Volume 104 · Issue 47 · 2024

Diabetic foot is a highly complex and severe complication of diabetes, posing significant challenges in treatment and imposing substantial medical costs. Wound healing stands as the primary concern for both healthcare professionals and patients in the management of diabetic foot. Individuals with severe diabetic foot often suffer from multiple organ failure and acute lesions. The comprehensive medical management plays a vital role in limb preservation and prolong survival. Drawing upon the team′s practical experience and cutting-edge advancements, this article aims to summarize the common medical complications(cardiovascular disease, kidney disease, severe infections, malnutrition) and treatment experience of patients with severe diabetic foot. The ultimate goal is to enhance clinicians′ ability of comprehensive diagnosis and treatment for diabetic foot.

Diabetes-related foot infections(DFI), including diabetes-related foot osteomyelitis, are generally treated with systemic antibiotics. However, systemic antibiotics are often overused and administered for excessively long periods, making patients more susceptible to multidrug-resistant bacteria. Local antibiotics may be beneficial to DFI patients. This article reviews the advantages and disadvantages, types and clinical evidence of local antibiotics in the treatment of DFI, and points out the research gaps and future research direction in this field. This article aims to provide a reference for clinicians in formulating anti-infectious treatment plans for DFI.

Biportal endoscopic spinal surgery is a non-coaxial endoscopic technique, which has a clear field of view under the microscope and flexible operation during the surgery, and has been widely used in clinic. However, the popularity of this technology is still limited in China, and there are still controversies in naming, indications and contraindications. In order to promote the standardization of the clinical application of this technology, the Spinal Minimally Invasive Surgery Group of the Orthopedic Branch of the Chinese Medical Doctor Association organized domestic spinal endoscopic experts to write this consensus. This consensus makes an in-depth discussion on the definition and naming, technical features, key surgical problems, indications, contraindications, complications and skill training of biportal endoscopic spinal surgery, and forms 9 recommendations, aiming to standardize and promote the clinical application of this technology.

To compare the efficacy of dorsal approach and medial approach in the treatment of Lisfranc injury.

A retrospective cohort study was conducted to analyze the clinical data of 43 patients with closed Lisfranc injuries admitted to Tongji Hospital of Tongji University from January 2017 to December 2021. The surgical approach were open reduction and internal fixation or metatarsal cuneiform joint fusion, with 23 cases using the dorsal approach and 20 cases using the medial approach. The duration of surgery, incisional complications, loss of internal fixation, internal fixation removal rate, patient′s clinical satisfaction, and American Orthopedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score of pain in the patients were reviewed based on the medical record system and follow-up records.

Of the patients, 33 were male and 10 were female, with a mean age of (45.2±13.4) years. All the patients were followed up for (17.9±6.7) months, and there was no statistically significant differences in the baseline data between the two groups. Preoperatively, the dorsal approach group and the medial approach group had a AOFAS score of (30.3±10.7) and (28.5±9.3), respectively, and a VAS score of (6.2±1.9) and (6.3±2.1), respectively (both P>0.05); the operation time was (112.2±25.0) min and (91.0±22.5) min, respectively in the two groups (P=0.006). Two patients in the dorsal approach group developed superficial infection in the incision, one patient experienced delayed healing in the medial approach group, while the remaining patients achieved primary healing. In the dorsal approach group, three patients suffered long-term numbness or pain on the dorsum of the foot during follow-up, which was alleviated with neurotrophic medications; in the medial approach group, one patient had abnormal sensations around the wound site, which gradually improved. During the follow-up period, a total of 10 patients underwent internal fixation removal, including 7 patients (30.4%) in the dorsal approach group and 3 patients (15.0%) in the medial approach group (P=0.294). The AOFAS score in the dorsal approach group and the medial approach group at the last follow-up was 83.8±7.7 and 86.7±6.9 (P=0.207), and the VAS scores was 2.1±1.0 and 1.3±0.5 (P=0.002), respectively, both showed improvement when compared with those before the surgery (both P<0.001). In both groups, the internal fixations were all in place, with no cases of lost implants. In the dorsal approach group, 3 patients (13.0%) were dissatisfied with the surgical outcome, while in the medial approach group, 1 patient (5%) was dissatisfied (P=0.848).

