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Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study. Acta Diabetol 2019; 56:1259-1264. [PMID: 31187250 DOI: 10.1007/s00592019-01376-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/04/2019] [Indexed: 05/28/2023]
Abstract
AIMS We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN). METHODS People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression. RESULTS Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN. CONCLUSIONS People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.
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Affiliation(s)
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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Chaudhary S, Bhansali A, Rastogi A. Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study. Acta Diabetol 2019; 56:1259-1264. [PMID: 31187250 DOI: 10.1007/s00592-019-01376-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/04/2019] [Indexed: 10/26/2022]
Abstract
AIMS We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN). METHODS People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression. RESULTS Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN. CONCLUSIONS People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.
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Affiliation(s)
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, 160012, India.
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Olotu B, Anderson F. Knowledge and attitude of patients undergoing lower extremity amputation at RK Khan Hospital, Chatsworth. S AFR J SURG 2019; 57:42. [PMID: 31773933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Amputation is one of the oldest and most commonly performed surgical procedures. OBJECTIVE To review the knowledge and attitude of patients undergoing lower extremity amputations and describe the associated causative factors. METHODOLOGY A questionnaire-based prospective study assessing patients either preoperatively or immediately postoperatively regarding their knowledge and attitudes toward lower extremity amputation was conducted between November 2016 and April 2017. Extracted data was captured into an Excel spreadsheet and imported into SPSS for statistical analysis. RESULTS Sixty-three amputations were performed with males accounting for 56% of the study population. The majority were in the age group of 61-70 years (33%). The commonest indication for amputation was complication of diabetes mellitus or diabetes foot sepsis (65%). Below-knee amputation (BKA) was the most frequently performed procedure and accounted for 56% of all amputations. Seventy per cent of the participants had formal education and 60% knew that their condition could lead to an amputation, but only approximately 10% visited the foot clinic before their major amputation despite the service being available at RK Khan Hospital. Smoking was the commonest habit associated with amputation. CONCLUSION There is a gradual temporal increase in the frequency of resected papillary cancer over a 16 year period while follicular has remained static. These changes may be attributable to better salt iodination.
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Affiliation(s)
- B Olotu
- Department of General Surgery, Nelson R. Mandela Medical School, University of KwaZulu-Natal, South Africa
| | - F Anderson
- Department of Hepato-Biliary Surgery, Inkosi Albert Luthuli Central Hospital, South Africa
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Wilson BM, Bessesen MT, Doros G, Brown ST, Saade E, Hermos J, Perez F, Skalweit M, Spellberg B, Bonomo RA. Adjunctive Rifampin Therapy For Diabetic Foot Osteomyelitis in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1916003. [PMID: 31755948 PMCID: PMC6902814 DOI: 10.1001/jamanetworkopen.2019.16003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Among patients diagnosed with diabetes, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers, and 20% to 60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis. OBJECTIVE To compare the clinical outcomes of patients treated for DFO in the Veterans Health Administration (VHA) with and without adjunctive rifampin. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used VHA databases to identify index DFO cases from January 1, 2009, through December 31, 2013, and analyzed patients alive and without high-level amputation at 90 days after diagnosis in whom antibiotic therapy was initiated within 6 weeks of diagnosis. Patients with death or major amputation within 90 days of diagnosis, who were not treated with systemic antibiotics dispensed by the VHA within 6 weeks of diagnosis, or who were treated at facilities where rifampin was not dispensed for DFO were excluded. The retrospective cohort to inform the planning of a multisite randomized clinical trial was first investigated in spring 2015; retrospective analysis was performed from February 2017 through September 2019. EXPOSURES Patients initiating rifampin therapy within 6 weeks of the DFO diagnosis and receiving the drug for at least 14 days within 90 days of diagnosis were considered treated with rifampin. Patients not administered rifampin within 90 days of diagnosis served as the comparator group. MAIN OUTCOMES AND MEASURES A combined end point of mortality or amputation within 2 years of diagnosis was analyzed. Differences in times to event were evaluated using log-rank tests. Differences in event rates were compared using χ2 tests and multivariable logistic regression. RESULTS The analysis population included 130 patients treated with rifampin and 6044 treated without rifampin (total of 6174; 6085 men [98.6%]; mean [SD] age, 64.9 [9.7] years). Lower event rates were observed among the rifampin group (35 of 130 [26.9%] vs 2250 of 6044 [37.2%]; P = .02). Patients treated with rifampin were younger (mean [SD] age, 62.2 [9.4] vs 64.9 [9.6] years), had fewer comorbidities (mean [SD] Charlson comorbidity index score, 3.5 [1.8] vs 4.0 [2.2]), had more infectious disease specialty consultations (63 of 130 [48.5%] vs 1960 of 6044 [32.4%]), and more often had Staphylococcus aureus identified in cultures (55 of 130 [42.3%] vs 1755 of 6044 [29.0%]) than patients not treated with rifampin. A logistic regression estimating the odds of events and controlling for these and other covariates yielded a significant association of rifampin (odds ratio, 0.65; 95% CI, 0.43-0.96; P = .04). CONCLUSIONS AND RELEVANCE In this cohort study, patients administered rifampin experienced lower rates of death and amputation than patients not treated with rifampin, which remained significant after adjustment for confounders. These results coupled with existing evidence from small clinical trials suggest the addition of rifampin to current treatment regimens may be a useful antimicrobial option in the treatment of DFO.
