Building Trustworthy Generative Artificial Intelligence for Diabetes Care and Limb Preservation: A Medical Knowledge Extraction Case.

BACKGROUND: Large language models (LLMs) offer significant potential in medical information extraction but carry risks of generating incorrect information. This study aims to develop and validate a retriever-augmented generation (RAG) model that provides accurate medical knowledge about diabetes and diabetic foot care to laypersons with an eighth-grade literacy level. Improving health literacy through patient education is paramount to addressing the problem of limb loss in the diabetic population. In addition to affecting patient well-being through improved outcomes, improved physician well-being is an important outcome of a self-management model for patient health education. METHODS: We used an RAG architecture and built a question-and-answer artificial intelligence (AI) model to extract knowledge in response to questions pertaining to diabetes and diabetic foot care. We utilized GPT-4 by OpenAI, with Pinecone as a vector database. The NIH National Standards for Diabetes Self-Management Education served as the basis for our knowledge base. The model's outputs were validated through expert review against established guidelines and literature. Fifty-eight keywords were used to select 295 articles and the model was tested against 175 questions across topics. RESULTS: The study demonstrated that with appropriate content volume and few-shot learning prompts, the RAG model achieved 98% accuracy, confirming its capability to offer user-friendly and comprehensible medical information. CONCLUSION: The RAG model represents a promising tool for delivering reliable medical knowledge to the public which can be used for self-education and self-management for diabetes, highlighting the importance of content validation and innovative prompt engineering in AI applications.

Comparison of bacterial species and clinical outcomes in patients with diabetic hand infection in tropical and nontropical regions.

Hand infection is a rare complication in patients with diabetes. Its clinical outcomes depend on the severity of hand infection caused by bacteria, but the difference in bacterial species in the regional disparity is unknown. The purpose of this study was to explore the influence of tropical and nontropical regions on bacterial species and clinical outcomes for diabetic hand. A systematic literature review was conducted using PubMed, EMBASE, Web of Science, and Google Scholar. Moreover, the bacterial species and clinical outcomes were analyzed with respect to multicenter wound care in China (nontropical regions). Both mixed bacteria (31.2% vs. 16.6%, p = 0.014) and fungi (7.5% vs. 0.8%, p = 0.017) in the nontropical region were significantly more prevalent than those in the tropical region. Staphylococcus and Streptococcus spp. were dominant in gram-positive bacteria, and Klebsiella, Escherichia coli, Proteus and Pseudomonas in gram-negative bacteria occupied the next majority in the two regions. The rate of surgical treatment in the patients was 31.2% in the nontropical region, which was significantly higher than the 11.4% in the tropical region (p = 0.001). Although the overall mortality was not significantly different, there was a tendency to be increased in tropical regions (6.3%) compared with nontropical regions (0.9%). However, amputation (32.9% vs. 31.3%, p = 0.762) and disability (6.3% vs. 12.2%, p = 0.138) were not significantly different between the two regions. Similar numbers of cases were reported, and the most common bacteria were similar in tropical and nontropical regions in patients with diabetic hand. There were more species of bacteria in the nontropical region, and their distribution was basically similar, except for fungi, which had differences between the two regions. The present study also showed that surgical treatment and mortality were inversely correlated because delays in debridement and surgery can deteriorate deep infections, eventually leading to amputation and even death.

Association of Preulcerative Foot Care and Outcomes of Diabetic Foot Ulceration.

