SOJ Cardiology and Current Trends in Surgery

Diabetic foot ulcers (DFUs) remain difficult to heal and notoriouslytend to relapse, approximately 40% at 1 year and 65% at 5years.¹ In this context, progress is needed in 6 areas:

Improved early diagnosis of neuropathy

Early diagnosis of diabetic polyneuropathy (DPN) is importantfor several reasons.1,2 First, careful and regular medical follow-upshould be offered to avoid neuropathic DFUs.^1,2 Secondly, optimisedglycaemic control and correction of other vascular risk factors (e.g.hypertension, dyslipidaemia etc) should be diligently pursued.^1,2Finally, daily foot hygiene and appropriate footwear are indispensable.¹ A number of practical bedside clinical tools contribute toimproved early diagnosis, such as the indicator test Neuropad assessingsweat production in the feet, Vibra Tip, the portable NC-statDPN Check device and others.² Neuropad has been extensively studiedand confirmed as an excellent, highly reproducible and practicalscreening tool with very high sensitivity and negative predictivevalue for DPN, which renders itself even for patient self-examination.2 Vibra Tip is a pocket-sized portable device which measuresvibration perception at the hallux, whose diagnostic utility has recentlybeen confirmed.³ NC-stat DPN Check is a special device forautomated nerve conduction study of the sural nerve, which maybe used by all health care professional after minimal training.² Wehave shown that it yields very high diagnostic performance (sensitivity,specificity, positive and negative predictive value) in bothdiabetes types.^4,5

Improved early identification of patients at high risk

Dryness of foot skin, as assessed by the indicator test Neuropad,has very recently been identified as an independent predictorof foot ulceration at 5 years.⁶ To this important purpose, the testyielded high sensitivity (86%) but low specificity (49%).⁶ Widerutilisation of this new screening tool is expected and should be encouraged.

Improved detection and appreciation of Ischaemia

Peripheral arterial disease (PAD) is common and may be formidablein diabetes mellitus⁷. Ankle brachial index (ABI) is widely employed,yet it may not detect distal but clinically relevant ischaemia.The latter, as demonstrated in a recent study, may more reliably beidentified by the toe brachial index (TBI) in subjects with DFUs.⁷Using arterial waveforms as a reference method, TBI had a higherAUC (area under the curve of the receiver operating characteristiccurve) than ABI, suggesting that it can detect PAD even if ABIis normal.⁷ These findings may prove useful and lead to change ofdiagnostic work-up and guidelines.

Improved organisation of diabetic foot clinics

Modern diabetic foot clinics need to be re-organised to copewith the increasing burden of DFUs.⁸ Expert multidisciplinary careneeds to be offered more quickly, especially in complex situationsor multi-morbid patients.⁸ Timely debridement and administrationof broad spectrum antibiotics, as well as urgent correction of ischaemiawhen needed, are of paramount importance in this endeavour.^9,10 Limb-threatening Ischaemia and extensive infection withgangrene represent real emergencies, for which care should be offeredas quickly as for stroke or myocardial infarction.¹⁰ This holdsespecially true for subjects with end-stage renal disease, in whomfoot outcomes are, generally, more sinister.¹¹

Improved use of new/adjunctive modalities

New therapeutic modalities are still being sought. Among these,hyperbaric oxygen therapy (both systemic and, more recently, local) may improve wound healing in selected subjects with ischaemia.^12–14 Improving nutrition is also thought to promote healingof DFUs.¹⁵ A well-balanced diet and healthy food habits under dieteticconsultation contribute to improve healing.¹⁵

Another issue relates to chronic administration route for antibiotics.Intravenous use is less practical and may require prolongedhospitalisation, increasing health costs. A recent trial has shownthat switch to oral antibiotics after a brief initial intravenous therapyis equally efficacious as long-term intravenous administration.¹⁶

In terms of wound care, several materials are considered asdressings for DFUs. One of these is sucrose octasulfate dressing.¹⁷This has been shown safe and superior to standard wound care inhealing of neuroischaemic DFUs at 20 weeks.¹⁷

A more recent approach is the use of adipose-derived mesenchymalcells (AMSCs) to enhance angiogenesis in subjects withdiabetes and PAD.¹⁸ Experimental evidence suggests that AMSCsenhance wound healing, accelerate granulation tissue formationand increase re-epithelialisation and neovascularisation. However,clinical trials are needed before its efficacy can be fully delineated.¹⁸

COVID-19 and its effects on diabetic foot care

In the face of the new COVID-19 pandemic, a shift towards outpatientconsultation and therapy emerged during the lockdown.^19–21Thus, a careful quick and reliable triage utilising telemedicine becamenecessary.^19-21 In Italy,¹⁹ USA²⁰ and UK,²⁰ this has been shownto be feasible and achieve very satisfactory outcomes. Hospitalisationbegan to be reserved for complicated ulcers (severe infection,ischaemia, deep to bone ulcers etc).^19,20 In hospitalised patients,treatment strategy should be determined by the urgency of surgicalintervention and the complexity of DFUs.^20–22 To help re-organisationof foot care and to standardise procedures, treatment algorithmshave already been proposed.^22,23 These appear useful andneed further utilisation in expert centres.

DFUs still represent a daily therapeutic challenge.1 Progress isneeded to improve diagnostic and therapeutic priorities.2 The situationis aggravated in the COVID-19 era,21 which has made telemedicineindispensable20 and emphasised the need for urgent andwell-co-ordinated care.

None.

None.

Author declares that there is no conflict of interest.

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