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Affiliation(s)
- Brigid M. Wilson
- Research Service and Geriatric Research, Education, and Clinical Center (GRECC),VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary T. Bessesen
- Division of Infectious Diseases, University of Colorado, Denver, School of Medicine, Department of Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Boston University School of Medicine, Boston, Massachusetts
| | - Sheldon T. Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elie Saade
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Service, VA Northeast Ohio Healthcare System, Cleveland
- University Hospitals of Cleveland, Cleveland, Ohio
| | - John Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of General Internal Medicine, Boston University, Boston, Massachusetts
| | - Federico Perez
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
| | - Marion Skalweit
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Robert A. Bonomo
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- CWRU (Case Western Reserve University)–Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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Dauer E, Yamaguchi S, Yu D, Lu X, Kelley K, Sharpe J, Manley N, Harvin JA, Taub EA, Goldenberg-Sandau A, Patel K, Omi E, Mashbari H, Hartwell J, Brocker J. Major venous injury and large volume crystalloid resuscitation: A limb threatening combination. Am J Surg 2019; 219:38-42. [PMID: 31604488 DOI: 10.1016/j.amjsurg.2019.10.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/26/2019] [Accepted: 10/04/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Major venous injury (MVI) affecting the lower extremity can result in subsequent amputation. The contribution of intraoperative resuscitation efforts on the need for amputation is not well defined. We hypothesized that intraoperative large volume crystalloid resuscitation (LVCR) increases the risk of amputation after MVI, while massive transfusion (MT) does not. METHODS We performed a retrospective review of patients with infrarenal MVI from 2005 to 2015 at seven urban level I trauma centers. The outcome of interest was the need for secondary amputation. RESULTS 478 patients were included. 31 (6.5%) patients with MVI required amputation. LVCR(p < 0.001), combined arterial/venous injury (p = 0.001), and associated fracture (p = 0.001) were significant risk factors for amputation. MT did not significantly increase amputation risk (p = 0.44). Multivariable logistic regression model demonstrated that patients receiving ≥5L LVCR(aOR (95% CI): 9.7 (2.9, 33.0); p < 0.001), with combined arterial/venous injury (aOR (95% CI):3.6 (1.5, 8.5); p = 0.004), and with an associated fracture (aOR (95% CI):3.2 (1.5, 7.1); p = 0.004) were more likely to require amputation. CONCLUSION Patients with MVI who receive LVCR, have combined arterial/venous injuries and have associated fractures are more likely to require amputation. MT was not associated with delayed amputation.
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Affiliation(s)
- Elizabeth Dauer
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Seiji Yamaguchi
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Daohai Yu
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Xiaoning Lu
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - Kathyrn Kelley
- Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad Street, Philadelphia, PA, 19140, USA.
| | - John Sharpe
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38163, USA.
| | - Nathan Manley
- Department of Surgery, University of Tennessee Health Science Center, 910 Madison Avenue, Memphis, TN 38163, USA.
| | - John A Harvin
- Department of Surgery, University of Texas at Houston Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX, 77030, USA.
| | - Ethan A Taub
- Department of Surgery, University of Texas at Houston Health Science Center, 6431 Fannin Street, MSB 4.264, Houston, TX, 77030, USA.
| | - Anna Goldenberg-Sandau
- Department of Surgery, Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ, 08103, USA.
| | - Krishan Patel
- Department of Surgery, Cooper Medical School of Rowan University, 401 Broadway, Camden, NJ, 08103, USA.
| | - Ellen Omi
- Advocate Christ Medical Center, 4440 95th St, Oak Lawn, IL, 60453, USA.
| | - Hassan Mashbari
- Advocate Christ Medical Center, 4440 95th St, Oak Lawn, IL, 60453, USA.
| | - Jennifer Hartwell
- Department of Surgery, Indiana University School of Medicine, 1604 N. Capitol Ave, B232, Indianapolis, IN, 46202, USA.
| | - Jason Brocker
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD, 21201, USA.
