Diagnosis of infection in the foot of patients with diabetes: A systematic review.

BACKGROUND: Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS: In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS: We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS: The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Interventions in the management of diabetes-related foot infections: A systematic review.

The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections from 30 June 2018 to 30 June 2022. We combined this search with our previous literature search of a systematic review performed in 2020, in which the infection committee of the International Working Group on the Diabetic Foot searched the literature until June 2018. We defined the context of the literature by formulating clinical questions of interest, then developing structured clinical questions (Patients-Intervention-Control-Outcomes) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and methodological quality. Our literature search identified a total of 5,418 articles, of which we selected 32 for full-text review. Overall, the newly available studies we identified since 2018 do not significantly modify the body of the 2020 statements for the interventions in the management of diabetes-related foot infections. The recent data confirm that outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetes-related foot are broadly equivalent across studies, with a few exceptions (tigecycline not non-inferior to ertapenem [±vancomycin]). The newly available data suggest that antibiotic therapy following surgical debridement for moderate or severe infections could be reduced to 10 days and to 3 weeks for osteomyelitis following surgical debridement of bone. Similar outcomes were reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various recent adjunctive therapies, such as cold plasma for infected foot ulcers and bioactive glass for osteomyelitis. Our updated systematic review confirms a trend to a better quality of the most recent trials and the need for further well-designed trials to produce higher quality evidence to underpin our recommendations.

IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

[Innovation Stimulates Development: How to Cope with the Constant Growth in Refractory Diabetic Foot Ulcers].

Diabetic foot ulcers, with an annual incidence as high as 8.1% in China, impose enormous social and economic burdens on diabetic patients, families and society. Substantial progress has been made in China in the work concerning diabetic foot ulcers in the past two decades, and the major amputation rate in patients with diabetic foot ulcers in China has decreased significantly, even though it is still far higher than the level of developed countries in Europe and North America. Therefore, if we are to further improve the diagnosis and treatment of diabetic foot ulcers in China, the only solution lies in reinforced efforts in innovation, including innovations in concepts, models, and technology, and the training of national and provincial-level leading experts in diabetic foot ulcer care. Only in this way, can we further reduce the disability and mortality caused by diabetic foot ulcers in China. We, herein, discussed the importance and necessity of establishing a comprehensive diabetic foot prevention and control system suited to the actual circumstances of China through strengthening innovative research. On that basis, we also reported existing problems and prospects for future development.

Ertapenem versus piperacillin/tazobactam for diabetic foot infections in China: a Phase 3, multicentre, randomized, double-blind, active-controlled, non-inferiority trial.

OBJECTIVES: Few randomized controlled studies have compared antibiotic regimens against diabetic foot infections (DFIs) in Chinese patients. We evaluated the efficacy and safety of ertapenem versus piperacillin/tazobactam for the treatment of DFIs in Chinese patients. METHODS: Patients with moderate to severe DFIs requiring parenteral antibiotics were randomized in a 1 : 1 ratio to receive ertapenem (1.0 g once daily) or piperacillin/tazobactam (4.5 g every 8 h) by 30 min intravenous (iv) infusions for ≥5 days. The primary outcome was favourable clinical response at discontinuation of iv therapy (DCIV). An evaluable-patient population was identified for primary analysis of non-inferiority at -15%. Safety was assessed. ClinicalTrials.gov: NCT01370616. RESULTS: Of 565 patients randomized, 443 patients (ertapenem = 219 and piperacillin/tazobactam = 224) were clinically evaluable for primary analysis. In the clinically evaluable population, the proportions of patients with favourable clinical response at DCIV were 93.6% (205/219) and 97.3% (218/224) in the ertapenem and piperacillin/tazobactam groups, respectively (difference: -3.8%, 95% CI: -8.3%, 0.0%). Ertapenem had a significantly lower favourable clinical response rate (91.5% versus 97.2%, 95% CI for difference: -12.1%, -0.3%) at DCIV in severe DFI patients. In the modified ITT population, 88.8% (237/267) and 90.6% (241/266) of patients in the ertapenem and piperacillin/tazobactam groups, respectively, had favourable clinical responses at DCIV (difference: -1.9%, 95% CI: -7.3%, 3.3%). Microbiological eradications of causative pathogens and adverse events were similar between treatment groups. CONCLUSIONS: Treatment with ertapenem was non-inferior to piperacillin/tazobactam in Chinese patients with DFIs. Ertapenem treatment resulted in a markedly lower rate of clinical resolution in severe DFIs.

