Toes

Using the electronic medical records system at each site, we searched the following ICD-9-CM codes to identify possible visits for hypoglycemia: 250.3 (diabetes with other coma), 250.8 (diabetes with other specified manifestations) 251.0 (hypoglycemic coma), 251.1 (other specified hypoglycemia), 251.2 (hypoglycemia, unspecified), 270.3 (leucine-induced hypoglycemia), 775.0 (hypoglycemia in an infant born to a diabetic mother), 775.6 (neonatal hypoglycemia), and 962.3 (poisoning by insulins and antidiabetic agents).
Given the diversity of potential ICD-9-CM codes, we searched this broad range of codes and in all diagnosis fields (up to ten listed) in an attempt to capture all possible ED hypoglycemia visits. For admitted patients, we examined only ED-based codes, to avoid inclusion of incident hypoglycemia that occurred during inpatient hospitalization. In cases where multiple candidate codes were present, we recorded only the first-listed code. The exception to this was for the more ambiguous codes 250.3 and 250.8, for which we preferentially recorded any of the other candidate codes if present. We based this strategy on detailed examination of the ICD-9-CM coding manual [9 ], review of the experience from previously reported approaches [10 (link)-14 (link)], and discussion with coding experts.
The code 250.8 may be used for other specific diabetes-associated complications in addition to hypoglycemia, including: 259.8 (secondary diabetic glycogenosis), 272.7 (diabetic lipidosis), 707.xx (ulcers of the lower extremity), 709.3 (Oppenheim-Urbach syndrome), and 730.0–730.2, 731.8 (osteomyelitis). Based on discussion with coding experts, we determined that 681.xx (cellulitis of fingers/toes), 682.xx (other cellulitis), and 686.9x (local skin infection) may also be utilized as a co-diagnoses for 250.8, although not specifically mentioned in the manual. We prospectively proposed the coding algorithm displayed in Figure 1 and validated its accuracy through chart review.
We identified all ED visits with candidate ICD-9-CM codes between July 1, 2005 and June 30, 2006 at each site, and obtained written ED charts. For patients with multiple ED visits during the data collection period, we requested only the first visit to avoid overrepresentation by certain patients. Trained research staff abstracted all charts using a standardized form, and the research group met weekly to discuss data collection and resolve abstraction issues. Additionally, two reviewers independently abstracted 10% of charts to evaluate inter-rater agreement in data collection. To enhance the reliability of our chart review, we abstracted only charts with complete ED triage assessment, nursing notes, and emergency physician notes and considered all other charts incomplete.

The two-step gait initiation protocol was used to capture dynamic plantar pressures, as it displays similar re-test reliability to the commonly used midgait protocol, however requires fewer trials [24 (link)-26 (link)]. The two step method involves striking the platform on the second step once a constant velocity has been reached, and is suggested to reproduce plantar force and pressure data that is reflective of foot function during gait. Trials were excluded and repeated if the plantar pressure recording was not satisfactorily positioned, the participant paused on the mat whilst walking, or if the participant did not continue to walk past the mat for more than two steps. Three trials of the left foot were recorded for each participant, as this number of trials has previously been found to be sufficient in ensuring adequate reliability of force and pressure data [27 (link),28 (link)]. Plantar force and pressure measurements were recorded at baseline, and repeated at follow up one week later. A one week duration between sessions was chosen to ensure participants' gait characteristics remained reasonably consistent.
Maximum force, peak pressure and average pressure were the parameters measured in this study at seven regions of the foot. These three variables were assessed as they are the standard outputs of the MatScan^® system, and peak plantar pressure in particular has been found to be of importance in the development of pathological foot problems such as ulceration [29 (link)] and osteoarthritis [30 (link)], and determining the efficacy of treatment modalities such as redistributive insoles [31 (link)] and therapeutic footwear [32 (link)]. We used a mask with seven regions (heel, midfoot, 1^st MPJ, 2^nd MPJ, 3^rd-5^th MPJs, hallux and lesser toes) to provide detailed information regarding the independent function of different segments of the foot. We have previously used this mask to examine age-related changes in foot function [33 (link)], clinical predictors of plantar loading in older people [34 (link)], and differences in plantar loading in people with osteoarthritis of the 1^st MPJ [35 (link)] and midfoot [30 (link)].

