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Wound assessment, imaging and monitoring systems in diabetic foot ulcers: A systematic review

Abstract

Patients with diabetes mellitus have a lifetime risk of 15% to 25% of developing diabetic foot ulcers (DFUs). DFU is associated with significant morbidity and mortality. Wound imaging systems are useful adjuncts in monitoring of wound progress. Our study aims to review existing literature on the available wound assessment and monitoring systems for DFU. This is a systematic review of articles from PubMed and Embase (1974 – March 2020). All studies related to wound assessment or monitoring systems in DFUs were included. Articles on other types of wounds, review articles, and non-English texts were excluded. Outcomes include clinical use, wound measurement statistics, hospital system integration, and other advantages and challenges. The search identified 531 articles. Seventeen full-text studies were eligible for the final analysis. Five modalities were identified: (a) computer applications or hand-held devices (n = 5), (b) mobile applications (n = 2), (c) optical imaging (n = 2), (d) spectroscopy or hyperspectral imaging (n = 4), and (e) artificial intelligence (n = 4). Most studies (n = 16) reported on wound assessment or monitoring. Only one study reported on data capturing. Two studies on the use of computer applications reported low inter-observer variability in wound measurement (inter-rater reliability >0.99, and inter-observer variability 15.9% respectively). Hand-held commercial devices demonstrated high accuracy (relative error of 2.1%-6.8%). Use of spectroscopy or hyperspectral imaging in prediction of wound healing has a sensitivity and specificity of 80% to 90% and 74%to 86%, respectively. Majority of the commercially available wound assessment systems have not been reviewed in the literature on measurement accuracy. In conclusion, most imaging systems are superior to traditional wound assessment. Wound imaging systems should be used as adjuncts in DFU monitoring.

Keywords: artificial intelligence; diabetic foot; mobile applications; wound healing; wounds and injuries.

[Tratto da: pubmed.ncbi.nlm.nih.gov ]

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Mobile technologies to support healthcare provider to healthcare provider communication and management of care

Background

The widespread use of mobile technologies can potentially expand the use of telemedicine approaches to facilitate communication between healthcare providers, this might increase access to specialist advice and improve patient health outcomes.

Objectives

To assess the effects of mobile technologies versus usual care for supporting communication and consultations between healthcare providers on healthcare providers’ performance, acceptability and satisfaction, healthcare use, patient health outcomes, acceptability and satisfaction, costs, and technical difficulties.

Search methods

We searched CENTRAL, MEDLINE, Embase and three other databases from 1 January 2000 to 22 July 2019. We searched clinical trials registries, checked references of relevant systematic reviews and included studies, and contacted topic experts.

Selection criteria

Randomised trials comparing mobile technologies to support healthcare provider to healthcare provider communication and consultations compared with usual care.

Data collection and analysis

We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence.

Main results

We included 19 trials (5766 participants when reported), most were conducted in high‐income countries. The most frequently used mobile technology was a mobile phone, often accompanied by training if it was used to transfer digital images. Trials recruited participants with different conditions, and interventions varied in delivery, components, and frequency of contact. We judged most trials to have high risk of performance bias, and approximately half had a high risk of detection, attrition, and reporting biases. Two studies reported data on technical problems, reporting few difficulties.

Mobile technologies used by primary care providers to consult with hospital specialists

We assessed the certainty of evidence for this group of trials as moderate to low.

Mobile technologies:

‐ probably make little or no difference to primary care providers following guidelines for people with chronic kidney disease (CKD; 1 trial, 47 general practices, 3004 participants);

‐ probably reduce the time between presentation and management of individuals with skin conditions, people with symptoms requiring an ultrasound, or being referred for an appointment with a specialist after attending primary care (4 trials, 656 participants);

‐ may reduce referrals and clinic visits among people with some skin conditions, and increase the likelihood of receiving retinopathy screening among people with diabetes, or an ultrasound in those referred with symptoms (9 trials, 4810 participants when reported);

‐ probably make little or no difference to patient‐reported quality of life and health‐related quality of life (2 trials, 622 participants) or to clinician‐assessed clinical recovery (2 trials, 769 participants) among individuals with skin conditions;

‐ may make little or no difference to healthcare provider (2 trials, 378 participants) or participant acceptability and satisfaction (4 trials, 972 participants) when primary care providers consult with dermatologists;

‐ may make little or no difference for total or expected costs per participant for adults with some skin conditions or CKD (6 trials, 5423 participants).

Mobile technologies used by emergency physicians to consult with hospital specialists about people attending the emergency department

We assessed the certainty of evidence for this group of trials as moderate.

