The effects of applied felted foam on wound healing and healing times in the therapy of neuropathic diabetic foot ulcers.

AIMS: The application of felted foam is a promising method for plantar pressure reduction in the ulcer region of diabetic foot ulcers, but knowledge of its effects on wound healing is sparse. The objective of this study was to evaluate the effects of felted foam on wound healing in diabetic foot ulcers compared with a standard method of plantar pressure relief. MATERIALS AND METHODS: A total of 54 Type 1 or Type 2 diabetic patients with neuropathic diabetic foot ulcers were evaluated in this prospective randomized controlled study. Ulcer healing was assessed by planimetric measurement of the wound area at beginning of the study and after 10 weeks and at least until wound healing. The patients were consecutively enrolled in the study; 24 patients were randomized to the felted foam therapy, and 30 patients were randomized to conventional therapy. RESULTS: In the felted foam group, the initial average wound area was 102.3 +/- 45.3 mm2 (mean +/- sd), and 5.4 +/- 3.1 mm2 after 10 weeks with an average healing time of 75 days [95% confidence interval (CI) 67-84]. In the conventional therapy group, the initial average wound area was 112.5 +/- 50.8 mm2, and 10.6 +/- 4.2 mm2 after 10 weeks with an average healing time of 85 days (95% CI 79-92) (P = 0.03). The mean wound radius decreased by 0.48 mm (95% CI 0.42-0.56) per week in the felted foam group and by 0.39 mm (95% CI 0.35-0.42) per week in the conventional group (P = 0.005). CONCLUSIONS: The felted foam technique appears to be at least as effective as conventional plantar ulcer treatment. It may be a useful alternative in treating neuropathic foot ulceration, especially in patients who are not able to avoid weight-bearing reliably.     

Potential risk factors and outcomes of infection with multidrug resistance among diabetic patients having ulcers: 7 years study

Diabetes Mellitus is characterized as a hyperglycemic condition, which results due to alteration in the secretion of insulin or action of insulin. The development and spread of microorganisms is known as a key health concern, and such cases are growing drastically in hospitals and communities. Therefore, the study aims to determine the potential risk factors and infection outcomes among diabetic patients with multi drug resistance, who are suffering from foot ulcerations. A prospective cohort analysis was carried out among 192 diabetic patients admitted in the Rajiv Gandhi Centre for Diabetes and Endocrinology of Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, India. The patients having ulcer or ulcers in their foot during the period December 2008–June 2015 were included in the study. The results indicated the rate of resistance to CS and PC, which was 56.7% and 51.9%. The most common isolates included Escherichia coli (25.5%), Staphylococcus aureus (22.6%), and Klebsiella sp (5.4%). A total of 121 isolates from 278 were associated with the MDR. Furthermore, anaerobic isolates were also included in the study which included Peptostreptococcus spp, Propionibacterium spp, Clostridium perfringens, Eggerthella lenta, and Bacteroides ureolyticus. Ulcer was found among majority of patients with the duration of 1 month; whereas, the ulcer size was also the major risk factor for diabetic patients. Therefore, it is concluded that there is a major need for surveillance of resistant bacteria to reduce the risk of major complications.     

糖尿病足溃疡病原菌种类及感染特征

糖尿病足是糖尿病的主要慢性并发症之一,40%～80%的糖尿病足溃疡合并感染,感染的病原菌以需氧革兰阳性球菌为主,其次是需氧革兰阴性杆菌、厌氧菌及真菌,最常见的是金黄色葡萄球菌.糖尿病足感染的主要特征是混合感染、多重耐药菌株感染、病原菌的性质及种类随溃疡深度变化及病程的进展而产生差异.糖尿病足感染患者年龄大并且创面愈合时间长,应对糖尿病足进行综合治疗,加强对感染的早期预防及诊治.     