Both surgical approaches resulted in a good prognosis, and there is no statistical difference between the two groups in terms of fixation effect, and the medial approach group is superior to the dorsal access in operative time, internal fixation removal rate, VAS score and patient clinical satisfaction.

To explore the risk factors of systemic inflammatory response syndrome (SIRS) in diabetes foot infection (DFI).

A retrospective analysis was conducted on the clinical data of 301 patients admitted to the Ninth Medical Center of the People′s Liberation Army General Hospital for DFI from January 2021 to December 2023, including 223 males and 78 females with the age of (63.3±12.0) years. The study population was divided into SIRS group (n=32) and non-SIRS group (n=269) based on whether SIRS occurred. Multivariate logistic regression model was used to analyze the risk factors of DFI combined with SIRS.

Compared with non-SIRS group, patients in SIRS group were younger [(60.3±8.5) vs (63.7±12.3) years, P=0.047], with lower serum albumin [M(Q₁, Q₃)] [32.7(29.3, 37.3) vs 36.2(33.6, 39.2) g/L, P=0.003] and hemoglobin [116.0(99.8, 125.3) vs 121.0(111.0, 136.0) g/L, P=0.022], and higher glycosylated hemoglobin [9.8%(8.7%, 11.6%) vs 8.7%(7.4%, 10.6%), P=0.007]; positive rate of diabetes foot history was lower [25.0%(8/32) vs 46.8% (123/269), P=0.019] and the proportion of combined osteomyelitis was higher [90.6% (29/32) vs 46.7% (168/269), P=0.002] in SIRS group. Multivariate logistic regression analysis showed that elevated glycosylated hemoglobin (OR=1.27,95%CI:1.03-1.58) and osteomyelitis (OR=4.5,95%CI:1.20-16.86)were risk factors for SIRS.

Poor blood glucose control and osteomyelitis are risk factors for DFI complicated with SIRS.

To analyze the distribution characteristics of foot deformities and the biomechanical features of the feet among elderly diabetic patients in the community.

A total of 3 148 elderly diabetic patients (6 296 feet) who participated in the diabetic foot screening program in Jinshan District, Shanghai, from March to May 2023 were included, with 1 357 males and 1 791 females, aged (70.7±6.0) years. According to arch deformities, the severity of hallux valgus, and the presence or absence of other toe deformities (hammer foot, mallet foot, and claw foot), the patients were grouped and compared in terms of biomechanical parameters such as plantar pressure, force-bearing area, foot axis angle, footprint length, and load ratio.

The the most common foot deformity was the combination of arch deformities, accounting for up to 41.0% (2 581/6 296), it was followed by hallux valgus at 21.8% (1 371/6 296) and other toe deformities at 13.4% (846/6 296). A total of 56.5% (3, 557/6 296) of the patients had at least one type of foot deformity, and 29.0% (1 032/3 557) presented with tow or more types of foot deformities. When grouped according to arch deformities, the patients in the low arch group, mild low arch group, normal arch group, mild high arch group, and high arch group was 343, 1 282, 3 715, 595, and 361 cases, respectively; and there were statistically significant differences in maximum pressure, mean pressure, force-bearing area, foot axis angle, anterior-posterior and lateral offsets of the center of plantar pressure, anterior-posterior foot load ratio, and medial-lateral load ratio among all the groups (all P<0.001). The high arch group exhibited the highest maximum and mean pressures on the plantar surface, with the smallest force-bearing area, while the opposite was true for the low arch group (all P<0.001). There were 4 925, 731, 640 cases in the no hallux valgus group, mild hallux valgus group, and moderate-to-severe hallux valgus group respectively when grouped according to the severity of hallux valgus. The moderate-to-severe hallux valgus group had the lowest medial load (P=0.002) and the highest lateral load ratio (P=0.001). Compared to the group without other toe deformities (n=5 450), the group with other toe deformities (n=846) exhibited higher maximum plantar pressure [(214.43±112.85) vs (202.88±113.63) kPa, P<0.001], a lower forefoot load ratio (54.35%±13.31% vs 55.94%±12.58%, P=0.001), and a higher hindfoot load ratio (45.65%±13.31% vs 44.06%±12.58%, P=0.001).