Mobile technologies:

‐ probably slightly reduce the consultation time between emergency physicians and hospital specialists (median difference −12 minutes, 95% CI −19 to −7; 1 trial, 345 participants);

‐ probably reduce participants’ length of stay in the emergency department by a few minutes (median difference −30 minutes, 95% CI −37 to −25; 1 trial, 345 participants).

We did not identify trials that reported on providers’ adherence, participants’ health status and well‐being, healthcare provider and participant acceptability and satisfaction, or costs.

Mobile technologies used by community health workers or home‐care workers to consult with clinic staff

We assessed the certainty of evidence for this group of trials as moderate to low.

Mobile technologies:

‐ probably make little or no difference in the number of outpatient clinic and community nurse consultations for participants with diabetes or older individuals treated with home enteral nutrition (2 trials, 370 participants) or hospitalisation of older individuals treated with home enteral nutrition (1 trial, 188 participants);

‐ may lead to little or no difference in mortality among people living with HIV (RR 0.82, 95% CI 0.55 to 1.22) or diabetes (RR 0.94, 95% CI 0.28 to 3.12) (2 trials, 1152 participants);

‐ may make little or no difference to participants’ disease activity or health‐related quality of life in participants with rheumatoid arthritis (1 trial, 85 participants);

‐ probably make little or no difference for participant acceptability and satisfaction for participants with diabetes and participants with rheumatoid arthritis (2 trials, 178 participants).

We did not identify any trials that reported on providers’ adherence, time between presentation and management, healthcare provider acceptability and satisfaction, or costs.

Authors’ conclusions

Our confidence in the effect estimates is limited. Interventions including a mobile technology component to support healthcare provider to healthcare provider communication and management of care may reduce the time between presentation and management of the health condition when primary care providers or emergency physicians use them to consult with specialists, and may increase the likelihood of receiving a clinical examination among participants with diabetes and those who required an ultrasound. They may decrease the number of people attending primary care who are referred to secondary or tertiary care in some conditions, such as some skin conditions and CKD. There was little evidence of effects on participants’ health status and well‐being, satisfaction, or costs.

[Tratto da: www.cochranelibrary.com ]

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Grazie 100.000!

Ebbene sì, siete in 100.000!

Ormai non ci sono parole per ringraziarvi per il supporto e per tutti gli attestati di stima che quotidianamente ci riservate.

Non ci rimane che percorrere questa strada iniziata nel Novembre 2017 (420 articoli ad oggi), con il solito entusiasmo e con qualche novità…

…Grazie lo STAFF

 

Pubblicato il

Ambulatorio Vulnologico Infermieristico

Dal  1° Settembre, è terminata la mia collaborazione professionale, con l’ AMBULATORIO INFERMIERISTICO VULNOLOGICO di Bergamo Sanità.

Un progetto nato in sordina, circa tre anni fa, in accordo con il Presidente dell’ Azienda sopracitata, in un territorio difficile, ma che sin da subito ha apportato: innovazione, qualità assistenziale e intervento multidisciplinare all’ avanguardia.

In regime privato ma a prezzi calmierati visto l’ indigenza dilagante, toccando e scoprendo un argomento ancor oggi sconosciuto a molti, subdolo, silente come le lesioni cutanee.

Ringrazio tutti indistintamente e auguro un futuro florido a questo importantissimo progetto, che perde un collaboratore- referente, ma non l’ importanza sociale per cui nacque.

Grazie IS.

Pubblicato il

Lesioni Tour marchio registrato, progetto che parte dal “basso”…

Terminato l’ iter burocratico di legge, finalmente il progetto LESIONI TOUR è un marchio registrato.

Le Lesioni Da Pressione, sono un problema ancora sconosciuto a molti e la mancanza di sensibilizzazione della popolazione su questo argomento è la principale motivazione di disorientamento di familiari/caregiver, che una volta colpiti, si troveranno ad affrontare la situazione brancolando nel buio con il rischio di commettere errori talvolta fatali.

Il progetto “Lesioni Tour” è nato a fine 2017  dopo un attento studio degli indicatori (natalità-decessi-età media) e qualità di vita della provincia bergamasca paragonati a quelli del territorio italiano e che si pone l’obiettivo di supportare chi si è trovato a convivere con una problematica così seria e si è sentito abbandonato,  mira a tradurre in maniera semplice un argomento complesso come quello delle lesioni cutanee, verranno realizzati dei piccoli spot che conterranno consigli per evitare laddove possibile l’errore e fornire le armi per scegliere la strada migliore per il proprio caro.