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Sen P, Demirdal T, Emir B. Meta-analysis of risk factors for amputation in diabetic foot infections. Diabetes Metab Res Rev 2019; 35:e3165. [PMID: 30953392 DOI: 10.1002/dmrr.3165] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Knowledge of risk factors is crucial to develop management and treatment protocols for the prevention of lower extremity amputation for patients with diabetic foot infections (DFIs). METHODS We searched the research literature for studies reporting risk factors for lower extremity amputation in patients with DFI. The main outcome variables included both minor and major amputations. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and the protocol was registered in PROSPERO (CRD42018118543). RESULTS A total of 2471 potential articles from the database search met the inclusion criteria. After reviewing the titles, abstracts, and full texts, remaining 25 articles were included in the final analysis. We identified 6132 patients with DFI in the 25 included articles. Of these, 1873 patients who underwent amputation were investigated. Male gender (odds ratio [OR]: 1.31), smoking (OR: 1.38), history of amputation (OR: 1.47), history of osteomyelitis (OR: 1.94), peripheral arterial disease (OR: 2.35), retinopathy (OR: 1.32), International Working Group on the Diabetic Foot (IWGDF) grades 3 and 4 (OR: 1.7 and 2.5), Wagner grades 4 and 5 (OR: 4.3 and 6.4), gangrene/necrosis (OR: 9.9), osteomyelitis (OR: 4.5), neuroischaemic DFI (OR: 3.06), severe infection (OR: 3.12), length of hospitalization (standardized mean difference [SMD]: 0.7), leukocytosis (OR: 1.76), mean erythrocyte sedimentation rate (ESR) (SMD: 0.5), mean C-reactive protein (CRP) (SMD: 0.8), tissue culture positivity (OR: 1.61), and isolation of Gram-negative bacteria from tissue culture (OR: 1.5) were found as predictors of amputation in DFI. CONCLUSIONS The present study highlighted some differences in diabetic foot ulcers and DFIs in terms of risk factors for lower extremity amputation. These data provide detailed information about risk factors for amputations among patients with DFI, thus contributing to the creation of new classification systems for assessment of high-risk patients.
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Affiliation(s)
- Pinar Sen
- Department of Infectious Diseases and Clinical Microbiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Tuna Demirdal
- Department of Infectious Diseases and Clinical Microbiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Busra Emir
- Department of Biostatistics, Izmir Katip Celebi University School of Medicine, Izmir, Turkey
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Dubský M, Jirkovská A, Bem R, Němcová A, Fejfarová V, Hazdrová J, Sutoris K, Chlupáč J, Skibová J, Jude EB. Impact of severe diabetic kidney disease on the clinical outcome of autologous cell therapy in people with diabetes and critical limb ischaemia. Diabet Med 2019; 36:1133-1140. [PMID: 31077439 DOI: 10.1111/dme.13985] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 12/21/2022]
Abstract
AIM To assess the impact of autologous cell therapy on critical limb ischaemia in people with diabetes and diabetic kidney disease. METHODS A total of 59 people with diabetes (type 1 or type 2) and critical limb ischaemia, persisting after standard revascularization, were treated with cell therapy in our foot clinic over 7 years; this group comprised 17 people with and 42 without severe diabetic kidney disease. The control group had the same inclusion criteria, but was treated conservatively and comprised 21 people with and 23 without severe diabetic kidney disease. Severe diabetic kidney disease was defined as chronic kidney disease stages 4-5 (GFR <30 ml/min/1.73 m²). Death and amputation-free survival were assessed during the 18-month follow-up; changes in transcutaneous oxygen pressure were evaluated at 6 and 12 months after cell therapy. RESULTS Transcutaneous oxygen pressure increased significantly in both groups receiving cell therapy compared to baseline (both P<0.01); no significant change in either of the control groups was observed. The cell therapy severe diabetic kidney disease group had a significantly longer amputation-free survival time compared to the severe diabetic kidney disease control group (hazard ratio 0.36, 95% CI 0.14-0.91; P=0.042); there was no difference in the non-severe diabetic kidney disease groups. The severe diabetic kidney disease control group had a tendency to have higher mortality (hazard ratio 2.82, 95% CI 0.81-9.80; P=0.062) than the non-severe diabetic kidney disease control group, but there was no difference between the severe diabetic kidney disease and non-severe diabetic kidney disease cell therapy groups. CONCLUSIONS The present study shows that autologous cell therapy in people with severe diabetic kidney disease significantly improved critical limb ischaemia and lengthened amputation-free survival in comparison with conservative treatment; however, the treatment did not influence overall survival.