BACKGROUND: The purpose of this study was to determine the association of preulcerative foot care and outcomes of diabetic foot ulcerations (DFUs). METHODS: This retrospective cohort study using the Mariner all-payers claims data set included participants with a new DFU from 2010 to 2019. Patients were stratified into two cohorts (foot care and control) based on whether they had received any outpatient foot care within 12 months before DFU. Adjusted comparison was performed by propensity matching for age, sex, and the Charlson Comorbidity Index (1:2 ratio). Kaplan-Meier estimates and logistic regression examined the association between foot care and outcomes of DFUs. RESULTS: Of the 307,131 patients in the study cohort, 4.7% (n = 14,477) received outpatient preulcerative foot care within the 12-month period before DFU. The rate of major amputation was 1.8% (foot care, 1.2%), and 9.0% of patients had hospitalizations for foot infection within 12 months after DFU (foot care, 7.8%). In the study cohort, patients who received pre-DFU foot care had greater major amputation-free survival (P < .001) on Kaplan-Meier estimate. In both the study and matched cohorts, multivariable analysis demonstrated that foot care was associated with lower odds of major amputation for both study (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.48-0.66) and matched (OR, 0.61; 95% CI, 0.51-0.72) cohorts, and lower odds of hospitalizations for a foot infection in both study (OR, 0.91; 95% CI, 0.86-0.96) and matched (OR, 0.88, 95% CI, 0.82-0.94) cohorts. CONCLUSIONS: Among patients with a new DFU, those who received outpatient preulcerative foot care within 12 months of diagnosis had lower risks of major amputation and hospitalizations for foot infection.

Comparative Effectiveness of Placental Allografts in the Treatment of Diabetic Lower Extremity Ulcers and Venous Leg Ulcers in U.S. Medicare Beneficiaries: A Retrospective Observational Cohort Study Using Real-World Evidence.

Objective: To compare the effectiveness of cellular tissue products (CTP) versus standard care in U.S. Medicare beneficiaries with diabetic lower extremity ulcers (DLEUs) or venous leg ulcers (VLUs). Approach: We performed a retrospective cohort study using real-world evidence from U.S. Medicare claims for DLEUs or VLUs between 2016 and 2020. There were three cohorts evaluated: viable cryopreserved placental membrane (vCPM) or viable lyopreserved placental membrane (vLPM); other CTP; and standard care. Claims were collapsed into episodes of care. Univariate and bivariate statistics were used to examine the frequency distribution of demographics and clinical variables. Multivariable zero-inflated binomial regressions were used to evaluate mortality and recurrence trends. Logistic regression compared three adverse outcomes (AOs): amputation; 1-year mortality; and wound recurrence. Results: There were 333,362 DLEU episodes among 261,101 beneficiaries, and 122,012 VLU episodes among 80,415 beneficiaries. DLEU treatment with vLPM was associated with reduced 1-year mortality (-26%), reduced recurrence (-91%), and reduced AOs (-71%). VLU treatment with vCPM or vLPM was associated with reduced 1-year mortality (-23%), reduced recurrence (-80%), and 66.77% reduction in AOs. These allografts were also associated with a 49% and 73% reduced risk of recurrence in DLEU and VLU, respectively, compared with other CTPs. Finally, vCPM or vLPM were associated with noninferior prevention of AOs related to amputation, mortality, and recurrence (95% CI: 0.69-1.14). Conclusions: DLEUs and VLUs treated with vCPM and vLPM allografts are associated with lowered 1-year mortality, wound recurrence, and AOs in DLEUs and VLUs compared with standard care. Decision makers weighing coverage of placental allografts should consider these added short- and long-term clinical benefits relative to costly management and high mortality of Medicare's most frequent wounds.

A purified reconstituted bilayer matrix shows improved outcomes in treatment of non-healing diabetic foot ulcers when compared to the standard of care: Final results and analysis of a prospective, randomized, controlled, multi-centre clinical trial.