Among elderly diabetic patients, the incidence rate of foot deformities is as high as 56.5%, with arch deformities being the most common. Foot mechanics analysis indicates that the high arch group has the highest maximum and average plantar pressures, but the smallest force-bearing area, while the opposite is true for the low arch group. Toe deformities can affect the patient′s plantar load ratio.

To analyze the efficacy of curative endoscopic submucosal dissection (ESD) for patients with early cardia and non-cardia gastric cancer.

Clinical data of patients with early gastric cancer who underwent curative ESD treatment in the Department of Gastroenterology, Zhongda Hospital, Southeast University from August 2016 to July 2023 were retrospectively collected. According to the location of lesions and postoperative pathology, the patients were divided into cardia group (early cardia gastric cancer and high-grade intraepithelial neoplasia) and non-cardia group. Follow-up ended in October 2023. Basic clinical information, endoscopy features and histopathological results, postoperative complications and prognosis were compared between the two groups. Kaplan-Meier method was used to present the survival curve and compare the metachronous recurrence-free survival rate and overall survival rate between the two groups.

A total of 279 patients were included, including 96 patients in the cardia group (83 males and 13 females), aged [M (Q₁, Q₃)] 68 (65, 74) years, and 183 patients in the non-cardia group (136 males and 47 females), aged 67 (59, 72) years. The follow-up duration after ESD was 35 (22, 53) months. Differences in postoperative pathological types and lesion invasion depth between the two groups were statistically significant (all P<0.05). The cardia group had the highest proportion of well/moderately differentiated adenocarcinoma [69.8% (67/96)] and T1-M3 invasion depth [58.3% (56/96)], while the non-cardia group had the highest proportion of well/moderately differentiated adenocarcinoma [52.5% (96/183)] and T1-M1 invasion depth [43.2% (79/183)]. The proportion of merging esophageal mucosal lesions [13.5% (13/96) vs 5.5% (10/183)] and deep cystic gastritis [19.8% (19/96) vs 2.7% (5/183)] in the cardia group were higher than those in the non-cardia group (all P<0.05). There were no statistically significant differences in postoperative complication rates [4.2% (4/96) vs 2.2% (4/183)] and mortality rates [1.0% (1/96) vs 2.2% (4/183)] between two groups (all P>0.05). The rate of metachronous recurrence in the cardia group [11.5% (11/96) vs 4.9% (9/183)] was higher than that in the non-cardia group (P=0.044). The 1-year, 3-year, 5-year metachronous recurrence-free survival rates were 97.9%, 89.6%, 79.8% in the cardia group and 100.0%, 96.3%, 92.1% in the non-cardia group, with statistically significant difference (P=0.015); the 1-year, 3-year, 5-year overall survival rates were 100.0%, 100.0%, 97.1% in the cardia group and 99.5%, 98.3%, 98.3% in the non-cardia group, with no statistically significant difference (P=0.597).

Compared to the non-cardia group, patients with early cardia gastric cancer treated with curative ESD have a poorer prognosis, with a higher incidence of metachronous recurrence.

To evaluate the analytical performance of Flash10 point-of-care testing (POCT) in the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid.

The analytical performance evaluation of the Flash10 POCT system and its matching kits was carried out based on the non-infectious phage virus-like particles (VLPs) samples and inactivated viral culture samples. The limit of detection (LoD) was evaluated by testing gradient-diluted non-variant and Omicron variants (BA.5 and BF.7) VLPs samples and negative samples and using Probit regression analysis. The precision was evaluated by testing non-variant and Omicron variants (BA.5 and BF.7) VLPs samples with concentrations of 3 000.00, 1 000.00, 333.33 and 111.11 copies/ml and calculating coefficient of variation (CV) for cycle threshold (Ct) value of ORF1ab gene and N gene. The analytical specificity was evaluated by detecting 13 common respiratory pathogens that can cause symptoms similar to coronavirus disease 2019 (COVID-19). The testing ability of SARS-CoV-2 variants were assessed by detecting the VLPs samples with variants that have been prevalent worldwide (including Alpha, Beta, Delta, Omicron and so on). The sealing of this POCT system was evaluated by studying cross-contamination and the risk of contamination of nucleic acid amplification products.