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Affiliation(s)
- M Dubský
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Jirkovská
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - R Bem
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - A Němcová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - V Fejfarová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Hazdrová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - K Sutoris
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Chlupáč
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Skibová
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - E B Jude
- Diabetes Centre, Tameside Hospital NHS Foundation Trust and University of Manchester, Manchester, UK
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Rollo G, Falzarano G, Ronga M, Bisaccia M, Grubor P, Erasmo R, Rocca G, Tomé-Bermejo F, Gómez-Garrido D, Pichierri P, Rinonapoli G, Meccariello L. Challenges in the management of floating knee injuries: Results of treatment and outcomes of 224 consecutive cases in 10 years. Injury 2019; 50 Suppl 4:S30-S38. [PMID: 30910244 DOI: 10.1016/j.injury.2019.03.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 12/01/2018] [Accepted: 12/04/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and the ipsilateral tibia. It is usually associated with several complications and mortality. This study was designed to present our experience with the treatment of this injury. MATERIAL AND METHOD This study was performed between January 2004 and December 2014. 224 cases of floating knee injuries gathered from the 34,480 lower extremities trauma files were studied, and the target information recorded. The injuries most frequently occurred in subjects between 16 and 35 years of age (60.71%), and in male subjects (85.71%). The most frequent mechanism of injury was traffic accident (92.85%). External fixation was the common type of treatment (82.14%) in emergency or as a definitive treatment. The treatment was performed within 24 h of the trauma. We performed a 36-month follow up with clinical examination, radiographs, assessing the complications, and using the Modified Cincinnati Rating System Questionnaire (MCRSQ) and the Karlström/Olerud Score (KOS) to evaluate the progression of the outcomes. RESULTS Early complications included 8 cases of compartment syndrome, 60 open fractures and 24 partially amputated limbs. A total amputation was performed in 3 patients. The most common late complication was heterotopic calcifications of the knee (n = 68, 30.6%). Good scores for MCRSQ and KOS were obtained only after patients were sent to a reference center for knee surgery. CONCLUSIONS Our experience revealed that the complication rate associated with floatingknee injuries remains high, regardless of the performed treatment. Surgeons should focus on reducing complications while treating these severe injuries.
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Affiliation(s)
- Giuseppe Rollo
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Gabriele Falzarano
- Department of Orthopedics and Traumatology, Azienda Ospedaliera "Gaetano Rummo", Benevento, Italy
| | - Mario Ronga
- Department of Medicine and Health Sciences 'Vincenzo Tiberio' University of Molise, Campobasso, Italy
| | - Michele Bisaccia
- Department of Orthopedics and Traumatology, Azienda Ospedaliera "Santa Maria della Misericordia", Perugia, Italy
| | - Predrag Grubor
- Clinic of Traumatology, University Hospital Clinical Center Banja Luka, Banja Luka, Bosnia and Herzegovina
| | - Rocco Erasmo
- Department of Orthopedics and Traumatology, Santo Spirito Hospital, Pescara, Italy
| | - Guido Rocca
- Department of Orthopedics and Traumatology, Trauma Center "Pietro Cosma", Camposampiero, PD, Italy
| | - Felix Tomé-Bermejo
- Orthopaedic and Traumatology Unit, Hospital General de Villalba, Madrid, Spain
| | - David Gómez-Garrido
- Orthopaedic and Traumatology Unit, Hospital General de Villalba, Madrid, Spain
| | - Paolo Pichierri
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy
| | - Giuseppe Rinonapoli
- Department of Orthopedics and Traumatology, Azienda Ospedaliera "Santa Maria della Misericordia", Perugia, Italy
| | - Luigi Meccariello
- Department of Orthopedics and Traumatology, Vito Fazzi Hospital, Lecce, Italy.
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Golledge J, Singh TP. Systematic review and meta-analysis of clinical trials examining the effect of hyperbaric oxygen therapy in people with diabetes-related lower limb ulcers. Diabet Med 2019; 36:813-826. [PMID: 31002414 DOI: 10.1111/dme.13975] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 11/29/2022]
Abstract
AIM To examine the efficacy of hyperbaric oxygen therapy in healing diabetes-related lower limb ulcers through a meta-analysis of randomized clinical trials. METHODS A literature search was conducted to identify appropriate clinical trials. Inclusion required randomized study design and reporting of the proportion of diabetes-related lower limb ulcers that healed. A meta-analysis was performed to examine the effect of hyperbaric oxygen therapy on ulcer healing. The secondary outcomes were minor and major amputations. RESULTS Nine randomized trials involving 585 participants were included. People allocated to hyperbaric oxygen therapy were more likely to have complete ulcer healing (relative risk 1.95, 95% CI 1.51-2.52; P<0.001), and less likely to require major (relative risk 0.54, 95% CI 0.36-0.81; P=0.003) or minor (relative risk 0.68, 95% CI 0.48-0.98; P=0.040) amputations than control groups. Sensitivity analyses suggested the findings were dependent on the inclusion of one trial. Adverse events included ear barotrauma and a seizure. Many of the trials were noted to have methodological weaknesses including absence of blinding of outcome assessors, lack of a justifiable sample size calculation and limited follow-up. CONCLUSIONS This meta-analysis suggests hyperbaric oxygen therapy improves the healing of diabetes-related lower limb ulcers and reduces the requirement for amputation. Confidence in these results is limited by significant design weaknesses of previous trials and inconsistent findings. A more rigorous assessment of the efficacy of hyperbaric the efficacy of hyperbaric oxygen therapy is needed.