As the incidence of diabetic foot ulcers (DFU) increases, better treatments that improve healing should reduce complications of these ulcers including infections and amputations. We conducted a randomized controlled trial comparing outcomes between a novel purified reconstituted bilayer membrane (PRBM) to the standard of care (SOC) in the treatment of non-healing DFUs. This study included 105 patients who were randomized to either of two treatment groups (n = 54 PRBM; n = 51 SOC) in the intent to treat (ITT) group and 80 who completed the study per protocol (PP) (n = 47 PRBM; n = 33 SOC). The primary endpoint was the percentage of wounds closed after 12 weeks. Secondary outcomes included percent area reduction, time to healing, quality of life, and cost to closure. The DFUs that had been treated with PRBM healed at a higher rate than those treated with SOC (ITT: 83% vs. 45%, p = 0.00004, PP: 92% vs. 67%, p = 0.005). Wounds treated with PRBM also healed significantly faster than those treated with SOC with a mean of 42 versus 62 days for SOC (p = 0.00074) and achieved a mean wound area reduction within 12 weeks of 94% versus 51% for SOC (p = 0.0023). There were no adverse events or serious adverse events that were related to either the PRBM or the SOC. In comparison to the SOC, DFUs healed faster when treated with PRBM. Thus, the use of this PRBM is an effective option for the treatment of chronic DFUs.

Evaluating the impact of an interdisciplinary integrated limb preservation service operating concurrently with a single-specialty service.

BACKGROUND: This study examined the efficacy of an interdisciplinary limb preservation service (LPS) in improving surgical outcomes for diabetic foot ulcer (DFU) patients compared to traditional care. METHODS: Data from January 1, 2017 to September 30, 2020 were retrospectively reviewed. An interdisciplinary LPS clinic began on August 1, 2018, coexisting with a preexisting single specialty service. Primary outcomes were major/minor amputation rates and ratios and hospital length of stay. Surgical endpoints pre- and post-LPS launch were compared. RESULTS: Among 976 procedures for 731 unique DFU patients, most were male (80.4%) and Hispanic (89.3%). Patient demographics were consistent before and after LPS initiation. Major amputation rates decreased by 45.5% (15.4%-8.4%, p = 0.001), with outpatient procedures increasing over 5-fold (3.3% pre-LPS to 18.7% post-LPS, p < 0.001). Hospital stay reduced from 10.1 to 8.5 days post-LPS (p < 0.001). The major to minor amputation ratio declined from 22.4% to 12.7%. CONCLUSIONS: The interdisciplinary LPS improved patient outcomes, marked by fewer major amputations and reduced hospital stays, suggesting the model's potential for broader application.

Topical pravibismane as adjunctive therapy for moderate or severe diabetic foot infections: A phase 1b randomized, multicenter, double-blind, placebo-controlled trial.

This Phase 1b study was designed to evaluate the safety and efficacy of pravibismane, a novel broad-spectrum topical anti-infective, in managing moderate or severe chronic diabetic foot ulcer (DFU) infections. This randomized, double-blind, placebo-controlled, multicenter study consisted of 39 individuals undergoing pravibismane treatment and 13 individuals in the placebo group. Assessment of safety parameters included clinical observations of tolerability and pharmacokinetics from whole blood samples. Pravibismane was well-tolerated and exhibited minimal systemic absorption, as confirmed by blood concentrations that were below the lower limit of quantitation (0.5 ng/mL) or in the low nanomolar range, which is orders of magnitude below the threshold of pharmacological relevance for pravibismane. Pravibismane treated subjects showed approximately 3-fold decrease in ulcer size compared to the placebo group (85% vs. 30%, p = 0.27). Furthermore, the incidence of ulcer-related lower limb amputations was approximately 6-fold lower (2.6%) in the pooled pravibismane group versus 15.4% in the placebo group (p = 0.15). There were no treatment emergent or serious adverse events related to study drug. The initial findings indicate that topical pravibismane was safe and potentially effective treatment for improving recovery from infected chronic ulcers by reducing ulcer size and facilitating wound healing in infected DFUs (ClinicalTrials.gov Identifier NCT02723539).

Predicting pressure injury risk in hospitalised patients using machine learning with electronic health records: a US multilevel cohort study.