糖尿病足Wagner分级方法和TEXAS大学分类法临床应用价值比较

目的评价两种糖尿病足分类方法：Wagner分级方法和TEXAS大学分类法对糖尿病足溃疡预后的影响。方法入选1999年3月至2009年9月新诊断的糖尿病足患者242例,其中男145例,女97例,年龄19～78岁,糖尿病病程0．5～27．0年,足部溃疡病程3d～2周。记录患者溃疡面积、有无感染、缺血、神经病变等,分别应用Wagner分级法和TEXAS大学分类法分类,采用回顾性队列研究设计,随访6个月,痊愈、截肢及死亡为终点事件。应用趋势卡方、生存分析Kaplan—Meier法及log—rank检验等统计方法,比较两种分类法对溃疡痊愈和截肢（趾）风险的预测价值。结果242例糖尿病足患者中,神经性溃疡133例（54．9％）,神经缺血性溃疡83例（34．3％）,缺血性溃疡5例（2．1％）,非神经非缺血性溃疡21例（8．7％）。在观察期内,痊愈147例（60．7％）,截肢（趾）50例（20．7％）,至6个月时溃疡仍未愈者34例（14％）,死亡3例（5．4％）。随着Wagner分级、TEXAS大学分期和分级的升高,截肢（趾）率升高（X^2=79．6420、32．8046、39．2448,均P〈0．01）。单纯感染性溃疡截肢（趾）的风险是无感染无缺血性溃疡的29倍（RR=29．237,95％CI：3．845～222．341,P〈0．01）,合并感染和缺血的溃疡则较无感染无缺血性溃疡的截肢（趾）风险增加48倍（RR=48．300,95％CI：6．209～375．703,P〈0．01）。单纯缺血性溃疡与无感染无缺血性溃疡相比,其截肢（趾）风险增加8倍,但差异无统计学意义（RR=8．364,95％CI：0．899～77．798,P〉0．05）。经log—rank检验,随TEXAS大学分类法的分期升高,溃疡愈合时间延长（X^2=11．234,df=3,P〈0．05）,而分级变化对溃疡愈合时间的影响无统计学意义（X^2=5．452,Jf=2,P〉0．05）;Wagner不同分级对溃疡愈合时间的影响亦无统计学意义（X^2=4．761,df=2,P〉0．05）。结论与Wagner分级法相比,TEXAS大学分类法与糖尿病足溃疡的截肢（趾）率及溃疡愈合时间均有较强的相关性,有更强的预测价值。     

Determinants and estimation of healing times in diabetic foot ulcers

AIMS: To assess the wound size reduction and time course for healing and to establish equations to predict the time course of wound healing in neuropathic, neuroischemic, and ischemic diabetic foot ulcers. METHODS: This prospective study evaluates wound healing over at least a 10-week period in 31 Type 1 or Type 2 diabetic patients with plantar foot ulcers. Thirteen consecutive diabetic patients with neuropathic foot ulceration, 10 consecutive diabetic patients with neuroischemic ulceration, and 8 diabetic patients with peripheral occlusive vascular disease were selected for the study. All patients received identical ulcer wound care including use of proper footwear, non-weight-bearing limb support, use of appropriate antibiotics, debridement, tight control of serum glucose levels, and careful monitoring of the ulcer. Ulcer healing was assessed by planimetric measurement of the wound area every second week until wound healing. The time course of wound healing was calculated by the daily wound radius reduction. RESULTS: The wound area (mean+/-S.E.) in the patients with neuropathic foot ulceration was 61.2+/-17.1 at the beginning and 3.2+/-1.5 mm(2) after 70 days (P=.005). The wound radius decreased by 0.045 mm (95% confidence interval [CI] 0.039-0.055) per day, with most of the wound healing being achieved between the first and seventh week of ulcer care. The average healing time was 77.7 (95% CI 62-93) days. In the neuroischemic group, the initial average wound area was 26.6+/-7.0 mm(2), and 6.25+/-1.7 mm(2) after 10 weeks (P=.007). The wound radius reduction was 0.019 mm/day (95% CI 0.017-0.023) with an average healing time of 123.4 (95% CI 101-145) days. The diabetic patients with peripheral occlusive vascular disease had an average wound size of 32.6+/-13.1 at the beginning and 23.9+/-10.7 mm(2) after 70 days of ulcer care (P=.06). The daily wound radius reduction was 0.0065 mm (95% CI 0.0039-0.0091). Average ulcer duration was 133 (95% CI 116-149) days, but three of eight patients achieved no wound healing. CONCLUSIONS: Providing standard care, the time course of wound healing in diabetic foot ulcers is predominantly determined by etiologic factors, and less by wound size. Taking wound etiology and wound radius into account, the expected healing time can reliably be estimated in neuropathic and neuroischemic ulcers.     