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Affiliation(s)
- J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, QLD, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD, Australia
| | - T P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, QLD, Australia
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Katsiki N, Dimitriadis G, Hahalis G, Papanas N, Tentolouris N, Triposkiadis F, Tsimihodimos V, Tsioufis C, Mikhailidis DP, Mantzoros C. Sodium-glucose co-transporter-2 inhibitors (SGLT2i) use and risk of amputation: an expert panel overview of the evidence. Metabolism 2019; 96:92-100. [PMID: 30980838 DOI: 10.1016/j.metabol.2019.04.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 12/12/2022]
Abstract
Sodium-glucose co-transporter-2 inhibitors (SGLT2i) are oral antidiabetic agents that exert their glucose-lowering effect by increasing renal excretion of glucose. These drugs have been reported to beneficially affect cardiovascular (CV) and renal outcomes. However, concerns have recently been raised in relation to increased risk of lower-extremities amputation with canagliflozin and it remains unclear whether and to what extent this side effect could also occur with other SGLT2i. The present expert panel overview focuses on the three SGLT2i available and widely used in the US and Europe, i.e. empagliflozin, canagliflozin and dapagliflozin and only refers briefly to other SGLT2i for which less data are available. The results of large CV outcome trials with these SGLT2i are presented, focusing specifically on the data in relation to amputation risk. The potential pathophysiological mechanisms involved in this side effect are discussed. Furthermore, available data reporting amputation cases in SGLT2i users are critically reviewed. The expert panel concludes that, based on current data, increased amputation risk seems to be related only to canagliflozin, thus representing a drug-effect rather than a SGLT2i class-effect. The exact pathways underlying this drug-induced adverse event, possibly related to off-target drug effects rather than SGLT2 inhibition per se, should be elucidated in future studies. Continuous monitoring and pharmacovigilance is necessary and head to head trials would also be essential to provide definitive conclusions.
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Affiliation(s)
- Niki Katsiki
- First Department of Internal Medicine, Division of Endocrinology and Metabolism, Diabetes Center, Medical School, AHEPA University Hospital, Thessaloniki, Greece.
| | - George Dimitriadis
- 2nd Department of Internal Medicine, Research Institute and Diabetes Center, "Attikon" University hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - George Hahalis
- Department of Cardiology, University of Patras Medical School, Patras, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Nikolaos Tentolouris
- First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | | | - Vasilios Tsimihodimos
- Department of Internal Medicine, School of Medicine, University of Ioannina, Ioannina, Greece
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Campus, University College London Medical School, University College London (UCL), London, UK.
| | - Christos Mantzoros
- Beth-Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Section of Endocrinology, Boston VA Healthcare System, Harvard Medical School, Boston, MA, USA
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Gojowy D, Kauke M, Ohmann T, Homann HH, Mannil L. Early and late-recorded predictors of health-related quality of life of burn patients on long-term follow-up. Burns 2019; 45:1300-1310. [PMID: 31176508 DOI: 10.1016/j.burns.2019.03.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 03/06/2019] [Accepted: 03/26/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Unintentional and intentional burn injuries vary across age groups, gender, income, and global region. In high-income countries, the trend over the last several years has been a reduction in burn incidence, burn severity, length of hospital stay, and mortality rate. However, there is a lack of data on predictors of the health-related quality of life (HRQoL) of major burn survivors extending beyond a follow-up period of 10 years. PATIENTS AND METHODS This single-center cross-sectional study is considering 42 long-term severe burn survivors with deep partial thickness burns and an affected total body surface area (TBSA) of ≥20%. For study eligibility design a minimum follow-up of 10 years was obligatory. Entitled individuals were asked to fill in the generic Short Form 36 (SF-36) questionnaire. The physical (PCS) and mental (MCS) component scores of the SF-36 were used as the primary outcome variables. Putative predictor variables were drawn from medical records. Burn-specific functionality and scar tissue quality were assessed using the Burn Specific Health Scale-Brief (BSHS-B) questionnaire and the Patient and Observer Scar Assessment Scale (POSAS), respectively. Correlation between putative predictor variables and SF-36 norm scores were evaluated by Pearson- and Point-Biserial correlation as well as multivariate linear regression. The SF-36 norm scores were compared to the general German population. RESULTS Mean follow-up was 14 (±3) years with a minimum and maximum of 10 and 28 years, respectively. Mean age at the time of the incident was 37 (±17) years. The majority of individuals were male (74%). The mean burn size was 39 (±17) % (TBSA) with 76% of the individuals showing a full thickness burn. SF-36 norm scores were not statistically different from the general population. Statistically significant independent predictor variables of the physical summary score were: age at the time of the injury (-0.381), time since injury (-0.466), length of hospital stay (-0.356), limb amputation (-0.318), unemployment (-0.433), work (0.593), hand function (0.601), body image (0.518), affect (0.355), simple abilities (0.602), burns involving the hands (-0.339) and back (-0.343), POSAS patient- (-0.521) and observer scores (-0.483). In multivariate analysis, work (4.315), the POSAS Score (-2.082) and the age at the time of the incident (-0.242) were statistically significant predictors. Statistically significant independent predictor variables of the mental summary score were: duration of mechanical ventilation (-0.459), hand function (0.415), body image (0.502), sexual activity (0.625), social support (0.542), burns involving the back (-0.315) and affect (0.692). In multivariate analysis, affect (13.844) and the length of mechanical ventilation (-0.115) were statistically significant independent predictor variables. CONCLUSION Ten years after the burn incident, the quality of life was on average comparable to the one in the general population. Multiple variables seem to influence the physical and mental long-term outcome. Herein presented data may support in adapting and designing follow-up strategies tailored to a patient's burn-specific circumstances.
