outcome variables.

ResultsOverall, 85 (88%) of 97 people admitted to the facility during the study periods consented; mean age 80(?9) years and 71% were female. The prevalence (95% confidence interval) of participants with active foot disease was 11.8% (6.3 ? 20.5), 32.9% (23.9 ? 43.5) had multiple foot disease risk factors, and overall, 56.5% (45.9 ? 66.5) had at least one foot disease risk factor. A self-reported history of peripheral neuropathy diagnosis was independently associated with having multiple foot disease risk factors (OR 13.504, p?=?0.001).

ConclusionThis study highlights the potential significance of the burden of foot disease in subacute inpatient rehabilitation facilities. One in eight subacute inpatients were admitted with active foot disease and one in two with at least one foot disease risk factor in this study. It is recommended that further multi-site studies and management guidelines are required to address the foot disease burden in subacute inpatient rehabilitation facilities.
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NewsBot · Nov 8, 2014

Burden of foot problems in diabetic subjects – a community-based study among urban poor in Bangalore, India
Chitra Nagaraj, Monica Ramakuri, Kavita S Konapur
The Journal of Diabetic Foot Complications, 2014; Volume 6, Issue 3, No. 1, Pages 60-66

In India and world-wide, non-communicable diseases, like diabetes mellitus, are rising at a very rapid rate. Diabetes related foot complications affect the quality of life and increase health care costs significantly, especially in the presence of ulcers and amputations. Epidemiological data on foot problems, particularly at a community level, is scarce. This study was designed to estimate the burden of foot problems in diabetic subjects and to assess the effectiveness of health education about awareness of foot care in an urban, poor, community setting. A community-based, cross-sectional study was undertaken in Parvathipura, an urban poor locality located in Bangalore, India. Using a semi-structured questionnaire, general and specific information about foot ulceration and the presence of corns, foot/toe amputations, and lower limb surgeries were collected from the study subjects. A clinical exam was done to ascertain foot problems, vasculopathy, and neuropathy. Baseline knowledge of foot care was collected, and changes in knowledge was assessed after health education was provided.
The study included 65 diabetic subjects. The mean age of the study subjects was 55.97 years old with a standard deviation (SD) of ±11.6 years, and of whom 48 (74%) were female. Illiteracy was present in 20 (30.77%) of the subjects, and 18 (27.69%) of the subjects had completed high school. Among the 65 subjects, 41 (63.08%) were unemployed. Most of the subjects, 46 (71%), were on oral hypoglycemic drugs. The mean duration since the diagnosis of diabetes was 9.57 ±6.45 years. Foot ulceration and hypoesthesia were the most common findings. Diabetic Peripheral Vasculopathy was found in 3 (5%) of the subjects, and Diabetic Peripheral Neuropathy was found in 8 (12%) of the subjects. Ulcers were present in 5 (8%) of the study subjects. A statistically significant improvement in diabetic foot care knowledge was noted among subjects after health education was provided (p<0.0001). Vasculopathy was present in 5% of the study subjects and neuropathy in 12%. Foot ulcers were present in 8% of the subjects. Improvement in knowledge of foot care was noted after health education, indicating an opportunity to reduce the burden of diabetic foot disease in these patients.
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NewsBot · Mar 12, 2015

Risk factors of diabetic foot of neuropathic origin in patients with type 2 diabetes.
Nehring P, Makowski A, Mrozikiewicz-Rakowska B, Sobczyk-Kopcioł A, Płoski R, Karnafel W.
Endokrynol Pol. 2015;66(1):10-4