Cost of treating diabetic foot ulcers in five different countries.

Most estimates in the literature for the economic cost of treating a diabetic foot ulcer (DFU) are from industrialized countries. There is also marked heterogeneity between the complexity of cases considered in the different studies. The goal of the present article was to estimate treatment costs and costs to patients in five different countries (Chile, China, India, Tanzania, and the United States) for two hypothetical, but well-defined, DFUs at the extreme ends of the complexity spectrum. A co-author, who is a treating physician in the relevant country, was asked to choose treatment plans that represented the typical application of local resources to the DFU. The outcomes were pre-defined as complete healing in case 1 and trans-tibial amputation in case 2, but the time course of treatment was determined by each investigator in a manner that would be typical for their clinic. The costs, in local currencies, for each course of treatment were estimated with the assistance of local hospital administrators. Typical reimbursement scenarios in each country were used to estimate the cost burden to the patient, which was then expressed as a percentage of the annual per capita purchasing power parity-adjusted gross domestic product. There were marked differences in the treatment plans between countries based on the availability of resources and the realities of local conditions. The costs of treatment for case 1 ranged from Int$102 to Int$3959 in Tanzania and in the United States, respectively. The cost for case 2 ranged from Int$3060 to Int$188,645 in Tanzania and in the United States, respectively. The cost burden to the patient varied from the equivalent of 6 days of average income in the United States for case 1 to 5.7 years of average annual income for case 2 in India. Although these findings do not take cost-effectiveness into account, they highlight the dramatic economic burden of a DFU for patients in some countries.

[Clinical characteristics and medical costs of diabetics with amputation at central urban hospitals in China].

OBJECTIVE: To explore the clinical characteristics, medical costs and its influencing factors in diabetics with amputation. METHODS: The data of diabetic amputation for the whole year of 2010 at 39 central municipal Class 3A hospitals all across China were retrospectively analyzed according to a unified protocol, including demographic characteristics, diabetic complications, classification of diabetic foot disease, level and prognosis of amputation and medical costs at hospitals. RESULTS: Among them, 28.2% of all amputated patients or 39.5% of non-traumatic patients were diabetics. There were 313 males and 162 females. The average age and duration of diabetes were (66 ± 12) years and (130 ± 94) months. The level of HbA1c was 8.9% ± 2.4%. Among all amputated diabetics, the concurrent conditions included neuropathy (50.1%), peripheral artery disease (74.8%), nephropathy (28.4%) and retinopathy (25.9%). The patients with foot ulcer at Wagner 4 (50.3%) were more common. Among them, 67.5% had minor amputation with a median hospitalization stay of 33.0 (24.0 - 45.0) days and a medical cost of 26 138 (16 155 - 46 021) yuan RMB. The duration of diabetes, diabetic complications, severity and location of ulcers and amputation level influenced their hospitalization durations and medical costs. CONCLUSION: The patients with diabetes and amputation are elder with more chronic diabetic complications and uncontrolled hyperglycemia. Most of them have complications of local gangrene and require minor amputation at admission. Their hospital stays are longer and medical costs higher significantly correlated with diabetic complications, severity and location of foot ulcers and level of amputations.

[Efficacy of tianmaixiaoke tablets in the treatment of newly diagnosed type 2 diabetes mellitus in China].