抑郁情绪对Wagner3级糖尿病足溃疡住院患者预后的影响

目的 通过对糖尿病足溃疡住院患者进行心理评估,探讨抑郁情绪对患者预后的影响.方法 对2010年6月至2011年5月因糖尿病足病住院的168例Wagner 3级足溃疡患者应用抑郁自评量表进行评估,按照抑郁程度分为不伴抑郁组和伴抑郁组,采用logistic回归分析抑郁情绪对糖尿病足患者足溃疡愈合以及对足溃疡愈合的患者行截肢手术的影响.结果 Wagner 3级患者中伴抑郁症者95例（56.5％）,不伴抑郁症者73例（43.5％）.卡方检验证实伴抑郁者溃疡不愈合率较不伴抑郁者显著增加（分别为18.9％和6.8％,OR=2.779,95％ CI：1.120 ～9.023）,logistic回归分析发现,在依次调整了与足溃疡预后密切相关的感染程度与动脉病变程度以及年龄、糖化血红蛋白、合并症Charlson评分等因素后,抑郁仍是患者溃疡不愈合的危险因素（OR=3.569,95％CI：1.220～10.442）.进一步对溃疡愈合组患者进行logistic回归发现,在依次调整上述因素后,抑郁情绪的存在也是溃疡愈合组患者截肢的危险因素（OR=2.793,95％ CI：1.361 ～ 5.732）.结论 糖尿病足溃疡患者普遍存在抑郁情绪并对患者预后产生不利影响.对其进行筛查并给予必要的心理治疗,可降低住院糖尿病足溃疡患者的手术风险.     

A psycho-educational intervention for the prevention of foot lesions in people with diabetes: Report of a clinical audit

Background and aimsMotivational approaches may help target the psychological aspects of self-care, improving adherence to good practices in individuals with diabetes. The present study was designed to test the feasibility and effectiveness of a psychoeducational program for diabetic foot prevention or disease progression.Methods and resultsEighty-one subjects with or at high risk of foot ulcer development entered a program consisting of six 120-min group sessions, conducted by a podiatrist and an expert in psycho-education. Occurrence/recurrence of lesions in a 3-year follow-up was compared with 172 cases with similar risk score (IWGDF score 2019), receiving education at any 6-month podiatric visit (standard-of-care). Motivation to self-care and competence were assessed by specific questionnaires. The experimental program increased adherence to follow-up. The prevalence of foot lesions was higher at baseline and was remarkably reduced at any time-point in patients attending the psychoeducational program, whereas it remained relatively stable in standard care (around 10% of cases). The cumulative incidence was lower in the psychoeducational program (13.2, 95% CI 9.2–18.0 per 100 patient-year vs. 26.1; 95% CI 22.1–30.2); time to new lesions was increased (P = 0.022). Cox proportional hazard analysis confirmed an overall reduction of lesions in the psychoeducational program (HR 0.34; 95% CI 0.18–0.66; P < 0.001), after adjustment for confounders. The program was associated with significant changes in competence and motivation to self-care.ConclusionA psychoeducational approach is both feasible and effective to support patients with diabetes at high risk of first or recurrent foot lesions, increasing their adherence to self-care practices.     

Impact of wound microbiology on limb preservation in patients with diabetic foot infection

Aims/Introduction:To investigate the association between specific bacterial pathogens and treatment outcome in patients with limb‐threatening diabetic foot infection (LT‐DFI).Materials and Methods:Consecutive patients treated for LT‐DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 and 2017. Patients with positive wound culture results at first aid were enrolled. Clinical factors, laboratory data, and wound culture results were compared. Lower‐extremity amputations and in‐hospital mortality were defined as a poor outcome.Results:Among the 558 patients, 272 (48.7%) patients had lower extremity amputation and 22 (3.9%) patients had in‐hospital mortality. Gram‐negative bacterial (GNB) infection was the independent factor following factors adjustment. When all the 31 microorganisms were analyzed, only E. coli (adjusted odds ratio [aOR], 3.01; 95% CI, 1.60–5.65), Proteus spp. (aOR, 2.99; 95% CI, 1.69–5.29), and Pseudomonas aeruginosa (aOR, 2.00; 95% CI 1.20–3.32) were associated with poor outcome. The analysis of specific GNB species in association with major‐ or minor‐ amputation have been reported. No specific pathogen was associated with cause of death in patients with mortality within 30 days. The antimicrobial‐resistant strains were not associated with a poor treatment outcome.Conclusions:The presence of GNB was associated with limb amputations. This study provides insight into more timely and appropriate management of the diabetic foot infection.     