INTRODUCTION:
Diabetic foot is a diabetes mellitus complication leading to recurrent ulcerations, risk of osteomyelitis and tissue necrosis which may finally result in amputation. Diabetic foot of neuropathic origin manifesting as autonomic and sensory motor neuropathy is the most common type of this complication. The aim of this study was to identify risk factors of diabetic foot of neuropathic origin occurrence in patients with type 2 diabetes.
MATERIAL AND METHODS:
The study included 240 patients, 74 with diabetic foot of neuropathic origin and 166 with diabetes. Cases and controls were matched in terms of age structure. Patients with peripheral arterial disease were excluded from the study. The study was conducted in the Gastroenterology and Metabolic Diseases Department, Medical University of Warsaw, Poland. We used logistic regression models, χ2, U Mann-Whitney's and t-Student tests.
RESULTS:
Logistic regression analysis showed that diabetic foot of neuropathic origin risk factors were: male gender (OR = 6.63; 95% CI: 3.31-13.27; p = 0.00001), duration of diabetes (OR = 1.10; 95% CI: 1.06-1.14; p = 0.00001), height (OR = 1.09; 95% CI: 1.06-1.13; p = 0.00001), weight (OR = 1.04; 95% CI: 1.04-1.06; p = 0.00001) and waist circumference (OR = 1.05; 95% CI: 1.02-1.08; p = 0.001). Although there was a correlation between diabetic foot of neuropathic origin and BMI value, it had no impact on DF occurrence risk.
CONCLUSION:
It is possible to identify patients at risk of diabetic foot development by evaluating anthropometric features. The existence of specific factors increasing the odds of diabetic foot of neuropathic origin occurring may lead to the identification of patients at risk of its development.
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NewsBot · May 2, 2015

The influence of peripheral neuropathy and peripheral vascular disease in the outcome of diabetic foot management – a prospective study
Prakash S Sundar, Krishnakumar, Prabha Chandra
International Journal of Medical Research & Health Sciences
Year : 2015, Volume : 4, Issue : 2

Objective
Peripheral neuropathy and Peripheral Vascular Disease are the risk factors for the development of diabetic foot. The aim of this study was to evaluate differences and predictors of outcome parameters in patients with diabetic foot by stratifying these subjects according to the severity of these risk factors.
Materials and Methods
This is a prospective study conducted in 70 patients in the age group of 30–90 years diagnosed as Type II Diabetes with foot ulcers. After detailed clinical examination the following tests were conducted in all the patients: Complete blood count (CBC), Haemoglobin (Hb), Random Blood Sugar (RBS), Erythrocyte Sedimentation rate (ESR), Chest X-ray(CXR), Electrocardiography (ECG), foot X-ray, pus culture, Neuropathy testing by Semmes Weinstein Monofilament Test and Vibration Perception Threshold and Peripheral vascularity assessment by Duplex Doppler. Then grading of the ulcers was done using Wagner's Grade. The outcome of the patients was assessed by recording the healing time, mode of surgery and amputation rates of the patients.
Results
A total of 70 patients with diabetic foot were consecutively included into the study (65.7% male, age (31% in 51–60 years), mean diabetes duration (5.2 years), Ulcer Grade (37% in Grade IV), Foot lesions (45.7% in toe), Blood sugar levels (64% in 300–400 mg/dl), Neuropathy (84%), Peripheral vascular disease (67%), major amputation (7%) and mortality (1.4%).
Conclusion
All diabetic patients should undergo testing for neuropathy and peripheral vascular disease apart from doing other tests.
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NewsBot · May 3, 2015

Categories of foot at risk in patients of diabetes at a tertiary care center: Insights into need for foot care.
Kishore S, Upadhyay AD, Jyotsna VP.
Indian J Endocrinol Metab. 2015 May-Jun;19(3):405-10

OBJECTIVE:
Diabetic foot ulcers and amputations are preventable. Aim of this study was to determine the distribution of categories of foot at risk in patients with diabetes, attending a tertiary care hospital and factors that affect it.
MATERIALS AND METHODS:
Detail history and examination including neurological and vascular assessment were performed in 100 patients with diabetes attending a Tertiary Care Hospital. Foot at risk was classified according to the task force of foot care interest Group of American Diabetes Association. Category of foot at risk was correlated with demographic and clinical features.
RESULTS:
Fifty-two percent patients had foot at risk-category 1 and 2. Loss of protective sensation (LOPS) was present in 33% (category 1). Peripheral arterial disease (PAD) was present in 19% (category 2). Both LOPS and PAD were present in 10% patients. 95% had never received foot care advice by health professionals, let alone prescriptive footwear or vascular consultation.
CONCLUSIONS:
This study brings forth that foot at risk of ulcer is rampant in patients with diabetes. There are lacunae in diabetic foot care at all levels of care. With the increase in diabetes, cost effective steps are required to improve foot care among diabetes in India. Considering the demographic profile of patients in our study, growing number of patients with diabetes, lack of time and staff allocated for foot care in our setup, audiovisual aids seems a good option to spread foot care awareness among diabetes.
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NewsBot · May 8, 2015