The LoD of the Flash 10 POCT system for detecting non-variant samples and Omicron variant (BA.5, BF.7) samples were 92.97 copies/ml (95%CI: 63.68-196.27 copies/ml)、95.49 copies/ml (95%CI: 67.26-200.14 copies/ml) and 99.27 copies/ml (95%CI: 67.77-209.89 copies/ml), respectively, which aligned with the LoD (100 copies/ml) claimed by the reagent instructions. When detecting non-variant and Omicron variant (BA.5, BF.7) samples with four different concentrations, the CV of the Ct value of ORF1ab gene and N gene were 2.41% to 4.97% and 2.29% to 4.48%, respectively, which were all below 5%. The detection results of 13 common respiratory pathogens other than SARS-CoV-2 were all negative. The variants that have been prevalent worldwide can be correctly detected. The evaluation results of the risk of cross-contamination and nucleic acid amplification products contamination indicated that the Flash 10 POCT testing system was well sealed.

The Flash10 POCT system demonstrates good analytical performance for SARS-CoV-2 nucleic acid detection.

The medical data of 10 patients with undifferentiated pleomorphic sarcoma (UPS) from the head and neck at Henan Cancer Hospital from January 2013 to January 2023 were retrospectively analyzed. There were 5 males and 5 females, aged (57.6±13.1) years. The lesions were located in the nasal cavity (one case), the paranasal sinuses (two cases), the parotid gland (one case), the nape (one case), the thyroid gland (one case), and the neck (four cases), respectively. Eight patients underwent surgical intervention, all of whom received adjuvant therapies, including post-surgery radiotherapy and chemotherapy. One patient declined treatment due to personal reasons, and another patient lost the opportunity for surgery and received chemotherapy instead. The follow-up period ranged from 1 to 128 months, with a median follow-up time of 31 (11, 101) months. During the follow-up period, there were a total of four deaths: two due to recurrence after surgery, one due to discontinuing treatment, and one due to severe illness that responded poorly to treatment.The remaining 6 patients who received surgery combined with radiotherapy or chemotherapy showed no recurrence. To sum up, UPS of the head and neck is rare, exhibits a high recurrence rate, and has a poor prognosis. Surgical resection combined with radiotherapy is an important treatment modality.

The patient, a 56-year-old male, was seen in the Sino-Japanese Friendship Hospital of Jilin University on November 27, 2023 due to "fever for 1 day, dyspnea, and dull pain in the precordial area for several hours". The patient was admitted with fever accompanied by chills and positive percussion pain in the liver area. Hepatic ultrasound showed that the heterogeneous echo area in the left lobe of the liver was 7.9 cm ×8.3 cm. After admission, there was sudden chest tightness, aggravation of dyspnea, blood pressure dropped to 70/50 mmHg, and liver ultrasound showed a heterogeneous echo area of 4.1 cm ×5.7 cm (smaller than before); Contrast-enhanced ultrasound considers liver abscess; Cardiac ultrasound showed a large amount of pericardial effusion (about 1.2 cm in thickness and diameter, which was more than 0.4 cm before admission); Ultrasound-guided puncture and catheter drainage of liver abscess and pericardial effusion was performed. Laboratory tests related to drainage fluid showed bacterial infection. Combined with contrast-enhanced ultrasound, the continuity of liver capsule and pericardium was interrupted at the 24th second of arterial phase, and a filling defect was seen. Finally, the diagnosis was pericardial abscess caused by bacterial liver abscess rupture. After 15 days of comprehensive treatment, the condition improved and the hospital was discharged. The patient was followed up until 3 months postoperatively and was in good condition.

Diabetes-related foot ulcer (DFU) is a serious complication with high disability and mortality rate of diabetes, which significantly reduces the quality of life of patients. In recent years, platelets and their derivatives such as platelet-rich plasma, platelet-rich fibrin, concentrated growth factors, platelet-derived exosomes, and platelet membrane vesicles have shown new potential in therapy. Platelet-rich plasma is rich in growth factors, which can promote wound healing; Platelet-rich fibrin can slowly release growth factors, which is suitable for chronic wounds; Concentrated growth factor has the advantage of sustained release, accelerating wound healing and reducing the risk of recurrence; Platelet-derived exosomes and membrane vesicles, on the other hand, carry growth factors and small molecule nucleic acids, which can promote angiogenesis and bring new ideas for DFU treatment. In this paper, the mechanism of action and clinical application of these derivatives in the treatment of DFU were reviewed in order to provide more effective treatment options for DFU patients.