Methicillin-resistant Staphylococcus aureus: an increasing problem in a diabetic foot clinic.

AIM: To study the prevalence of pathogenic organisms and the prevalence and outcome of methicillin-resistant Staphylococcus aureus (MRSA) infection in foot ulcers in diabetic patients. METHODS: A retrospective analysis of wound swabs taken from infected foot ulcers in diabetic patients, selected from an outpatient diabetic foot clinic. Seventy-five patients (79 ulcers) with positive wound swabs were included. Size of ulcer and time to healing, in particular for MRSA-infected ulcers, were measured in all patients. RESULTS: Gram-positive aerobic bacteria were the commonest micro-organism isolated (56.7%) followed by gram-negative aerobic bacteria and anaerobes (29.8% and 13.5%, respectively). Of the gram-positive aerobes, S. aureus was found most frequently and 40% were MRSA. MRSA was isolated more commonly in patients treated with antibiotics prior to the swab compared to those who had not received antibiotics (P = 0.01). Patients whose foot ulcers were infected by MRSA had longer healing time than patients whose ulcers were infected by methicillin-sensitive S. aureus (mean (range) 35.4 (19-64) and 17.8 (8-24) weeks, respectively, P = 0.03). CONCLUSION: MRSA infection is common in diabetic foot ulcers and is associated with previous antibiotic treatment and prolonged time to healing. Further studies are required to assess the need for antibiotics in treating foot ulcers in diabetes and to assess the optimum therapeutic approach to this problem.     

Diabetic Foot Infection and Select Comorbidities Drive Readmissions in Outpatient Parenteral Antimicrobial Therapy

BackgroundOutpatient parenteral antimicrobial therapy (OPAT) facilitates early patient discharge, but readmissions prior to completion of therapy may offset its advantages. The objective of this study was to evaluate unplanned readmissions of patients undergoing OPAT at our institution and to identify risk factors. We hypothesized that host factors were most relevant.MethodsWe retrospectively identified all patients discharged to receive OPAT during 2017 who experienced at least one unplanned readmission to the hospital prior to its completion. We determined the proportion of patients readmitted, and the causes for readmission. Using a control group, we identified risk factors through multivariate logistic regression analysis.ResultsOut of 684 patients, 17% had an unplanned readmission while receiving OPAT. Causes included worsening infection in 18%, venous access problems in 11%, acute events unrelated to infection in 19%, treatment intolerance in 19%, progression of underlying comorbidity in 20%, and social and other problems in 13%. In multivariate analysis diabetic foot infection (OR 3.24; 95%CI 1.38–8.31; p = 0.01), the presence of chronic kidney disease, decubitus ulcer or heart failure (OR 2.65; 95% CI 1.51–4.70; p < 0.001), and narcotics prescribed at discharge (OR 1.93; 95% CI 1.06–3.60; p = 0.049) were independent risk factors for readmission.ConclusionsUnplanned hospital readmissions were frequent and due to very heterogeneous causes. Diabetic foot infection, selected comorbidities, and discharge on opioids were identified as independent risk factors. In the efforts to decrease readmissions among patients receiving outpatient parenteral antimicrobial a focus on these high-risk groups is a priority.     

Guidelines on the classification of diabetic foot ulcers (IWGDF 2019)