OBJECTIVE: To explore the efficacy and influencing factors of chromium picolinate (tianmaixiaoke tablet) in the treatment of newly diagnosed type 2 diabetes mellitus in China. METHODS: A total of 84 outpatients with newly diagnosed type 2 diabetes mellitus visiting 4 hospitals in Beijing were randomly divided into two equal groups: study group receiving tianmaixiaoke tablet 240 mg bid for 24 weeks (n = 42) and control group sitagliptin 100 mg qd for 24 weeks (n = 42). The levels of fasting plasma glucose (FPG), plasma glucose 2 h after meal (PG2 h) and glycated hemoglobin (HbA1c) were detected before and 24 weeks after treatment. The serum levels of chromium and insulin were detected. RESULTS: Study was completed in 76 patients. The serum level of chromium was significantly lower in the diabetes group than in the normal group at baseline ((56 ± 28) µg/L vs (112 ± 21) µg/L, P = 0.00). At 24 weeks after treatment, the levels of HbA1c, FPG and PG2 h decreased while the serum level of chromium increased significantly in both groups. There were 11 patients with changed HbA1c from baseline (ΔHbA1c) ≥ 1% in the study group. At 24 weeks after treatment, HbA1c decreased by 1.61% (from 8.38% ± 0.72% to 6.77% ± 0.62%) and serum level of chromium increased by 35.14 µg/L in the ΔHbA1c ≥ 1% group with a low baseline serum level of chromium ((36.2 ± 18.0) µg/L). Both study group and control group were divided into three subgroups according to baseline serum level of chromium. ΔHbA1c reduced with the increase in baseline serum level of chromium in study group, while in control group, ΔHbA1c was unrelated with baseline serum level of chromium. At 24 weeks after treatment, insulin resistance index (HOMA-IR) reduced, ß cell function index (HOMA-ß) and insulinogenic index (IGI) increased in both groups. Multiple linear regression showed that the variables significantly associated with ΔHbA1c were baseline HbA1c and the baseline serum level of chromium. CONCLUSIONS: Chromium is commonly deficient in the newly diagnosed type 2 diabetics in China. HbA1c decreases and serum chromium increases significantly after chromium supplementation in the patients with a low baseline serum level of chromium.

[Association of a high ankle brachial index with microvascular diseases of diabetes].

OBJECTIVE: To evaluate the association of a high ankle brachial index (ABI) with microvascular diseases of diabetes and to compare its strength with that of a low ABI. METHODS: ABI was obtained in 3293 patients undergoing the screening of chronic complications at the Diabetic Center, No. 306 Hospital of PLA during the period of September 2003 to June 2010. The patient profiles and laboratory data were reviewed. The associations of ABI with microvascular diseases of diabetes were determined by univariate and stepwise Logistic regression analysis. RESULTS: ABI was normal in 3060 patients. 44 had ABI measurements < 0.7, 139 had ABI measurements between 0.7 - 0.9, and 50 had ABI measurements > 1.3. Multivariate analysis indicated that the factors significantly associated with a high ABI were smoking (OR: 2.605; 95%CI: 1.458 - 4.656, P = 0.001) and systolic blood pressure (OR: 1.019; 95%CI: 1.005 - 1.033, P = 0.006). The conditions of nephropathy, neuropathy and retinopathy were not associated with a high ABI. CONCLUSION: Diabetics with a high ABI carry not more adverse atherosclerotic risk factors and suffer no more severe microvascular diabetic complications than those with a normal ABI.

[Postprandial glycemic control using insulin aspart with NPH in inadequately controlled diabetics].

OBJECTIVE: To compare the efficacy and safety of insulin aspart (IAsp) and human insulin (HI) when applied as meal-time insulin with neutral protamine Hagedorn insulin (NPH) at bedtime in diabetics. METHODS: A total of 220 Chinese subjects with type 1 or type 2 diabetes from 5 different hospitals were randomized by a ratio of 1:1 into two groups accepting IAsp or HI combined with NPH respectively. The main endpoints were assessed by fasting plasma glucose (FPG), 2 hour postprandial plasma glucose (2 h PPG), HbAlc and hypoglycemia. RESULTS: A greater reduction in mean 2 h PPG was achieved in the IAsp group [(14.6 +/- 5.3) mmol/L] as compared with the HI group [(8.4 +/- 4.1) mmol/L] (P < 0.01, adjusted for baseline value, center effect and diabetes type). Significantly more IAsp-treated subjects reached the 2 h PPG target (50.0% vs 25.5%, P < 0.01). HbA1c was reduced more in IAsp/NPH group [(9.3 +/- 1.4)% vs (7.7 +/- 1.3)%] than in HI/NPH group [(9.2 +/- 1.2)% vs (7.7 +/- 1.2)%]. HbA1c target was reached by 24.5% (IAsp) vs 14.5% (HI) of subjects (P < 0.05). No major hypoglycemia or serious adverse events were observed for the IAsp group. Lower incidence of nocturnal hypoglycemia (IAsp/NPH: 3% vs HI/NPH: 4%) was reported in the IAsp group. Average daily insulin doses were 0.60/0.23 (IAsp/NPH) and 0.65/0.24 (HI/NPH) IU/kg respectively. CONCLUSION: Treatment of IAsp in basal-bolus therapy in combination with NPH provides a superior postprandial glucose control and allows more subjects to reach the glycemic target without elevating the nocturnal hypoglycemic risk or adverse events.