OBJECTIVE: To predict the risk of hospital-acquired pressure injury using machine learning compared with standard care. DESIGN: We obtained electronic health records (EHRs) to structure a multilevel cohort of hospitalised patients at risk for pressure injury and then calibrate a machine learning model to predict future pressure injury risk. Optimisation methods combined with multilevel logistic regression were used to develop a predictive algorithm of patient-specific shifts in risk over time. Machine learning methods were tested, including random forests, to identify predictive features for the algorithm. We reported the results of the regression approach as well as the area under the receiver operating characteristics (ROC) curve for predictive models. SETTING: Hospitalised inpatients. PARTICIPANTS: EHRs of 35 001 hospitalisations over 5 years across 2 academic hospitals. MAIN OUTCOME MEASURE: Longitudinal shifts in pressure injury risk. RESULTS: The predictive algorithm with features generated by machine learning achieved significantly improved prediction of pressure injury risk (p<0.001) with an area under the ROC curve of 0.72; whereas standard care only achieved an area under the ROC curve of 0.52. At a specificity of 0.50, the predictive algorithm achieved a sensitivity of 0.75. CONCLUSIONS: These data could help hospitals conserve resources within a critical period of patient vulnerability of hospital-acquired pressure injury which is not reimbursed by US Medicare; thus, conserving between 30 000 and 90 000 labour-hours per year in an average 500-bed hospital. Hospitals can use this predictive algorithm to initiate a quality improvement programme for pressure injury prevention and further customise the algorithm to patient-specific variation by facility.

Recommendations for management of diabetes and its complications during Hajj (Muslim Pilgrimage) - 2024 update.

Hajj is an obligatory duty for all healthy adult Muslims once in the lifetime subjected to the ability. Considering the 10.5 % global prevalence of diabetes coupled with the numbers of Muslims performing the Hajj, ∼ 1.8 million in 2023, it is estimated that Muslims with diabetes performing Hajj may exceed 340,000 this year. During Hajj the pattern and amount of their meal, fluid intake and physical activity are markedly altered. Many people with diabetes insist on doing the Hajj duty, thereby creating a medical challenge for themselves and their health care providers. It is therefore important that medical professionals be aware of the potential risks that may be associated with Hajj. People with diabetes may face many health hazards during Hajj including but not limited to the killer triad which might occur during Hajj: Hypoglycemia, Foot injury and Infections. Many precautions should be taken to prevent and treat these potentially serious complications. Risk stratification, medication adjustments, proper clinical assessment, and education before doing Hajj are crucial.

Management of Acute Wounds - Expert Panel Consensus Statement.

SIGNIFICANCE: The Wound Healing Foundation recognized the need for consensus-based unbiased recommendations for the treatment of wounds. As a first step, a consensus on the treatment of chronic wounds was developed and published in 2022.(1) The current publication on acute wounds represents the second step in this process. Acute wounds may result from any number of conditions, including burns, military and combat operations, and trauma to specific areas of the body. The management of acute wounds requires timely and evidence-driven intervention to achieve optimal clinical outcomes. This consensus statement provides the clinician with the necessary foundational approaches to the causes, diagnosis and therapeutic management of acute wounds. Presented in a structured format, this is a useful guide for clinicians and learners in all patient care settings. RECENT ADVANCES: Recent advances in the management of acute wounds have centered on stabilization and treatment in the military and combat environment, Specifically advancements in hemostasis, resuscitation, and the mitigation of infection risk through timely initiation of antibiotics and avoidance of high pressure irrigation in contaminated soft tissue injury. . CRITICAL ISSUES: Critical issues include infection control, pain management and the unique considerations for the management of acute wounds in pediatric patients. FUTURE DIRECTIONS: Future directions include new approaches to preventing the progression and conversion of burns through the use of the microcapillary gel, a topical gel embedded with the anti-inflammatory drug infliximab.(38) Additionally, the use of three-dimensional bioprinting and photo-modulation for skin reconstruction following burns is a promising area for continued discovery.