The International Working Group on the Diabetic Foot (IWGDF) has been publishing evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This publication represents a new guideline addressing the use of classifications of diabetic foot ulcers in routine clinical practice and reviews those which have been published. We only consider systems of classification used for active diabetic foot ulcers and do not include those that might be used to define risk of future ulceration. The guidelines are based on a review of the available literature and on expert opinion leading to the identification of eight key factors judged to contribute most to clinical outcomes. Classifications are graded on the number of key factors included as well as on internal and external validation and the use for which a classification is intended. Key factors judged to contribute to the scoring of classifications are of three types: patient related (end‐stage renal failure), limb‐related (peripheral artery disease and loss of protective sensation), and ulcer‐related (area, depth, site, single, or multiple and infection). Particular systems considered for each of the following five clinical situations: (a) communication among health professionals, (b) predicting the outcome of an individual ulcer, (c) as an aid to clinical decision‐making for an individual case, (d) assessment of a wound, with/without infection, and peripheral artery disease (assessment of perfusion and potential benefit from revascularisation), and (d) audit of outcome in local, regional, or national populations. We recommend: (a) for communication among health professionals the use of the SINBAD system (that includes Site, Ischaemia, Neuropathy, Bacterial Infection and Depth); (b) no existing classification for predicting outcome of an individual ulcer; (c) the Infectious Diseases Society of America/IWGDF (IDSA/IWGDF) classification for assessment of infection; (d) the WIfI (Wound, Ischemia, and foot Infection) system for the assessment of perfusion and the likely benefit of revascularisation; and (e) the SINBAD classification for the audit of outcome of populations.     

Amputation and infection are the greatest fears in patients with diabetes foot complications

AimsTo determine the degree patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations fear complications (death, dialysis, heart attack, stroke, blindness, diabetic foot infection, minor and major lower extremity amputation [LEA]) that can occur and to assess if there is a difference between fears of patients with diabetic foot ulcers, Charcot neuroarthropathy and neuropathic fractures and dislocations and diabetic patients without these complications.Methods478 patients completed an eight question Likert scale survey. The study group was defined as non-infected foot ulcers, neuropathic fractures and Charcot neuroarthropathy.ResultsOf the 478 patients, 121 (25.3 %) had diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations and 357 (74.7 %) did not. The study group had significantly higher odds of reporting extreme fear of foot infection (OR 2.8, 95 % CI 1.8–4.5), major LEA (OR 2.8, 95 % CI 1.8–4.4), minor LEA (OR 2.3, 95 % CI 1.5–3.5), blindness (OR 2.0, 95 % CI 1.3–3.2), dialysis (OR 2.0, 95 % CI 1.1–3.3), and death (OR 2.4, 95 % CI 1.4–4.2). In the study group highest rated fear measures were foot infection (3.71, SD 1.23), minor amputation (3.67, SD 1.45) and major amputation (3.63, SD 1.52). There were no significant differences in the mean fear of infection, minor amputation or major amputation.ConclusionPatients with diabetic foot ulcers, Charcot neuroarthropathy or neuropathic fractures and dislocations reported higher fear ratings of diabetes-related complications compared to those without these complications.     

Multidrug resistant gram-negative bacilli as predominant bacteremic pathogens in liver transplant recipients

Background. Bacteremias, which are often caused by gram‐negative bacteria, are the most frequently occurring infectious complications after liver transplantation (LT). The aim of this study was to investigate bacteremic incidence, pathogenic spectrum, risk factors for bacteremia due to multidrug resistant (MDR) gram‐negative bacilli, and its impact on mortality after LT. Methods. A cohort analysis of prospectively recorded data was done in 475 LT recipients, who were divided into 3 categories: cases with gram‐negative bacteremia, cases with MDR gram‐negative bacteremia, and cases without bacteremia as controls. Results. In 475 LT recipients, there were 152 (32.0%) patients with gram‐negative bacillus bacteremia in the first 6 months after LT. Out of 152 patients, there were 225 bacteremic episodes, which accounted for 69.7% in a total 323 bacteremic episodes. A total of 190 bacteremic episodes were caused by Stenotrophomonas maltophilia, Enterobacteriaceae, Ochrobactrum anthropi, Pseudomonas, and Acinetobacter baumanii, all of which were the most frequent gram‐negative isolates in this study, and MDR bacilli constituted 56.3%. The most frequent source was intravascular catheters. There were 70 patients with MDR gram‐negative bacillus bacteremia. Independent risk factors for bacteremia due to MDR gram‐negative bacillus were as follows: post‐LT abdominal infection (P<0.0001, odds ratio [OR] 0.066, 95% confidence interval [CI] 0.019–0.226), post‐LT reoperative episodes (P<0.0001, OR 10.505, 95% CI 3.055–36.121), or one or more episodes of acute rejection (P=0.042, OR 4.457, 95% CI 0.988–20.103). In the first 6 months after LT, MDR gram‐negative bacillus bacteremia‐related mortality was significantly higher than that due to antibiotic‐susceptible bacillus (38.6% vs. 14.6%, P<0.001). Conclusion. Post‐LT bacteremias caused by MDR gram‐negative bacilli are common, and associated with allograft acute rejection, post‐LT reoperation, and abdominal infection. The increasing isolates of MDR gram‐negative bacilli pose a great challenge for clinical treatment.     