[Features of insulin secretion and insulin resistance in newly diagnosed type 2 diabetes of different body mass indices].

OBJECTIVE: To investigate insulin secretion function and insulin resistance in Chinese newly diagnosed type 2 diabetes (obese and non-obese patients) in order to provide evidence for clinical treatment. METHODS: 408 newly diagnosed type 2 diabetes and 40 normal controls were recruited. Height, weight were measured, insulin and glucose of 0 min, 30 min, 60 min, 120 min during oral glucose tolerance test were examined. The patients with fasting glucose level greater than 8.3mmol/L were treatment with Gliclazide for 1 - 3 months. After normalization of the plasma glucose levels for more than 2 weeks, and withdraw this medication for 48 hours, then OGTT were repeated to assess IR and IS. RESULTS: The patients were divided into four groups based on fasting plasma glucose (DM1: FPG < 6.9mmol/L; DM2: 6.9 mmol/L < or = FPG < 8.3 mmol/L; DM3: 8.3 mmol/L < or = FPG < 9.7 mmol/L; DM4: FPG > or = 9.7 mmol/L). Every groups were further stratified to subgroups by cut point of BMI = 24 kg/m(2). Their insulin sensitivity and insulin secretion function compared between subgroups. (1) True insulin level in BMI > or = 24 (FPG < 6.9 mmol/L) subgroups were higher than control's (3.5 +/- 0.5 vs 3.2 +/- 0.6 natural logarithm) (P < 0.05). (2) In BMI > or = 24 subgroups, their insulin sensitivity were even worse than BMI < 24 groups', but their insulin secretion function were better at the same FPG level. (3) After intervention, the change of insulin sensitivity in BMI < 24 group was better than BMI > or = 24 group's (-4.7 +/- 0.9 vs -5.5 +/- 1.4 natural logarithm) (P < 0.05); but the change of insulin secretion function in BMI < 24 group was worse. CONCLUSION: (1) In newly diagnostic type 2 diabetes, insulin sensitivity and insulin secretion function were decreased with the increase of FPG, but they were different between obese and non-obese group. (2) Insulin secretion function was recovered better in obese group when eliminated glucose toxicity.

Prevalence and risk factors of peripheral arterial disease in diabetic patients over 50 years old in China.

OBJECTIVE: To investigate the prevalence of peripheral arterial disease (PAD) in China type 2 diabetic patients and to demonstrate the relationships between putative risk factors and PAD. METHODS: In total 1,397 type 2 diabetic patients aged 50 years and older were enrolled and determined ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) in 15 Class III Grade A hospitals in 7 major cities of China. RESULTS: Mean patient age was 63.7 +/- 8.2 years and mean duration of diabetes mellitus was 9.39 +/- 7.4 years. Two hundreds and seventy-two (19.47%) patients were diagnosed as PAD by ABI < 0.9, 122 (18.37%) in male and 150 (20.46%) in female. PAD patients had a significantly longer duration of diabetes mellitus, higher hemoglobin A1c, and a significantly lower mean body mass index than non-PAD ones. Aging, smoking, and systolic blood pressure were found to be positively related with the prevalence of PAD. In terms of lipid profiles, no variable was found to relate with PAD. Notably, baPWV showed as the same significant guiding index for PAD, almost matched with ABI. CONCLUSIONS: PAD is a common complication in China type 2 diabetic patients. Therefore, PAD screening and treatment should be emphasized for diabetic patients with high risk factors.

[The medical cost of diabetic patients with foot problems due to peripheral artery disease].

OBJECTIVE: To investigate the medical cost of diabetic patients with foot problems and peripheral artery disease. METHODS: Type 2 diabetic patients with foot problems admitted into the endocrinology departments of 14 teaching hospitals from Jan. 1 to Dec. 31, 2004 were surveyed for their type and phase of foot ulcers, diabetic complications, medical cost and general personal characteristics. RESULTS: The average medical cost of the hospitalization of these patients was RMB yen 14,906 +/- 7072 (about US $ 1640 +/- 873); medication and examination cost was separately 56% and 19% of the total cost. There was obviously higher medical cost for these patients with longer diabetes duration of over 20 years and with the occupation of laborer and retired worker. Patients with kidney disease had significantly higher medical cost than those without (RMB yen 11 690.7 vs yen 9493.0; P = 0.0013), even if the hospital stay was nearly the same (21 days vs 20 days). The medical cost increase with the severity of diabetic foot problems based on the classification of Wagner System or Texas System. Patients with infection, ischemic foot and gangrene foot stayed in the hospitals longer and had much higher medical cost. CONCLUSION: The medical cost is higher for diabetic patients with foot problems and is related with the presence of complicating kidney disease, infection and ischemia as well as the severity of foot ulcers.