An Augmented Vision of Our Medical and Surgical Future, Today?

Incorporating consumer electronics into the operating room, we evaluated the Apple Vision Pro (AVP) during limb preservation surgeries, just as we evaluated Google Glass and FaceTime more than a decade ago. Although AVP's real-time mixed-reality data overlay and controls offer potential enhancements to surgical precision and team communication, our assessment recognized limitations in adapting consumer technology to clinical environments. The initial use facilitated intraoperative decision-making and educational interactions with trainees. The current mixed-reality pass-through resolution allows for input but not for highly dexterous surgical interactions. These early observations indicate that while AVP may soon improve aspects of surgical performance and education, further iteration, evaluation, and experience are needed to fully understand its impact on patient outcomes and to refine its integration into clinical practice.

Offloading and adherence through technological advancements: Modern approaches for better foot care in diabetes.

OBJECTIVE: This manuscript aims to provide a review and synthesis of contemporary advancements in footwear, sensor technology for remote monitoring, and digital health, with a focus on improving offloading and measuring and enhancing adherence to offloading in diabetic foot care. METHODS: A narrative literature review was conducted by sourcing peer-reviewed articles, clinical studies, and technological innovations. This paper includes a review of various strategies, from specifically designed footwear, smart insoles and boots to using digital health interventions, which aim to offload plantar pressure and help prevent and manage wounds more effectively by improving the adherence to such offloading. RESULTS: In-house specially made footwear, sensor technologies remotely measuring pressure and weight-bearing activity, exemplified for example, through applications like smart insoles and SmartBoot, and other digital health technologies, show promise in improving offloading and changing patient behaviour towards improving adherence to offloading and facilitating personalised care. This paper introduces the concept of gamification and emotive visual indicators as novel methods to enhance patient engagement. It further discusses the transformative role of digital health technologies in the modern era. CONCLUSIONS: The integration of technology with footwear and offloading devices offers unparallelled opportunities for improving diabetic foot disease management not only through better offloading but also through improved adherence to offloading. These advancements allow healthcare providers to personalise treatment plans more effectively, thereby promising a major improvement in patient outcomes in diabetic foot ulcer healing and prevention.

Wound Bed Preparation 2024: Delphi Consensus on Foot Ulcer Management in Resource-Limited Settings.

GENERAL PURPOSE: To review a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Summarize issues related to wound assessment.2. Identify a class of drugs for the treatment of type II diabetes mellitus that has been shown to improve glycemia, nephroprotection, and cardiovascular outcomes.3. Synthesize strategies for wound management, including treatment in resource-limited settings.4. Specify the target time for edge advancement in chronic, healable wounds.

Chronic wound management in low-resource settings deserves special attention. Rural or underresourced settings (ie, those with limited basic needs/healthcare supplies and inconsistent availability of interprofessional team members) may not have the capacity to apply or duplicate best practices from urban or abundantly-resourced settings. The authors linked world expertise to develop a practical and scientifically sound application of the wound bed preparation model for communities without ideal resources. A group of 41 wound experts from 15 countries reached a consensus on wound bed preparation in resource-limited settings. Each statement of 10 key concepts (32 substatements) reached more than 88% consensus. The consensus statements and rationales can guide clinical practice and research for practitioners in low-resource settings. These concepts should prompt ongoing innovation to improve patient outcomes and healthcare system efficiency for all persons with foot ulcers, especially persons with diabetes.

Comparison of bacterial species and clinical outcomes in patients with diabetic hand infection in tropical and nontropical regions.