Increased Mortality Associated with Diabetic Foot Ulcer

The objective of this study was to evaluate the relationship between foot ulceration and short-term mortality in veterans of the American military services with diabetes mellitus. A total of 725 diabetic subjects participated in a prospective study of risk factors for lower extremity complications between 1990 and 1994. Mean follow-up was 691.8 days (± SD 339.9, range 28–1436 days). Subjects who died during follow-up (n = 72) had a similar mean duration of diabetes to those who survived (12.6 years vs 11.2), but their mean age was greater (65.9 years vs 63.2, p = 0.026). The relative risk (RR) of death was 2.39 (95% confidence interval (CI) 1.13 to 4.58) in the subjects who developed foot ulcer (n = 88) compared to those who did not. The risk of death for those with foot ulcer was 12.1 per 100 person-years of follow-up compared to 5.1 in those without foot ulcer. Cox regression analysis demonstrated a greater than two-fold increased risk of death in ulcerated subjects after adjustment for age; diabetes type, duration, and treatment; glycosylated hemoglobin level; history of lower extremity amputation; and cumulative pack years smoked. Higher ankle–arm index was significantly related to lower mortality risk, independent of foot ulcer occurrence. We conclude that foot ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects. The reasons for this excess mortality require further investigation.     

Clinical and microbiological profile of diabetic foot ulcer patients in a tertiary care hospital

Aim

To evaluate the clinical and microbiological profile of diabetic foot ulcer patients admitted to a tertiary care hospital.

Prognosis of the infected diabetic foot ulcer: a 12‐month prospective observational study

Aims

To determine clinical outcomes and explore prognostic factors related to ulcer healing in people with a clinically infected diabetic foot ulcer.

Methods

This multicentre, prospective, observational study reviewed participants’ data at 12 months after culture of a diabetic foot ulcer requiring antibiotic therapy. From participants’ notes, we obtained information on the incidence of wound healing, ulcer recurrence, lower extremity amputation, lower extremity revascularization and death. We estimated the cumulative incidence of healing at 6 and 12 months, adjusted for lower extremity amputation and death using a competing risk analysis, and explored the relationship between baseline factors and healing incidence.

Results

In the first year after culture of the index ulcer, 45/299 participants (15.1%) had died. The ulcer had healed in 136 participants (45.5%), but recurred in 13 (9.6%). An ipsilateral lower extremity amputation was recorded in 52 (17.4%) and revascularization surgery in 18 participants (6.0%). Participants with an ulcer present for ~2 months or more had a lower incidence of healing (hazard ratio 0.55, 95% CI 0.39 to 0.77), as did those with a PEDIS (perfusion, extent, depth, infection, sensation) perfusion grade of ≥2 (hazard ratio 0.37, 95% CI 0.25 to 0.55). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06).

Conclusions

Clinical outcomes at 12 months for people with an infected diabetic foot ulcer are generally poor. Our data confirm the adverse prognostic effect of limb ischaemia, longer ulcer duration and the presence of multiple ulcers.     

25-Hydroxyvitamin D [25(OH)D] levels and diabetic foot ulcer: Is there any relationship?