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Affiliation(s)
- David Gojowy
- Department for Hand Surgery and Plastic Surgery, Burn Center, BG Trauma Center Duisburg, Klinikum Duisburg, Germany.
| | - Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Ohmann
- Department for Hand Surgery and Plastic Surgery, Burn Center, BG Trauma Center Duisburg, Klinikum Duisburg, Germany
| | - Heinz-Herbert Homann
- Department for Hand Surgery and Plastic Surgery, Burn Center, BG Trauma Center Duisburg, Klinikum Duisburg, Germany
| | - Lijo Mannil
- Department for Plastic and Aesthetic Surgery, St. Vinzenz Hospital, Cologne, Germany
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112
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Yang JY, Wang T, Pate V, Gower EW, Crowley MJ, Buse JB, Stürmer T. Sodium-glucose co-transporter-2 inhibitor use and risk of lower-extremity amputation: Evolving questions, evolving answers. Diabetes Obes Metab 2019; 21:1223-1236. [PMID: 30697897 PMCID: PMC6459697 DOI: 10.1111/dom.13647] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 01/11/2019] [Accepted: 01/24/2019] [Indexed: 02/06/2023]
Abstract
AIM To examine whether sodium-glucose co-transporter-2 (SGLT2) inhibitors are associated with a higher risk of lower-extremity amputation than dipeptidyl-peptidase-4 (DPP-4) inhibitors and sulphonylureas. METHODS We conducted a retrospective cohort study, using the MarketScan Commercial Claims and Encounters Database (2013-2015), to compare the incidence of lower-extremity amputation (LEA) between initiators of SGLT2 inhibitors and initiators of two second-line drugs, DPP-4 inhibitors and sulphonylureas (SUs). We estimated crude incidence rates (IRs) and adjusted hazard ratios (aHR), with 95% confidence intervals (CIs), before and after propensity-score weighting. We additionally conducted sensitivity analyses using a comparator group of all non-metformin, non-SGLT2 inhibitor glucose-lowering drugs, as previous studies used this approach. RESULTS In a cohort of 328 150 individuals aged 18 to 64 years, the IR of LEA ranged from 1.5 to 2.4 per 1000 person-years. In as-treated analysis, the estimated hazard of LEA was increased among SGLT2 inhibitor initiators compared to DPP-4 inhibitor initiators (aHR 1.69, 95% CI 1.20-2.38), but not compared to SU initiators (aHR 1.02, 95% CI 0.67-1.55) or non-metformin, non-SGLT2 inhibitor initiators (aHR 1.02, 95% CI 0.54-1.93). Results were consistent in intention-to-treat analysis and across a number of sensitivity analyses. CONCLUSIONS Among commercially insured patients in the United States, our results suggest that initiation of SGLT2 inhibitors may increase the risk of LEA compared to initiation of DPP-4 inhibitors. Contrasting results when comparing SGLT2 inhibitor initiators to DPP-4 inhibitor and SU initiators highlight the importance of choosing appropriate comparator drugs when addressing comparative effectiveness and safety questions that can inform clinical decision-making.