Purpose: Hand infection is a rare complication in patients with diabetes. Its clinical outcomes depend on the severity of hand infection caused by bacteria, but the difference in bacterial species in the regional disparity is unknown. The purpose of this study was to explore the influence of tropical and nontropical regions on bacterial species and clinical outcomes for diabetic hand. Patients and Methods: A systematic literature review was conducted using PubMed, EMBASE, Web of Science, and Google Scholar. Moreover, the bacterial species and clinical outcomes were analyzed with respect to multicenter wound care in China (nontropical regions). Results: Both mixed bacteria (31.2% vs. 16.6%, p=0.014) and fungi (7.5% vs. 0.8%, p=0.017) in the nontropical region were significantly more prevalent than those in the tropical region. Staphylococcus and Streptococcus spp. were dominant in gram-positive bacteria, and Klebsiella, Escherichia coli, Proteus and Pseudomonas in gram-negative bacteria occupied the next majority in the two regions. The rate of surgical treatment in the patients was 31.2% in the nontropical region, which was significantly higher than the 11.4% in the tropical region (p=0.001). Although the overall mortality was not significantly different, there was a tendency to be increased in tropical regions (6.3%) compared with nontropical regions (0.9%). However, amputation (32.9% vs. 31.3%, p=0.762) and disability (6.3% vs. 12.2%, p=0.138) were not significantly differentbetween the two regions. Conclusion: Similar numbers of cases were reported, and the most common bacteria were similar in tropical and nontropical regions in patients with diabetic hand. There were more species of bacteria in the nontropical region, and their distribution was basically similar, except for fungi, which had differences between the two regions. The present study also showed that surgical treatment and mortality were inversely correlated because delays in debridement and surgery can deteriorate deep infections, eventually leading to amputation and even death.

Improvement in Protective Sensation: Clinical Evidence From a Randomized Controlled Trial for Treatment of Painful Diabetic Neuropathy With 10 kHz Spinal Cord Stimulation.

BACKGROUND: Painful diabetic neuropathy (PDN) can result in the loss of protective sensation, in which people are at twice the likelihood of foot ulceration and three times the risk of lower extremity amputation. Here, we evaluated the long-term effects of high-frequency (10 kHz) paresthesia-independent spinal cord stimulation (SCS) on protective sensation in the feet and the associated risk of foot ulceration for individuals with PDN. METHODS: The SENZA-PDN clinical study was a randomized, controlled trial in which 216 participants with PDN were randomized to receive either conventional medical management (CMM) alone or 10 kHz SCS plus CMM, with optional treatment crossover after 6 months. At study visits (baseline through 24 months), 10-g monofilament sensory assessments were conducted at 10 locations per foot. Two published methods were used to evaluate protective sensation via classifying risk of foot ulceration. RESULTS: Participants in the 10 kHz SCS group reported increased numbers of sensate locations as compared to CMM alone (P < .001) and to preimplantation (P < .01) and were significantly more likely to be at low risk of foot ulceration using both classification methods. The proportion of low-risk participants approximately doubled from preimplantation to 3 months postimplantation and remained stable through 24 months (P ≤ .01). CONCLUSIONS: Significant improvements were observed in protective sensation from preimplantation to 24 months postimplantation for the 10 kHz SCS group. With this unique, disease-modifying improvement in sensory function, 10 kHz SCS provides the potential to reduce ulceration, amputation, and other severe sequelae of PDN. TRIAL REGISTRATION: The SENZA-PDN study is registered on ClinicalTrials.gov with identifier NCT03228420.

Current Status and Principles for the Treatment and Prevention of Diabetic Foot Ulcers in the Cardiovascular Patient Population: A Scientific Statement From the American Heart Association.