[A multicenter survey on the diabetic foot and its neuropathy in China].

OBJECTIVE: To investigate the characteristics of diabetic foot with neuropathy and its related factors. METHODS: 530 out- and in-patients in 14 grade A class 3 comprehensive hospitals in China with foot problems were surveyed. 337 of the 500 patients (63.58%) suffered from neuropathy, 172 (32.45%) with diabetic foot with simple neuropathy and 165 (31.13%) with simple neuropathy combined with peripheral artery disease (PAD). 193 of the 500 patients (36.42%) suffered from peripheral artery disease (PAD). 77.7% of ulcer were caused by physical factors. Questionnaire survey was conducted to collect the demographic data, present and past history, history of the hyperglycemia and lipid disorders, classification and phases of the foot ulcers based on Wagner' system and Texas system, characteristics of neuropathy and other diabetic complications, and relative risk factors. Detailed physical examination was performed, including 10 g nylon filament sensation examination. RESULTS: The duration of diabetic foot of the patients with simple neuropathy was 3 (1, 60) months, significantly shorter than that of the diabetic foot patients with PAD [5 (1, 96) months, P < 0.001]. The Wagner degree of ulcer was related to the duration of diabetes, economic income, foot deformity, nerve reflection, diapason vibration sensation of foot, sensation point of 10 g nylon filament, ankle/brachial index (ABI), foot artery pulse, fasting blood sugar (FBS) and glycated hemoglobin (HbA1c). Stepwise regression analysis revealed that ABI of left posterior tibial artery, vibration detection threshold and economic income were the most significant influencing factors of the degree of ulcer. CONCLUSION: Neuropathy ulcer is common in diabetic foot patients. The prognosis of healing in diabetic foot with neuropathy is prior to that of diabetic foot with PAD. The neuropathy and PAD of foot influence each other and aggravate the condition of diabetic foot. The examinations of diapason vibration sensation of foot, sensation point of 10 g nylon filament, and Achilles tendon reflex are simple and practical, and are worth recommending.

[Analysis of peripheral arterial obstructive disease related factors among diabetic population aged > or = 50].

OBJECTIVE: To analyze the peripheral arterial obstructive disease (PAD) related factors among diabetic population aged > or = 50 in China. METHODS: The clinical data of 1397 diabetic patients aged > or = 50 with at least one of the following risk factors: smoking, hypertension, and hyperlipidemia, from 15 Class III Grade A hospitals in 7 major cities of China were collected. Diagnosis of PAD was based on the ankle brachial index (ABI) < 0.9, and diagnosis of arteriosclerosis was based on pulse wave velocity (PWV) > 1400 cm/s. Regression studies were made to analyze the relations among PAD and various risk factors: age, sex, body mass index (BMI), smoking, hypertension, hyperlipidemia, history of cerebral vascular disease (CVD), history of ischemia heart disease (IHD) etc. RESULTS: The current prevalence rate of PAD was 19.47% among the 1397 patients, 18.3% (122/664) among the male patients, and 20.4% (150/733) among the female patients. The prevalence of PAD in the patients aged > or = 70 was as high as 31.9%. The duration of diabetes course was positively correlated with the prevalence of PAD (chi2 = 11.9, P = 0.0026). The ABI abnormality rate was 15.78% among those with a diabetic course of 5 years and was 23.84% among those with a diabetic course of 10 years. The abnormal ABI rate of the patients with CVD was 30.57%, significantly higher than that of hose without CVD (17.29%, chi2 = 21.49, P < 0.0001). The abnormal ABI rate of the patients with IHD was 24.64%, significantly higher than that of the patients without IHD (18.20%, chi2 = 5.85, P = 0.0155). The HbA1c value of the PAD patients was significantly higher than that of the patients without PAD (chi2 = 5.10, P = 0.0239) Odd risk analysis showed that age increase of 10 years increased the PAD risk by 1.64 times (OR = 1.6444, P = 0.0001). The PAD risk of the smokers was 1.68 times higher than that of the non-smokers (OR = 1.6852, P = 0.0001). Increase of 10 mm Hg in systolic blood pressure (SBP) increased the PAD risk by 1.19 times (OR = 1.1926, P = 0.01). The PAD risk of the patients with abnormal HbAlc was 2.44 times higher than that of the patients with normal HbA1c (OR = 2.4473, P = 0.0001). One-year's increase of the hypertension course increased the PAD risk by 1.02 times (OR = 1.0194, P = 0.03). Logistic analysis indicated that the relations among PWV and the risk factors were almost the same among ABI abnormality and the risk factors. CONCLUSION: Approximately one fifth of diabetic patients aged > or = 50 in China suffer from PAD. Age, course of diabetes, blood glucose level, SBP, IHD, and CVD are risk factors for PAD. Early intervention and treatment of hypertension and hyperglycemia, and quitting smoking are important in reducing the occurrence of PAD. ABI and PWV are not only diagnostic means for PAD, but also alarm guide indexes for cerebral vascular disease (CVD).