AimsIn recent years, there has been an effort to understand possible roles of 25(OH)D, including its role in the immune system particularly on T cell medicated immunity, pancreatic insulin secretion and insulin action. 25(OH)D stimulates the cell differentiation and reduces cell proliferation, which is essential for cell growth and wound healing. However, data on the association between low level of plasma 25(OH)D and diabetic foot syndrome are scarce.Materials and MethodsCirculating plasma levels of 25(OH)D were measured in diabetic patients with ulcer (n = 162) and without ulcer (n = 162) in a prospective cohort hospital based study.ResultsOf these patients, 85.1% had type 2 diabetes. Subjects with diabetic foot ulcer showed lower median plasma level of 25(OH)D [6.3(4.2–11.1) vs 28.0(21.4–37.0)] ng/ml after adjusting the age and BMI. Regardless of the low levels of 25(OH)D in cases and controls, it was associated with neuropathy, sex (female), duration of ulcer healing, and smoking status and independent of confounding factors, including BMI (kg/m²), A1c (%), hypertension, nephropathy, foot ulcer, retinopathy, CAD, PAD, HDL-C (mg/dl) and LDL-C (mg/dl). The factors which predict the risk of developing ulcer independent of 25(OH)D status were A1c (>6.9%) [OR 4.37; RR 1.77], HDL-C (<40 mg/dl) [OR 1.16; RR 1.07], LDL-C (>100 mg/dl) [OR 1.07; RR 1.03], triglycerides (>200 mg/dl) [OR 1.40; RR 1.19], neuropathy [OR 6.88; RR 3.12], retinopathy [OR 3.34; RR 1.91], hypertension [OR 1.64; RR 1.28], nephropathy [OR 3.12; RR 1.87] and smoking [OR 4.53; RR 2.99] using odds and risk ratios.ConclusionIt is not clear whether the suppression of delayed wound healing seen during 25(OH)D deficiency is due to the secondary effect or is a direct action of vitamin D on certain components of the immune system. Long-term randomized trials are needed to see the impact of vitamin D supplementation on the outcome of diabetic foot patients.     

Risk factors associated with adverse outcomes in a population-based prospective cohort study of people with their first diabetic foot ulcer

AIMS/HYPOTHESIS: The aim of this study was to determine which clinic-based measures of diabetes and foot status at baseline were associated with adverse outcomes 18 months later in people with diabetes presenting with their first foot ulcer. SUBJECTS AND METHODS: This was a prospective population-based cohort study of adults with type 1 and type 2 diabetes mellitus presenting with their first foot ulcer (excluding those with severe ischaemia, ankle brachial pressure index <0.5). The main explanatory variables were age, sex, smoking status, ulcer site (dorsal or plantar), size and severity of ulcer, severity of neuropathy, ischaemia, glycosylated haemoglobin, presence of micro- and macrovascular complications, and depression. The main outcomes recorded were death, amputation and recurrence of ulceration, and the time taken for each outcome to occur. RESULTS: Two hundred fifty-three people were recruited. There were 40 deaths (15.8%), 36 amputations (15.5%), and 99 recurrences (43.2%) at 18 months. Our main findings were that being older [hazard ratio (HR) 1.07, 95% CI 1.04-1.11], having lower glycosylated haemoglobin (HR 0.73, 95% CI 0.56-0.96), moderate ischaemia (HR 2.74, 95% CI 1.46-5.14), and depression (HR 2.51, 95% CI 1.33-4.73) were associated with mortality. Ulcer severity was the only explanatory factor significantly associated with amputation (HR 3.18, 95% CI 1.53-6.59). Microvascular complications were the only explanatory factor associated with recurrent ulceration (HR 3.34, 95% CI 1.17-9.56). CONCLUSIONS/INTERPRETATION: Commonly used primary and secondary care clinic-based measures could provide the basis for a risk assessment tool for adverse outcomes following first presentation of diabetic foot ulcers.     

Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem.

AIMS: To determine if there has been a change in the prevalence of pathogenic organisms in foot ulcers in diabetic patients in 2001 compared with our previous study in 1998. METHODS: A retrospective analysis of wound swabs taken from infected foot ulcers in diabetic patients attending the outpatient clinic in the Manchester Foot Hospital over a twelve-month period. A total of 63 patients with positive wound swabs were identified. RESULTS: Gram-positive aerobic bacteria still predominate (84.2%) and the commonest single isolate remains Staphylococcus aureus (79.0%) which is higher than we previously reported. MRSA was isolated in 30.2% of the patients which is almost double the proportion of MRSA-affected patients three years ago. This did not appear to be related to prior antibiotic usage. There was no increase in hospitalisation because of MRSA infection. CONCLUSIONS: The problem of MRSA continues to increase despite the precautions taken to prevent MRSA spread. There is a need for a multi-centre study looking into the prevalence of MRSA in diabetic foot ulcer and how this can be reduced in the diabetic foot clinic.