Evaluating Classification Systems of Diabetic Foot Ulcer Severity: A 12-Year Retrospective Study on Factors Impacting Survival

Abstract

(1) Background: This study examines the survival of patients after their first presentation with diabetic foot ulcers (DFUs) to the regional Diabetes, Nutrition, and Metabolic Diseases Clinic within the Emergency Clinical Hospital “Sf. Spiridon”, Iaşi, and analyzes the factors associated with this outcome. (2) Methods: In this retrospective study, patients with DFUs consecutively referred between 1 January 2007 and 31 December 2017 were followed up until 31 December 2020 (for 13 years). The study group included 659 subjects. (3) Results: During the study period, there were 278 deaths (42.2%) and the average survival time was 9 years. The length of hospitalization, diabetic nephropathy, chronic kidney disease, glomerular filtration rate, cardiovascular disease, hypertension, anemia, and DFU severity were the most significant contributors to the increase in mortality. Patients with severe ulcers, meaning DFUs involving the tendon, joint, or bone, had a higher mortality risk than those with superficial or pre-ulcerative lesions on initial presentation (Texas classification HR = 1.963, 95% CI: 1.063–3.617; Wagner–Meggitt classification HR = 1.889, 95% CI: 1.024–3.417, SINBAD Classification System and Score HR = 2.333, 95% CI: 1.258–4.326) after adjusting for confounding factors. (4) Conclusions: The findings of this study suggested that patients presenting with severe ulcers involving the tendon, joint, or bone exhibited a significantly higher risk of mortality, even when potential confounders were taken into consideration.

Survival Prediction in Diabetic Foot Ulcers: A Machine Learning Approach

“…At present, ML methods are based on random initialization and various types of random choices during learning that control the impact of confounders. Unlike our previous paper, which did not identify the SEWSS as a relevant predictor of mortality [ 20 ], in the present study, the SEWSS proved to be an important predictor for the 5-year mortality estimation model. However, it is a less relevant predictor for the 10-year mortality classifier.…”

“…Initially, the study undertook the process of feature selection, which led to the identification of several non-invasive predictors related to the 5- and 10-year mortality outcome: age, hemoglobine, creatinine, urea, length of hospitalization, The University of Texas Staging System for Diabetic Foot Ulcers score, ischemia from the Saint Elian Wound Score System (SEWSS), neuropathy from the SEWSS, glomerular filtration rate, cardiovascular disease, SEWSS score, the Wagner–Meggitt classification of foot ulcers grade, topographic aspects of the lesion from the SEWSS, hypertension, diabetic nephropathy, peripheral artery disease, hyperuricemia, and depth of lesion from the SEWSS. This is in accordance with the scientific literature as, to date, many of these variables were studied as mortality predictors in diabetes mellitus patients [ 17 , 18 , 19 , 20 ]. However, our paper is the first to consider combining the predictive power of all these variables by developing an AI/ML classifier.…”

“…In a previous study based on conventional survival analysis, we showed that patients with deep ulcers involving the tendon, joint, or bone had a higher mortality risk [ 20 ]. In this paper, we passed beyond traditional modeling.…”

Loss of sensation and trophic lesions in the feet of people with type 2 diabetes mellitus

“…(7,8) Asimismo, es importante destacar que la escala de Wagner constituye un sistema de estadiaje ampliamente empleado para la evaluación de lesiones tróficas en los pies de pacientes con diabetes, fundamentado en criterios que abarcan extensión y profundidad de las lesiones, la posible presencia de condiciones como osteomielitis o gangrena, así como la presencia de la necrosis tisular. (9) Su aplicación se ha extendido a lo largo de varias décadas y en diversos países, desempeñando un papel crucial en la determinación del alcance del daño y la elaboración de pronósticos precisos para los pacientes afectados. (10,11) Recientemente, se ha descubierto que más del 70 % los pacientes que llegan a casos de lesiones graves en los pies que requieren amputación y pueden llegan a morir en los primeros 5 años después de la amputación, principalmente aquellos que mantienen una situación más crítica que presentan niveles glicémicos descontrolados y otras enfermedades paralelas.…”