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Affiliation(s)
- Jeff Y. Yang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Tiansheng Wang
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Virginia Pate
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Emily W. Gower
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | | | - John B. Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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Bonilla GA, Hornsby PP, Pannone AF, Case SK, Aviles ES, Carrasco Apolinario ME, Mercedes D, Mota A, Ibrahim A. Demographic and clinical characteristics of dominican adults admitted to a diabetic foot clinic in the Dominican Republic, 2015. Diabetes Metab Syndr 2019; 13:1727-1732. [PMID: 31235085 DOI: 10.1016/j.dsx.2019.03.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 03/21/2019] [Indexed: 12/26/2022]
Abstract
AIM To identify the demographic and clinical characteristics of Dominican adults admitted to a diabetic foot clinic and compare these characteristics by sex to better characterize and understand the severity of diabetes in the Dominican Republic. METHODS We conducted a retrospective medical chart review of Dominican adults admitted to the National Institute of Diabetes, Endocrinology, and Nutrition's (INDEN) diabetic foot clinic between January 1st, 2015 and December 31st, 2015. We generated descriptive statistics and compared results by sex. RESULTS We assessed 447 medical charts of patients admitted in 2015. More men visited the clinic than women (65% vs. 35%). The average duration of diabetes was 14.4 ± 8.9 years. Abscess was the most common foot problem (74% in men, 68% in women, p = 0.164). A slightly smaller proportion of men received amputations than women (46% vs. 51%, p = 0.390). Women were older (p < 0.001), less educated (p = 0.004), and less likely to be married (p < 0.001). Women also exhibited higher rates of obesity (p = 0.003), hypertension (p = 0.005), cardiovascular disease (p = 0.011), ischemic foot (p = 0.008), and above the knee amputations (p = 0.002). CONCLUSION Implementation of diabetes education programs, introduction of proper foot care, and improved resources for lifestyle management are needed to increase awareness and subsequently decrease diabetes and its negative impact on the health and economy of the Dominican Republic. Our findings suggest that various risk factors and comorbidities important to the development of diabetes may be disproportionately affecting women. Interventions should focus on women and their behaviors that increase risk for diabetes.
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Affiliation(s)
| | | | | | - Samuel K Case
- University of Virginia School of Medicine, United States
| | | | | | - Desideria Mercedes
- National Institute of Diabetes, Endocrinology, and Nutrition, Dominican Republic
| | - Aura Mota
- National Institute of Diabetes, Endocrinology, and Nutrition, Dominican Republic
| | - Ammar Ibrahim
- National Institute of Diabetes, Endocrinology, and Nutrition, Dominican Republic
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Abstract
INTRODUCTION Diabetic foot disease has been considered as an important complication of diabetes mellitus. The main risk factor to cause diabetic foot disease is peripheral neuropathy. Diabetic foot disease usually started from diabetic foot ulceration, it would develop to diabetic foot infection and amputation even death when conducting the poor prognosis and management of diabetic foot ulceration. Despite this, incidence of diabetic foot disease is still increasing and is therefore potentially under-recognized, under-diagnosed and under-treated all over the word, especially in the US. The aim of this study is to clarify the needs of the adults at risk and health care providers in diagnosis and treatment of diabetic foot disease in the US. METHODS Cochrane library, bibliographic databases, American Diabetes Association website and DFS questionnaire website have been used to search the relevant literature of diabetic foot disease among adults in the US. Additionally, conducting subgroup analysis to review the relevant literature. RESULTS The findings of this health needs assessment described that diabetic foot disease in the adults is higher in men than women in the US. American Indian achieved the highest prevalence of diabetic foot disease, in comparison to other ethnic groups. Meanwhile, age has been defined as an important factor to influence the diabetic foot disease rate. Diagnosing properly is important, in accordance with understanding the etiopathogenesis of diabetic foot disease for health professionals. A comprehensive Foot Examination has been established and developed by the American Diabetes Association (ADA). It has been used widely with the characters of easy conducting and rapid performance. Moreover, treatment of DFUs with becaplermin gel obtained the lower cost and the larger clinical benefit when comparing the traditional wound care.
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Affiliation(s)
- Hanxu Shi
- Department of Public Health, University of Aberdeen, Aberdeen, AB25 2ZD, United Kingdom.
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115
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Alghnam S, Alsulaim HA, BinMuneif YA, Al-Zamil A, Alahmari A, Alshafi A, Alsaif A, Albabtain I. Injuries following motorcycle crashes at a level-1 trauma center in Riyadh. Ann Saudi Med 2019; 39:185-191. [PMID: 31215223 PMCID: PMC6832331 DOI: 10.5144/0256-4947.2019.185] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/02/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Motor vehicle crashes are the third leading cause of death in Saudi Arabia. Motorcycle riders, in particular, are considered more vulnerable than occupants, yet there are no previous studies that have examined the epidemiology of their injuries and outcomes in the country. Better understanding is needed to inform policymakers and guide future prevention programs. OBJECTIVE Describe patterns of injury among conscious and unconscious patients injured in motorcycle crashes. DESIGN Retrospective chart review. SETTINGS Level 1 trauma center in Riyadh. PATIENTS AND METHODS This retrospective study included all patients involved in motorcycle crashes who were admitted between 2001 and 2017. Medical records were reviewed, and data about injury characteristics, outcomes and healthcare utilization were ascertained. MAIN OUTCOME MEASURES Injury site and mortality rate. SAMPLE SIZE AND CHARACTERISTICS 572 patients included 488 males (85.3%) and 232 <18 years of age (40.5%), mean (SD) age 21.1 (11.6) years. RESULTS About 3% of patients died either before or after admission. Extremity injuries (356, 62.2%) were most common followed by head injuries (229, 40%). Fifty-six (9%) suffered amputation, mostly to a lower limb. CONCLUSION This study underscores the significant burden of motorcycle-related injuries on population health of Saudi Arabia. The number of amputations due to motorcycle injuries is striking. Therefore, we need to increase enforcement of safety measures during recreational use of motorcycles and to raise awareness about the dangers of motorcycle crashes to improve traffic safety and ultimately population health. LIMITATIONS The study was conducted at a single hospital which may affect the generalizability of the data to the Saudi population. CONFLICT OF INTEREST None.