Diabetic Foot Complications and Their Risk Factors from a Large Retrospective Cohort Study.
Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, Alamri BN.
PLoS One. 2015 May 6;10(5):e0124446. doi: 10.1371/journal.pone.0124446

BACKGROUND:
Foot complications are considered to be a serious consequence of diabetes mellitus, posing a major medical and economical threat. Identifying the extent of this problem and its risk factors will enable health providers to set up better prevention programs. Saudi National Diabetes Registry (SNDR), being a large database source, would be the best tool to evaluate this problem.
METHODS:
This is a cross-sectional study of a cohort of 62,681 patients aged ≥25 years from SNDR database, selected for studying foot complications associated with diabetes and related risk factors.
RESULTS:
The overall prevalence of diabetic foot complications was 3.3% with 95% confidence interval (95% CI) of (3.16%-3.44%), whilst the prevalences of foot ulcer, gangrene, and amputations were 2.05% (1.94%-2.16%), 0.19% (0.16%-0.22%), and 1.06% (0.98%-1.14%), respectively. The prevalence of foot complications increased with age and diabetes duration predominantly amongst the male patients. Diabetic foot is more commonly seen among type 2 patients, although it is more prevalent among type 1 diabetic patients. The Univariate analysis showed Charcot joints, peripheral vascular disease (PVD), neuropathy, diabetes duration ≥10 years, insulin use, retinopathy, nephropathy, age ≥45 years, cerebral vascular disease (CVD), poor glycemic control, coronary artery disease (CAD), male gender, smoking, and hypertension to be significant risk factors with odds ratio and 95% CI at 42.53 (18.16-99.62), 14.47 (8.99-23.31), 12.06 (10.54-13.80), 7.22 (6.10-8.55), 4.69 (4.28-5.14), 4.45 (4.05-4.89), 2.88 (2.43-3.40), 2.81 (2.31-3.43), 2.24 (1.98-2.45), 2.02 (1.84-2.22), 1.54 (1.29-1.83), and 1.51 (1.38-1.65), respectively.
CONCLUSIONS:
Risk factors for diabetic foot complications are highly prevalent; they have put these complications at a higher rate and warrant primary and secondary prevention programs to minimize morbidity and mortality in addition to economic impact of the complications. Other measurements, such as decompression of lower extremity nerves, should be considered among diabetic patients.
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NewsBot · Jun 18, 2015

Foot deformities, function in the lower extremities, and plantar pressure in patients with diabetes at high risk to develop foot ulcers
Ulla Hellstrand Tang et al.
Diabetic Foot & Ankle 2015, 6: 27593

Objective: Foot deformities, neuropathy, and dysfunction in the lower extremities are known risk factors that increase plantar peak pressure (PP) and, as a result, the risk of developing foot ulcers in patients with diabetes. However, knowledge about the prevalence of these factors is still limited. The aim of the present study was to describe the prevalence of risk factors observed in patients with diabetes without foot ulcers and to explore possible connections between the risk factors and high plantar pressure.

Patients and methods: Patients diagnosed with type 1 (n=27) or type 2 (n=47) diabetes (mean age 60.0±15.0 years) were included in this cross-sectional study. Assessments included the registration of foot deformities; test of gross function at the hip, knee, and ankle joints; a stratification of the risk of developing foot ulcers according to the Swedish National Diabetes Register; a walking test; and self-reported questionnaires including the SF-36 health survey. In-shoe PP was measured in seven regions of interests on the sole of the foot using F-Scan®. An exploratory analysis of the association of risk factors with PP was performed.

Results: Neuropathy was present in 28 (38%), and 39 (53%) had callosities in the heel region. Low forefoot arch was present in 57 (77%). Gait-related parameters, such as the ability to walk on the forefoot or heel, were normal in all patients. Eighty percent had normal function at the hip and ankle joints. Gait velocity was 1.2±0.2 m/s. All patients were stratified to risk group 3. Hallux valgus and hallux rigidus were associated with an increase in the PP in the medial forefoot. A higher body mass index (BMI) was found to increase the PP at metatarsal heads 4 and 5. Pes planus was associated with a decrease in PP at metatarsal head 1. Neuropathy did not have a high association with PP.