Diabetic foot (DF) is one of the most serious complications of diabetes mellitus, with extremely high mortality and mortality rate. The mortality rate is much higher than that of ordinary diabetic patients, and heart disease is the most important cause of death in DF patients. The damage of hyperglycemia to the heart is manifested as coronary artery, myocardium and cardiac autonomic nerve lesions. Compared with ordinary diabetic patients, what is the particularity of heart disease in DF patients? This review analyzes the driving factors of cardiac disease in DF patients from the causes, mechanisms and clinical manifestations of diabetic heart disease, and puts forward the directions that need to be focused on in clinical diagnosis, treatment and research. By finding relevant risk factors, DF patients can be managed in a more refined hierarchical manner, so as to achieve early screening, early prevention and early treatment, so as to improve the prognosis.

Esophageal cancer incidence and mortality remain high, and early diagnosis is essential to improve patient prognosis and improve survival. Autoantibodies refer to a class of antibodies produced by the body's immune system against autoantigens, which play an important role in early diagnosis of cancer in recent years. This article reviews the research progress and clinical significance of tumor-associated autoantibodies (TAAbs) in the screening and diagnosis of esophageal squamous cell carcinoma (ESCC), focusing on the generation mechanism, detection technology and possible application of TAAbs and their combination models in the early diagnosis of ESCC. The application of TAAbs in the early diagnosis of ESCC in the future is promising, and it is expected to become an important tool for optimizing screening strategies.

The 27-year-old female patient visited the emergency department of Peking Union Medical College Hospital in November 2023 due to sudden abdominal pain while carrying heavy objects. Blood routine: white blood cells 3.66×10⁹/L, hemoglobin 41 g/L, platelets 30×10⁹/L; Abdominopelvic enhanced CT: the spleen was obviously enlarged, the lower pole reached the level of the iliac fossa, the density in the parenchyma was uneven with flaky slightly higher density shadows, the lumen at the confluence of the three branches of the portal vein was obviously widened, and tortuous and thickened blood vessel shadows were seen in the lower left (yellow arrows in Figures A and B); Ultrasound of the left lower limb: extensive skin layer, subcutaneous tissue and intramuscular lesions of the lower limb, considering vascular malformation. Physical examination: the left lower limb was significantly thickened, longer than the right lower limb (Figure C), splenomegaly, 5 cm past the anterior median line. Past history: both lower limbs were of unequal length, and the left lower limb was swollen and thickened for more than 20 years. Splenectomy was performed when splenic rupture was considered in emergency department. Postoperative pathology: splenic vascular malformation and hemangioma. Combined with the past medical history of the patient, it was considered that vascular bone hypertrophy syndrome (KTS) was highly likely. KTS is a rare congenital disorder presenting as a triad of cutaneous vascular plaques, venous malformations, and limb overgrowth with or without lymphatic malformations. Most patients with KTS carry somatic variants of PIK3 CA, and multiple genetic defects have now been found to be likely causative factors in KTS, including angiogenic growth factor VG5 Q overexpression and nascent supernumeral circular chromosome 18. The comprehensive diagnosis of KTS is mainly based on the important clinical features mentioned above, and localized intravascular coagulopathy in the area of venous malformation is a common complication, so patients with KTS have an increased risk of deep vein thrombosis and pulmonary embolism. This patient had typical lower extremity malformations, multiple venous malformations of the spleen, and excessive limb growth, considering KTS. Platelets were normal and anemia improved after splenectomy. Regarding the venous malformation of the affected limb, the deep vein and lymphatic trunk are evaluated. At present, there is no stenosis and occlusion. No surgical intervention is required for the time being. Elastic stockings can be worn to increase reflux. The vascular ultrasound and D-dimer levels of the lower limb can be closely monitored to be alert to thrombosis.