Despite the known higher risk of cardiovascular disease in individuals with type 2 diabetes, the pathophysiology and optimal management of diabetic foot ulcers (DFUs), a leading complication associated with diabetes, is complex and continues to evolve. Complications of type 2 diabetes, such as DFUs, are a major cause of morbidity and mortality and the leading cause of major lower extremity amputation in the United States. There has recently been a strong focus on the prevention and early treatment of DFUs, leading to the development of multidisciplinary diabetic wound and amputation prevention clinics across the country. Mounting evidence has shown that, despite these efforts, amputations associated with DFUs continue to increase. Furthermore, due to increasing patient complexity of management secondary to comorbid conditions, such as cardiovascular disease, the management of peripheral artery disease associated with DFUs has become increasingly difficult, and care delivery is often episodic and fragmented. Although structured, process-specific approaches exist at individual institutions for the management of DFUs in the cardiovascular patient population, there is insufficient awareness of these principles in the general medicine communities. Furthermore, there is growing interest in better understanding the mechanistic underpinnings of DFUs to better define personalized medicine to improve outcomes. The goals of this scientific statement are to provide salient background information on the complex pathogenesis and current management of DFUs in cardiovascular patients, to guide therapeutic and preventive strategies and future research directions, and to inform public policy makers on health disparities and other barriers to improving and advancing care in this expanding patient population.

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update).

AIMS: Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. MATERIALS AND METHODS: We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability. RESULTS: For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice. CONCLUSION: These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

Microbiome of limb-threatening diabetic foot ulcers indicates the association of fastidious Stenotrophomonas and major amputation.

BACKGROUND: Proper identification of the polymicrobial microorganisms in patients with limb-threatening diabetic foot ulcers (LTDFUs) using conventional culture is insufficient. This prospective study evaluates the potential value of adjuvant molecular testing assisting in identify fastidious micro-organisms in LTDFUs compared to standard treatment alone. METHODS: Ninety patients with LTDFUs received interdisciplinary and standard antibiotic treatment in a referral diabetic foot center. A simultaneous 16S amplicon sequencing (16S AS) specimen along with conventional culture collected at admission was used to retrospectively evaluate the microbiological findings and its association with amputation outcomes. RESULTS: The microorganism count revealed by 16S AS overwhelmed that of conventional culturing (17 vs. 3 bacteria/ulcer respectively). The Stenotrophomonas spp. revealed in 29 patients were highly correlated with major (above ankle) amputation (OR: 4.76, 95% CI 1.01-22.56), while only one had been concomitantly identified by conventional culturing. Thus, there were 27 cases without proper antibiotics coverage during treatment. CONCLUSIONS: Adjuvant molecular testing assisted identification of fastidious pathogens such as Stenotrophomonas infection and might be associated with major amputation in patients with LTDFUs.

Reliability of an AI-Powered Application Across Different Mobile Devices for Assessment of Chronic Wounds.

Objective: Evaluate the inter- and intrarater reliability of a wound assessment tool in iPhone 12 and 13 mini modalities against a validated iPad mini/Structure Sensor configuration. Approach: We assessed a wound measurement application (eKare inSight®) for result consistency in patients presenting with wounds. Assessments were analyzed using a two-way analysis of variance. Intraclass correlation coefficient (ICC) was computed for intrarater (ICC1,1) and inter-rater (ICC2,1) analysis using a two-way random effects model. Paired t-test assessed the statistical difference between measurement methods. Results: Forty-two lesions were analyzed with surface areas ranging from 0.2 to 23 cm2 (average 4.33 ± 5.44 cm2). A high level of reliability was observed for repeat wound area measurements by the same examiner (ICC1,1 = 0.997) and between examiners with iPhone 13 mini (ICC2,1 = 0.998). There was no significant difference between iPhone 12 and iPad mini/Structure Sensor (p = 0.78) or between iPhone 13 mini and iPhone 12 (p = 0.22). Minimal difference existed between iPhone 13 mini and iPad mini/Structure Sensor (p = 0.049, Cohen's d = 0.01). Innovation: Increased pervasiveness of smartphones in clinical care, coupled with advances in smartphone imaging and machine learning, allows for a potential solution to the problem of fast and accurate wound measurements. The application investigated produces wound measurement results quickly and with demonstrated accuracy. It does not require a calibration sticker or reference marker and allows for automatic wound boundary delineation. Conclusion: The results of this study suggest that a digital planimetry mobile application may offer high levels of reliability across devices and users.