Conclusions: This study identified several potential risk factors for the onset of diabetic foot ulcers (DFU). Hallux valgus and hallux rigidus appeared to increase the PP under the medial forefoot and a high BMI appeared to increase the PP under the lateral forefoot. There is a need to construct a simple, valid, and reliable assessment routine to detect potential risk factors for the onset of DFU.
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NewsBot · Jun 19, 2015

High probability of healing without amputation of plantar forefoot ulcers in patients with diabetes.
Örneholm H, Apelqvist J, Larsson J, Eneroth M
Wound Repair Regen. 2015 Jun 17. doi: 10.1111/wrr.12328

Diabetic foot ulcer is an important entity which in many cases is the first serious complication in diabetes. Although a plantar forefoot location is common, there are few studies on larger cohorts and in such studies there is often a combination of various types of ulcer and ulcer locations. The purpose of this study is to discern the outcome of plantar forefoot ulcers and their specific characteristics in a large cohort. All patients (n=770), presenting with a plantar forefoot ulcer at a multidisciplinary diabetes foot clinic from January 1st 1983 to December 31st 2012 were considered for the study. 701 patients (median age 67 (22-95) fulfilled the inclusion criteria and were followed according to a pre-set protocol until final outcome (healing or death). Severe peripheral vascular disease (SPVD) was present in 26% of the patients and 14% had evidence of deep infection upon arrival at the foot clinic. Fifty-five per cent (385/701) of the patients healed without foot surgery, 25% (173/701) healed after major debridement, nine per cent (60/701) healed after minor or major amputation and 12% (83/701) died unhealed. Median healing time was 17 weeks. An ulcer classified as Wagner grade 1 or 2 at inclusion and independent living were factors associated with a higher healing rate. Seventy-nine per cent of 701 patients with diabetes and a plantar forefoot ulcer treated at a multidisciplinary diabetes foot clinic healed without amputation. For one third some form of foot surgery was needed to achieve healing.
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NewsBot · Jul 28, 2015

A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS).
Crawford F, Cezard G, Chappell FM, Murray GD, Price JF, Sheikh A, Simpson CR, Stansby GP, Young MJ
Health Technol Assess. 2015 Jul;19(57):1-210. doi: 10.3310/hta19570.

BACKGROUND:
Annual foot risk assessment of people with diabetes is recommended in national and international clinical guidelines. At present, these are consensus based and use only a proportion of the available evidence.
OBJECTIVES:
We undertook a systematic review of individual patient data (IPD) to identify the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes.
DATA SOURCES:
Studies were identified from searches of MEDLINE and EMBASE.
REVIEW METHODS:
The electronic search strategies for MEDLINE and EMBASE databases created during an aggregate systematic review of predictive factors for foot ulceration in diabetes were updated and rerun to January 2013. One reviewer applied the IPD review eligibility criteria to the full-text articles of the studies identified in our literature search and also to all studies excluded from our aggregate systematic review to ensure that we did not miss eligible IPD. A second reviewer applied the eligibility criteria to a 10% random sample of the abstract search yield to check that no relevant material was missed. This review includes exposure variables (risk factors) only from individuals who were free of foot ulceration at the time of study entry and who had a diagnosis of diabetes mellitus (either type 1 or type 2). The outcome variable was incident ulceration.
RESULTS:
Our search identified 16 cohort studies and we obtained anonymised IPD for 10. These data were collected from more than 16,000 people with diabetes worldwide and reanalysed by us. One data set was kept for independent validation. The data sets contributing IPD covered a range of temporal, geographical and clinical settings. We therefore selected random-effects meta-analysis, which assumes not that all the estimates from each study are estimates of the same underlying true value, but rather that the estimates belong to the same distribution. We selected candidate variables for meta-analysis using specific criteria. After univariate meta-analyses, the most clinically important predictors were identified by an international steering committee for inclusion in the primary, multivariable meta-analysis. Age, sex, duration of diabetes, monofilaments and pulses were considered most prognostically important. Meta-analyses based on data from the entire IPD population found that an inability to feel a 10-g monofilament [odds ratio (OR) 3.184, 95% confidence interval (CI) 2.654 to 3.82], at least one absent pedal pulse (OR 1.968, 95% CI 1.624 to 2.386), a longer duration of a diagnosis of diabetes (OR 1.024, 95% CI 1.011 to 1.036) and a previous history of ulceration (OR 6.589, 95% CI 2.488 to 17.45) were all predictive of risk. Female sex was protective (OR 0.743, 95% CI 0.598 to 0.922).
LIMITATIONS:
It was not possible to perform a meta-analysis using a one-step approach because we were unable to procure copies of one of the data sets and instead accessed data via Safe Haven.
CONCLUSIONS:
The findings from this review identify risk assessment procedures that can reliably inform national and international diabetes clinical guideline foot risk assessment procedures. The evidence from a large sample of patients in worldwide settings show that the use of a 10-g monofilament or one absent pedal pulse will identify those at moderate or intermediate risk of foot ulceration, and a history of foot ulcers or lower-extremity amputation is sufficient to identify those at high risk. We propose the development of a clinical prediction rule (CPR) from our existing model using the following predictor variables: insensitivity to a 10-g monofilament, absent pedal pulses and a history of ulceration or lower-extremities amputations. This CPR could replace the many tests, signs and symptoms that patients currently have measured using equipment that is either costly or difficult to use.
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NewsBot · Sep 7, 2015