[Differences in risk factors of diabetic foot in the patients in South and North China].

OBJECTIVE: To investigate the differences on the diabetic foot problems and its risk factors in south and north of China. METHODS: Patients with foot problems were surveyed from January 1 to December 31, 2004 in 14 teaching hospitals located in different cities in China, including demographic data, present and past history of the foot problems and peripheral artery disease (PAD), the classification of the foot ulcers based on the Wagner' system, control of the hyperglycemia and lipids disorder, medical cost in hospital and the diabetic complications. All the patients were divided into two groups due to their geographical data, south and north. RESULTS: There were 285 and 349 patients for the group south and group north. No significant differences were found for duration of diabetes or foot problems, fasting or post-meal glucose, total cholesterol, triglycerides, HDL-C, and the numbers of patients with smoke, hypertension, nephropathy or neuropathy between the two groups. There were significant differences for the age (70 yrs vs 66 yrs), percentage of the patients with average person income with over RMB 1000 per month (57.7% vs 45.6%), coronary heart disease (42.6% vs 61.0%) and retinopathy (35.7% vs 49.5%), HbA1c (7.90% vs 8.80 %), LDL-C (2.75 mmol/L vs 2.98 mmol/L), WBC (6.70 x 10(9) vs 7.40 x 10(9)/L), HCT (0.37 vs 0.38), creatinine (87 micromol/L vs 76 micromol/L) and uric acid (333 mmol/L vs 271 mmol/L), and amputation rate (2.6% vs 9.7%) between south and north groups. Logistic analysis showed that severity of the foot problems was associated with ABI and WBC in south group, and with ABI, PLT and HCT in north group. CONCLUSION: Diabetic foot problems were more severe, with more risk factors and with more medical cost in north patients.

Prevalence of dyslipidemia and its control in type 2 diabetes: A multicenter study in endocrinology clinics of China.

OBJECTIVE: The aim of this study was to assess the levels of serum lipid and awareness, treatment, and control of dyslipidemia in type 2 diabetes mellitus (T2DM) patients from top-ranked endocrinology clinics in large cities of China. MATERIALS AND METHODS: A cross-sectional study in a representative sample of 4807 Chinese adults 40 to 75 years of age was conducted during 2010 to 2011 at 20 endocrinology clinics in top-ranked hospitals covering most of the major cities of China. Serum lipid levels were measured, and treatment of dyslipidemia was recorded and assessed. RESULTS: In the present study, the prevalence of dyslipidemia was 67.1% in T2DM subjects. Among those with dyslipidemia, the proportion of awareness and treatment was 68.7% and 55.9%. Among participants with lipid-lowering therapy, 686 subjects achieved the low-density lipoprotein cholesterol (LDL-C) control less than 2.60 mmol/L, with the rate being 39.4%. In those patients with previous cardiovascular disease, the percentage of participants who achieved LDL-C goal (1.80 mmol/L) was 15.3%. CONCLUSION: The prevalence of dyslipidemia is high, and the awareness, treatment, and control of dyslipidemia are relatively low in Chinese T2DM patients. This calls for the awareness and intervention of dyslipidemia in these patients.