Perchè il caregiver è elemento fondamentale per la prevenzione delle lesioni cutanee.

Per l’emergenza COVID19 gli incontri, salvo ulteriori imprevisti riprenderanno nel 2021 con ulteriori novità.

Nel frattempo ringrazio chi ha creduto sin da subito nel progetto.

Per ulteriori informazioni scrivere alla mail: lesionitour@gmail.com

GRAZIE.

 

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The “Balgrist Score” for evaluation of Charcot foot: a predictive value for duration of off-loading treatment

Objective: To develop a new magnetic resonance imaging(MRI) scoring system for evaluation of active Charcot foot and to correlate the score with a duration of off-loading treatment ≥ 90 days.

Methods: An outpatient clinic database was searched retrospectively for MRIs of patients with active Charcot foot who completed off-loading treatment. Images were assessed by two radiologists (readers 1 and 2) and an orthopedic surgeon (reader 3). Sanders/Frykberg regions I-V were evaluated for soft tissue edema, bone marrow edema, erosions, subchondral cysts, joint destruction, fractures, and overall regional manifestation using a score according to degree of severity (0-3 points). Intraclass correlations (ICC) for interreader agreement and receiver operating characteristic analysis between MR findings and duration of off-loading-treatment were calculated.

Results: Sixty-five feet in 56 patients (34 men) with a mean age of 62.4 years (range: 44.5-85.5) were included. Region III (reader 1/reader 2: 93.6/90.8%) and region II (92.3/90.8%) were most affected. The most common findings in all regions were soft tissue edema and bone marrow edema. Mean time between MRI and cessation of off-loading-treatment was 150 days (range: 21-405). The Balgrist Score was defined in regions II and III using soft tissue edema, bone marrow edema, joint destruction, and fracture. Interreader agreement for Balgrist Score was excellent: readers 1/2: ICC 0.968 (95% CI: 0.948, 0.980); readers 1/2/3: ICC 0.856 (0.742, 0.917). A cutoff of ≥ 9.0 points in Balgrist Score (specificity 72%, sensitivity 66%) indicated a duration of off-loading treatment ≥ 90 days.

Conclusion: The Balgrist Score is a new MR scoring system for assessment of active Charcot foot with excellent interreader agreement. The Balgrist Score can help to identify patients with off-loading treatment ≥ 90 days.

Keywords: Charcot foot; Conservative treatment; Diabetic foot; MR imaging; Neuropathic arthropathy.

[ Tratto da: www.pubmed.ncbi.nlm.nih.gov ]

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Uno studio pilota di fattibilità della sospensione cellulare della pelle autologa non coltivata per la guarigione delle ulcere del piede diabetico

È stato condotto uno studio di fattibilità prospettico a braccio singolo per valutare i risultati di guarigione delle DFU trattate con sospensione di cellule cutanee autologhe (ASCS) in combinazione con la terapia standard. Sono state incluse ferite di dimensioni fino a 100 cm 2 che non sono riuscite a guarire con la terapia convenzionale e la guarigione delle ferite, il dolore, i punteggi dell’essudato, la qualità della vita, i punteggi di soddisfazione e gli esiti di sicurezza sono stati valutati per un periodo di 26 settimane. Sono stati arruolati sedici soggetti con una durata media della DFU di 60,4 settimane. Tutte le ulcere in questo studio hanno avuto una traiettoria di guarigione positiva, con una riepitelizzazione media dell’84,9% e 12,2 cm 2riduzione dell’area dell’ulcera. Per le ulcere che non hanno acquisito un’infezione dei tessuti molli dopo il trattamento, tutte sono guarite o hanno raggiunto una riepitelizzazione ≥95%, comprese alcune con tendine esposto. Sono stati osservati miglioramenti in tutti gli aspetti del questionario sulla qualità della vita correlata alla salute e soggetti e medici sono stati molto soddisfatti in tutte le visite post-operatorie. Questo studio preliminare suggerisce che l’ASCS è una terapia ben tollerata e promettente per il trattamento delle DFU poiché tutte le ulcere valutate hanno avuto risultati di guarigione positivi indipendentemente dalle dimensioni, dalla profondità e dalla durata della ferita. Sono necessari studi futuri per indagare l’ASCS rispetto allo standard di cura per tutte le ulcere del piede diabetico, compresa la valutazione degli algoritmi di trattamento e dei prodotti di combinazione. (Registro degli studi clinici n. NCT02799121).

Parole chiave: dispositivo per il prelievo di cellule autologhe; Sospensione autologa delle cellule della pelle; Ferite croniche; Ulcere del piede diabetico.