A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS).
Crawford F, Cezard G, Chappell FM, Murray GD, Price JF, Sheikh A, Simpson CR, Stansby GP, Young MJ
Health Technology Assessment Volume: 19 Issue: 57

BACKGROUND: Annual foot risk assessment of people with diabetes is recommended in national and international clinical guidelines. At present, these are consensus based and use only a proportion of the available evidence.

OBJECTIVES: We undertook a systematic review of individual patient data (IPD) to identify the most highly prognostic factors for foot ulceration (i.e. symptoms, signs, diagnostic tests) in people with diabetes.

DATA SOURCES: Studies were identified from searches of MEDLINE and EMBASE.

REVIEW METHODS: The electronic search strategies for MEDLINE and EMBASE databases created during an aggregate systematic review of predictive factors for foot ulceration in diabetes were updated and rerun to January 2013. One reviewer applied the IPD review eligibility criteria to the full-text articles of the studies identified in our literature search and also to all studies excluded from our aggregate systematic review to ensure that we did not miss eligible IPD. A second reviewer applied the eligibility criteria to a 10% random sample of the abstract search yield to check that no relevant material was missed. This review includes exposure variables (risk factors) only from individuals who were free of foot ulceration at the time of study entry and who had a diagnosis of diabetes mellitus (either type 1 or type 2). The outcome variable was incident ulceration.

RESULTS: Our search identified 16 cohort studies and we obtained anonymised IPD for 10. These data were collected from more than 16,000 people with diabetes worldwide and reanalysed by us. One data set was kept for independent validation. The data sets contributing IPD covered a range of temporal, geographical and clinical settings. We therefore selected random-effects meta-analysis, which assumes not that all the estimates from each study are estimates of the same underlying true value, but rather that the estimates belong to the same distribution. We selected candidate variables for meta-analysis using specific criteria. After univariate meta-analyses, the most clinically important predictors were identified by an international steering committee for inclusion in the primary, multivariable meta-analysis. Age, sex, duration of diabetes, monofilaments and pulses were considered most prognostically important. Meta-analyses based on data from the entire IPD population found that an inability to feel a 10-g monofilament [odds ratio (OR) 3.184, 95% confidence interval (CI) 2.654 to 3.82], at least one absent pedal pulse (OR 1.968, 95% CI 1.624 to 2.386), a longer duration of a diagnosis of diabetes (OR 1.024, 95% CI 1.011 to 1.036) and a previous history of ulceration (OR 6.589, 95% CI 2.488 to 17.45) were all predictive of risk. Female sex was protective (OR 0.743, 95% CI 0.598 to 0.922).

LIMITATIONS: It was not possible to perform a meta-analysis using a one-step approach because we were unable to procure copies of one of the data sets and instead accessed data via Safe Haven.

