Watjer Roeland M, Heckmans Kim Ml, Eekhof Just Ah, Gummi Luise, Quint Koen D, Numans Mattijs E, Bonten Tobias N
Public Health and Primary Care, Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands
Leiden University Medical Center, Leiden, Zuid-Holland, Netherlands.
BMJ Open. 2024 Apr 23;14(4):e076441. doi: 10.1136/bmjopen-2023-076441.
Diabetic foot ulcers are feared complications of diabetes mellitus (DM), requiring extensive treatment and hospital admissions, ultimately leading to amputation and increased mortality. Different factors contribute to the development of foot ulcers and related complications. Onychomycosis, being more prevalent in patients with diabetes, could be an important risk factor for developing ulcers and related infections. However, the association between onychomycosis and diabetic complications has not been well studied in primary care.
To determine the impact of onychomycosis on ulcer development and related complications in patients with diabetes in primary care, a longitudinal cohort study was carried out using routine care data from the Extramural Leiden University Medical Center Academic Network. Survival analyses were performed through Cox proportional hazards models with time-dependent covariates.
Data from 48 212 patients with a mean age of 58 at diagnosis of DM, predominantly type 2 (87.8%), were analysed over a median follow-up of 10.3 years. 5.7% of patients developed an ulcer. Onychomycosis significantly increased the risk of ulcer development (HR 1.37, 95% CI 1.13 to 1.66), not affected by antimycotic treatment, nor after adjusting for confounders (HR 1.23, 95% CI 1.01 to 1.49). The same was found for surgical interventions (HR 1.54, 95% CI 1.35 to 1.75) and skin infections (HR 1.48, CI 95% 1.28 to 1.72), again not affected by treatment and significant after adjusting for confounders (HR 1.32, 95% CI 1.16 to 1.51 and HR 1.27, 95% CI 1.10 to 1.48, respectively).
Onychomycosis significantly increased the risk of ulcer development in patients with DM in primary care, independently of other risk factors. In addition, onychomycosis increased the risk of surgeries and infectious complications. These results underscore the importance of giving sufficient attention to onychomycosis in primary care and corresponding guidelines. Early identification of onychomycosis during screening and routine care provides a good opportunity for timely recognition of increased ulcer risk.
糖尿病足溃疡是糖尿病（DM）令人担忧的并发症，需要广泛的治疗和住院，最终会导致截肢并增加死亡率。不同因素导致足部溃疡及相关并发症的发生。甲癣在糖尿病患者中更为普遍，可能是发生溃疡及相关感染的重要危险因素。然而，在初级保健中，甲癣与糖尿病并发症之间的关联尚未得到充分研究。
为了确定甲癣对初级保健中糖尿病患者溃疡发生及相关并发症的影响，利用莱顿大学医学中心校外学术网络的常规护理数据进行了一项纵向队列研究。通过具有时间依赖性协变量的Cox比例风险模型进行生存分析。
对48212例糖尿病诊断时平均年龄为58岁、主要为2型糖尿病（87.8%）的患者数据进行了分析，中位随访时间为10.3年。5.7%的患者发生了溃疡。甲癣显著增加了溃疡发生风险（风险比1.37，95%置信区间1.13至1.66），不受抗真菌治疗影响，调整混杂因素后依然显著（风险比1.23，95%置信区间1.01至1.49）。手术干预（风险比1.54，95%置信区间1.35至1.75）和皮肤感染（风险比1.48，95%置信区间1.28至1.72）情况相同，同样不受治疗影响，调整混杂因素后显著（风险比分别为1.32，95%置信区间1.16至1.51和风险比1.27，95%置信区间1.10至1.48）。
在初级保健中，甲癣显著增加了糖尿病患者溃疡发生风险，独立于其他危险因素。此外，甲癣增加了手术和感染性并发症风险。这些结果强调了在初级保健及相应指南中充分关注甲癣的重要性。在筛查和常规护理期间早期识别甲癣为及时识别溃疡风险增加提供了良好机会。