Questo articolo è protetto da copyright. Tutti i diritti riservati.

[Tratto da: www.pubmed.ncbi.nlm.nih.gov ]

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Il piede diabetico infetto: i biomarcatori sierici possono prevedere l’osteomielite dopo dimissione ospedaliera per infezioni del piede diabetico?

Lo scopo di questo studio è di valutare i biomarcatori sierici per monitorare i pazienti ad alto rischio per la reinfezione delle ossa. Trentacinque pazienti sono stati arruolati in modo prospettico con infezioni da piede diabetico da moderato a grave con il sospetto di osteomielite. Sono stati ottenuti campioni di ossa per coltura e istologia. Le caratteristiche cliniche e gli esiti dei pazienti sono stati confrontati usando χ 2prova quadrata. I biomarcatori (conta dei globuli bianchi, tasso di sedimentazione degli eritrociti, proteina c-reattiva, procalcitonina, interleuchina-6, interleuchina-8 e proteina chemoatattante dei monociti 1) sono stati valutati al basale, 3 e 6 settimane dopo l’inizio del trattamento e valutati per la correlazione con reinfezione dell’osso. Dopo 6 settimane di trattamento antibiotico, ESR a 73,5 mm / h (sensibilità 62,5%, specificità 100%, area sotto la caratteristica operativa del ricevitore (AUROC) 0,7839, IC 95% 0,54-1,00, P <.01) e IL-8 a 15,09 mg / dL (sensibilità 42,9%, specificità 92,0% AUROC 0,6286, IC 95% 0,36-0,90, P = 0,0496) sono stati associati alla reinfezione dell’osso. Un aumento di IL-8 dalla settimana 0 a 6> 0,95 mg / dL è stato associato a reinfezione (sensibilità 71%, specificità 72% AUROC 0,7057, IC 95% 0,49-0,92, P = 0,04). Una variazione di VES dalla settimana 0-6 di -16. 5% (sensibilità 71,4%, specificità 86,4% AUROC 0,7403, IC 95% 0,48-1,00, P = 0,02), CRP (-) 74,4% (sensibilità 66,7%, specificità 91,3% AUROC 0,7174, IC 95% 0,40-1,00, P = .04), IL-6 (-) 49,9% (sensibilità 71,4%, specificità 76% AUROC 0,7371, IC 95% 0,47-1,00, P = 0,04) e IL-8 29% (sensibilità 85,7%, specificità AUROC 56,0% di 0,7343, IC 95% 0,54-0,93, P = 0,048) sono stati associati ad un aumentato rischio di reinfezione. I dati pilota suggeriscono che i biomarcatori sierici (ESR, IL8 e IL6, MCP-1) potrebbero essere correlati allo sviluppo dell’osteomielite e potrebbero essere utilizzati per monitorare i pazienti ad alto rischio per la reinfezione. e IL-8 29% (sensibilità 85,7%, specificità 56,0% AUROC di 0,7343, IC 95% 0,54-0,93, P = 0,048) sono stati associati ad un aumentato rischio di reinfezione. I dati pilota suggeriscono che i biomarcatori sierici (ESR, IL8 e IL6, MCP-1) potrebbero essere correlati allo sviluppo dell’osteomielite e potrebbero essere utilizzati per monitorare i pazienti ad alto rischio per la reinfezione. e IL-8 29% (sensibilità 85,7%, specificità 56,0% AUROC di 0,7343, IC 95% 0,54-0,93, P = 0,048) sono stati associati ad un aumentato rischio di reinfezione. I dati pilota suggeriscono che i biomarcatori sierici (ESR, IL8 e IL6, MCP-1) potrebbero essere correlati allo sviluppo dell’osteomielite e potrebbero essere utilizzati per monitorare i pazienti ad alto rischio per la reinfezione.

[Tratto da: www.pubmed.gov ]06

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GLYCEMIC CONTROL AND DIABETIC FOOT ULCER OUTCOMES: A SYSTEMATIC REVIEW AND META-ANALYSIS OF OBSERVATIONAL STUDIES

Role of glycemic control in diabetic foot ulcers (DFUs) is unclear.

Previous meta-analyses have included small numbers of studies.

Higher A1C and fasting glucose are associated with increased amputation risk in patients with DFUs.

A1C and glucose were not associated with wound healing.

ABSTRACT

Objective

To evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs).

Research design and methods

Medline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. A meta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842).

Results

Of 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses (n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes.

Conclusions

Our findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.

[Tratto da: www.diabeticfootonline.com ]