CONCLUSIONS: The findings from this review identify risk assessment procedures that can reliably inform national and international diabetes clinical guideline foot risk assessment procedures. The evidence from a large sample of patients in worldwide settings show that the use of a 10-g monofilament or one absent pedal pulse will identify those at moderate or intermediate risk of foot ulceration, and a history of foot ulcers or lower-extremity amputation is sufficient to identify those at high risk. We propose the development of a clinical prediction rule (CPR) from our existing model using the following predictor variables: insensitivity to a 10-g monofilament, absent pedal pulses and a history of ulceration or lower-extremities amputations. This CPR could replace the many tests, signs and symptoms that patients currently have measured using equipment that is either costly or difficult to use.
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NewsBot · Oct 30, 2015

Risk factors of diabetic foot ulcer in patients attending diabetic foot outpatient clinic at Tanta University Hospital in Egypt
Ghada Al-Ghazaly, MD* Loai Al-Ahwal, MD Khaled Zagloul, MD
The Journal of Diabetic Foot Complications, 2015; Volume 7, Issue 2, No. 3, Pages 42-48

Foot ulceration is one of the most serious and disabling complications of diabetes mellitus (DM). It is the most common cause of non-traumatic foot amputation worldwide. This study aimed to determine the prevalence of diabetic foot ulcers (DFU) in a group of diabetic patients and to describe the risk factors associated with this disease in the studied patients. The study included 300 diabetic patients, with different disease durations. A complete history was taken, and fasting, post-prandial glucose, HbA1c, serum cholesterol, and Doppler ultrasound for assessment of ankle-brachial index (ABI) were performed at baseline. The data was analyzed using the statistical package SPSS. Eighty eight patients (29.3%) were found to have foot ulcer disease; 198 out of the 300 patients (63.3%) had vascular complications, and neuropathy was reported in 264 patients (88.0%). In this study, 88 patients (29.3%) were found to have foot ulcer disease. Uncontrolled hyperglycemia and prolonged disease duration were the most important risk factors for DFU and were associated with a worse prognosis.
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NewsBot · Nov 7, 2015

Predictive Role of Preventive Measures in Preventing the Progression of Diabetic Foot.
Zukic E et al
Mater Sociomed. 2015 Aug;27(4):234-6

INTRODUCTION:
Diabetes mellitus (DM) is one of the most common endocrine disease of modern life. Diabetic foot (DF) is the term for a foot of a patient suffering from DM with the potential risk of a number of pathological sequels, including infection, ulceration and/or destruction of deep tissue.
GOAL:
To determine the importance of preventive measures to prevent the development of diabetic foot.
RESULTS:
The gender structure of respondents categorized by the complication of DF (yes/no) was uniform. The average age was 60.15?12.2 years. Respondents without DF, 63% had 2 visits to the doctor a month, while in the group of those with DF, 39% of them had 3 visits to a doctor and 33% four or more times. Wearing comfortable shoes and foot hygiene in relation to the development of the DF are interdependent: c(2)=4,409; c(2) = 12.47 (p <0.0005). Also, recurrent foot injury, and slow healing of sores in comparison to the development of the DF are mutually dependent; c(2)=13,195; c(2)=14 (p <0.0005).
CONCLUSION:
We found that there is a significant statistical relationship between preventive measures and development of the DF.
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NewsBot · Nov 21, 2015

A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index
Fife Caroline E., Horn Susan D., Smout Randall J., Barrett Ryan S., and Thomson Brett. Advances in Wound Care. ahead of print.

Objective: To develop a healing index for patients with diabetic foot ulcers (DFUs) for use in clinical practice, research analysis, and clinical trials.

Approach: U.S. Wound Registry data were examined retrospectively and assigned a clear outcome (healed, amputated, etc.). Significant variables were identified with bivariate analyses. A multivariable logistic regression model was created based on significant factors (p < 0.05) and tested on a hold-out sample of data. Out of 13,266 DFUs from the original dataset, 6,440 were eligible for analysis. The logistic regression model included 5,239 ulcers, of which 3,462 healed (66.1%). The 10% validation sample utilized 555 ulcers, of which 377 healed (67.9%).

Results: Variables that significantly predicted healing were as follows: wound age (duration in days), wound size, number of concurrent wounds of any etiology, evidence of bioburden/infection, patient age, Wagner grade, being nonambulatory, renal dialysis, renal transplant, peripheral vascular disease, and patient hospitalization for any reason.

Innovation: We present a validated stratification system, previously described as the Wound Healing Index (WHI), which predicts healing likelihood of patients with DFUs, incorporating patient- and wound-specific variables.

Conclusion: The DFU WHI is a comprehensive and user-friendly validated predictive model for DFU healing. It can risk stratify patients enrolled in clinical research trials, stratify patient data for quality reporting and benchmarking activities, and identify patients most likely to require costly therapy to heal.
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