Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study.

AIM: This study was an analysis of how diabetic patients with infected foot wounds are managed in hospital by departments specializing in diabetic foot pathology, including an evaluation of the outcome 1 year after discharge. METHODS: This was a prospective study of a cohort of patients hospitalized for diabetic foot infection at 38 hospital centres in France and followed-up for 1 year after discharge. RESULTS: Altogether, 291 patients were included (73% male; 85% type 2 diabetes; mean age: 64.3±11.7 years). Most of the wounds were located on the toes and forefoot, and infection was most often graded as moderate; nevertheless, in about 50% of patients, osteomyelitis was suspected. Also, 87% of patients had peripheral neuropathy and 50-62% had peripheral artery disease. Gram-positive cocci, and Staphylococcus aureus in particular, were by far the most frequently isolated microorganisms. During hospitalization, lower-limb amputation was performed in 35% of patients; in 52%, the wound healed or had a favourable outcome. A year after discharge, 150 non-amputated patients were examined: at this time, 19% had to undergo amputation, whereas 79% had healed their wounds with no relapse. Risk factors for amputation were location (toes), severity of the wound and presence of osteomyelitis. Peripheral artery disease was associated with a poor prognosis, yet was very often neglected. CONCLUSION: In spite of being managed at specialized centres that were, in general, following the agreed-upon published guidelines, the prognosis for diabetic foot infection remains poor, with a high rate (48%) of lower-limb amputation.

[Physiopathology of the diabetic foot]. / Physiopathologie du pied diabétique.

Diabetic foot ulcerations result from different physiopathological mechanisms; a clear understanding of them is crucial to reduce their incidence, provide early care, and finally delay the amputation risk. The three main diabetes complications involved in foot ulcerations are neuropathy, peripheral arterial disease, and infection. The most common pathway to ulceration is peripheral sensorimotor and autonomic neuropathy, leading to loss of sensitivity, foot deformities, high foot pressure, and dry skin. Peripheral arterial disease is more frequent and more serious in the diabetic population. It delays cicatrization and causes gangrene and finally amputation. Infection is also a major complication of ulceration because of its risk of spreading into deep tissue and bone, which increases the risk of amputation. Infection may also generalize and become life-threatening. These complications preferentially affect the foot because it is exposed to hyper pressure, neuropathy, and peripheral arterial disease, which cause distal lesions, and the foot is exposed to a closed atmosphere, a source of soaking and skin frailty. Diabetes itself may enhance the risk of complications stemming from the disease's long-term progression and poor glucose control, thereby affecting ocular and renal functions. Finally, some psychosocial situations such as depression syndrome or poor hygiene possibly enhance diabetic foot occurrence.

Factors associated with diabetic patients at high risk for foot ulceration.

In order to define risk factors for foot ulcers, associated with the major contributing factors (peripheral sensorimotor neuropathy, peripheral vascular disease, altered foot biomechanics and history of foot ulceration or lower limb amputation), a multivariate analysis was performed in 446 patients free from foot ulceration. Four significant risk factors for foot ulcers have been identified: retinopathy, poor psychosocial status, hyperkeratosis, and diabetes duration. A relation was present between the probability of belonging to the high-risk groups and the number of associated factors. This study points out to the importance of screening especially in case of diabetes of long duration, with microvascular complications, and in socially-deprived people.

Screening diabetic patients at risk for foot ulceration. A multi-centre hospital-based study in France.

BACKGROUND: To determine the prevalence of risk factors for diabetic foot ulceration in diabetic patients free of active pedal ulceration in a hospital setting. METHODS: In sixteen French diabetology centres, a survey was conducted on a given day in all diabetic people attending the units, both as in- or out-patients. RESULTS: 664 patients were evaluated: 105 had an active foot ulcer and were excluded from the analysis as were four other patients due to lack of reliable data. From the 555 assessable patients, 40 (7.2%) had a history of foot ulcer or lower-limb amputation. Sensory neuropathy with loss of protective sensation, as measured by the 5.07 (10 g) Semmes-Weinstein monofilament testing, was present in 27.1% of patients, whereas 17% had a peripheral arterial disease mainly based on the clinical examination. On addition, foot deformities were found in 117 patients (21.1%). According to the classification system of the International Working Group on the Diabetic Foot, 72.8% of patients were at low-risk for pedal ulceration (grade 0) and 17,5% were in the higher-risk groups (grade 2 & 3). If patients with isolated peripheral arterial disease were considered as a separate risk group (as was those with isolated neuropathy), percentage of low-risk patients decreased to 65.6%. There was a clear trend between the increasing severity of the staging and age, duration of diabetes, prevalence of nephropathy and retinopathy. CONCLUSIONS: Prevalence of risk factors for foot ulceration is rather high in a hospital-based diabetic population, emphasising the need for implementing screening and preventive strategies to decrease the burden of diabetic foot problems and to improve the quality of life for people with diabetes.

MR imaging of osteomyelitis and neuropathic osteoarthropathy in the feet of diabetics.

Distinguishing between osteomyelitis and neuropathic osteoarthropathy of the foot frequently presents a clinical and radiologic challenge in patients with diabetes. Magnetic resonance (MR) imaging was performed in 26 diabetic patients to observe changes in signal intensity in the complicated diabetic foot. In every patient with osteomyelitis (n = 13), signal intensity abnormalities were seen within the bone marrow (low signal intensity on T1-weighted images and high signal intensity on T2-weighted images in 12 cases). Most of these patients had cortical lesions (n = 9) or associated soft-tissue infection (n = 12). Normal bone marrow signal intensity was observed in three of the four patients without osteomyelitis. Characteristic MR imaging findings (decreased signal intensity in bone marrow regardless of pulse sequence) were seen in patients with chronic neuropathic osteoarthropathy (n = 7), who were easily distinguished from patients with osteomyelitis. Conversely, in patients with acutely evolving neuropathic osteoarthropathy (n = 2), signal intensity changes within the bone marrow were similar to those observed in osteomyelitis, leading to potential diagnostic pitfalls. Familiarity with MR imaging findings observed in osteomyelitis and neuropathic osteoarthropathy can help identify these two entities, allowing early diagnosis and appropriate therapy.

A micromethod for the evaluation of hemoglobin A1c: technique and preliminary results.

A microtechnique of column chromatography on a Biorex 70 resin monitored by permanent recording of the effluent o.d., permits to obtain the percent of Hb A1C in an hemolyzate within 1.5 hr (in the place of 6 hrs in the usual techniques). This evaluation was carried out in 18 normal subjects and 32 patients suffering from diabetes mellitus and was repeated several times in 10 patients. The average level in the normal subjects was 5.01% (3.2 to 6.1%), in the equilibrated patients with a glycemia under 2 g/l: 6.44% (5.74 to 7.14%) and in the poorly equilibrated patients: 8.9% (5.5 to 15.3%). Hemoglobin A1C appears as a valuable index of sugar metabolic equilibrium.