All patients with T2DM were asked whether they had numbness, pain (prickling or stabbing, shooting, burning or aching pain), and paresthesia (abnormal cold or heat sensation, allodynia and hyperalgesia) in the toes, feet, legs or upper-limb. Then, an experienced physician performed the neurologic examination which included vibration, light touch, and achilles tendon reflexes on both sides in the knee standing position (as being either presence or weakening or loss). Vibration perception threshold (VPT) was assessed at the metatarsophalangeal joint dig I using a neurothesiometer (Bio- Thesiometer; Bio-Medical Instrument Co., Newbury, OH, USA). First, the patients were informed how to know the vibration sensation is felt by gradually turning the amplitude from zero to maximum, then the test began again from zero and they were asked to say the moment that they first felt it. Measurements were made on the planter aspect of the big toe bilaterally, three times consecutively for each big toe. The median of three readings is accepted as the VPT value of that measurement (35 (link)). Sensitivity to touch was also tested using a 5.07/10-g Semmes-Weinstein monofilament (SWM) at four points on each foot: three on the plantar and one on the dorsal side. The 10-g SWM was placed perpendicular to the skin and pressure was applied until the filament just buckled with a contact time of 2 s. Inability to perceive the sensation at any one site was considered abnormal (36 (link), 37 (link)). DPN was defined as VPT ≥25 V and/or inability to feel the monofilament (35 (link)), and then participants were divided into DPN group and no DPN group.
Ankle brachial index (ABI) was measured noninvasively by a continuous-wave Doppler ultrasound probe (Vista AVS, Summit Co., USA) with participants in the supine position after at least 5 min of rest. Leg-specific ABI was calculated by dividing the higher SBP in the posterior tibial or dorsalis pedis by the higher of the right or left brachial SBP (33 (link), 38 (link)). Patients were diagnosed as having PAD if an ABI value <0.9 on either limb (33 (link), 38 (link)).
DFU was defined as ulceration of the foot (distally from the ankle and including the ankle) associated with neuropathy and different grades of ischemia and infection (39 (link)).

The kinematic data of both lower limbs of FUS were gathered in this study using the plug-in gait lower limb model (Figure 1). The experimental operators calibrated the athletes once they became accustomed to the experimental setting and constructed the three - dimensional image before the experiment. Then, using a ruler, the scientist completed the work required for personalized static modeling and measured the athletes’ bilateral lower limbs’ leg length, knee width, and ankle width. The lower limb joints of the athletes were then calibrated using reflecting markers by a scientist. The plug-in gait had 16 anatomical positions, including the left anterior superior spine (LASI), the right anterior superior spine (RASI), the left posterior superior spine (LPSI), the right posterior superior spine (RPSI), the left and right knees, the left and right tibias, the left and right ankles, the left and right toes, and the left and right heels (RTOE).

Demographics, including sex, age of onset, occupation, past neuropsychological and other substance consumption history, history of N₂O use, onset-to-admission time, ways of admission to the hospital, length of hospital stay, abnormal events during hospitalization, recovery status at discharge, and records of natural follow-up at our outpatient clinic were collected. The history of N₂O use consists of the length of exposure, the recent increase in use, and the concealment of N₂O consumption at the first admission.
Neurological symptoms and signs were comprehensively assessed during hospitalization. Based on the clinical evaluations, the functional disability rating score (FDRS) was calculated by two experienced neurologists. The score has been used widely in the clinical severity evaluation of SCDs, including N₂O-related neuropathies (11 (link), 13 (link), 14 (link)). The five-part scoring system is described as follows: (1) gait (0 = normal, 1 = positive Romberg's sign, 2 = impaired but able to walk unsupported, 3 = substantial support required for ambulation, 4 = wheelchair-bound or bedridden); (2) sensory disturbances including hypesthesia, dysesthesia, vibration/joint-position impairment (0 = normal, 1 = impairment only in toes and fingers, 2 = impairment in the ankles and wrists, 3 = impairment in the upper arms and legs); (3) mental impairment (0 = normal, 1 = intellectual or behavioral impairment requiring no social support, 2 = partial dependence for all activities of daily living, 3 = complete dependence for all activities of daily living); (4) neuropathy (0 = normal reflex, 1 = loss or reduction of deep tendon reflexes of the ankle, 2 = loss or reduction of deep tendon reflexes of the patella, 3 = loss or reduction of deep tendon reflexes of the biceps); and (5) pyramidal tract signs (0 = normal, 1 = positive Babinski sign, 2 = spastic paraparesis, 3 = spastic tetraparesis). The cumulative score ranges from 0 to 16. A higher score indicated increased severity of neurological impairment and a worse functional status of a patient.