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Affiliation(s)
- Suliman Alghnam
- From the Department of Population Helath, King Abdullah International Research Center, Riyadh, Saudi Arabia
| | - Hatim A. Alsulaim
- From the Department of Surgery, Unaizah College of Medicine, Qassim University, Qassim, Saudi Arabia
| | | | - Abdulmohsen Al-Zamil
- From the College of Medicine, Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
| | - Abdullah Alahmari
- From the College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Abdullah Alshafi
- From the College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Ahmad Alsaif
- From the College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ibrahim Albabtain
- From the Department of Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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116
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Bai HX, Davis AJO, Mantell MP, Troiano MA, Brandis AW, Redmond JRB, Clark TWI. Prediction of Limb Salvage Following Percutaneous Vascular Intervention Using a Composite Tibial Artery Perfusion Score. Cardiovasc Intervent Radiol 2019; 42:1080-1087. [PMID: 31001667 DOI: 10.1007/s00270-019-02223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 04/11/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess a novel tibial artery perfusion score (TPS) for predicting limb salvage in critical limb ischemia (CLI) patients undergoing percutaneous vascular intervention (PVI). PATIENTS AND METHODS A consecutive cohort of 115 CLI patients undergoing PVI in 144 limbs from 2011 to 2016 was analyzed. TPS comprised a 27-point scale based on: (1) patent tibial vessels following PVI, (2) severity of calcification of the tibial arteries, (3) presence of an intact pedal arch following intervention, (4) whether or not revascularization was direct or indirect based on the target angiosome, (5) presence of angiosome blush at the completion of index intervention. Limbs were stratified into (1) High [21-27 points], (2) Medium [13-20 points], and (3) Low [0-12 points] TPS. Predictive value of TPS was evaluated using logistic regression and Cox proportional hazards models. RESULTS The median follow-up was 15.7 months (range 0.4-69.9 months). Limb salvage in High, Medium, and Low TPS groups was 90.6%, 85.9%, and 55.6%, respectively, as freedom from the composite outcome: (1) limb complication resulting in death, (2) tibial bypass surgery, (3) above-the-knee amputation, or (4) below-the-knee amputation in patients without supratibial disease at the time of PVI. TPS was significantly associated with limb salvage defined as freedom from both the composite outcome and major amputation. CONCLUSIONS Based on this preliminary investigation, TPS was associated with limb salvage in CLI limbs, particularly in high-risk limbs. Further validation in a prospective cohort may identify patients with high-risk limbs in need of closer surveillance and earlier reintervention. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Harrison X Bai
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Andrew J O Davis
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Mark P Mantell
- Division of Vascular Surgery, Department of Surgery, Penn Presbyterian Medical Center, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Michael A Troiano
- Department of Podiatry, Penn Presbyterian Medical Center, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Aaron W Brandis
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Jonas R B Redmond
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA
| | - Timothy W I Clark
- Section of Interventional Radiology, Department of Radiology, Penn Presbyterian Medical Center, Perelman School of Medicine, University of Pennsylvania, 39th and Market Streets, Philadelphia, PA, 19104, USA.
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Carceller A, Javierre C, Ríos M, Viscor G. Amputation Risk Factors in Severely Frostbitten Patients. Int J Environ Res Public Health 2019; 16:ijerph16081351. [PMID: 30991721 PMCID: PMC6517929 DOI: 10.3390/ijerph16081351] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/04/2019] [Accepted: 04/10/2019] [Indexed: 01/20/2023]
Abstract
In recent years, the incidence of frostbite has increased among healthy young adults who practice winter sports (skiing, mountaineering, ice climbing and technical climbing/alpinism) at both the professional and amateur levels. Moreover, given that the population most frequently affected is healthy and active, frostbite supposes a substantial interruption of their normal activity and in most cases is associated with long-term sequelae. It particularly has a higher impact when the affected person’s daily activities require exposure to cold environments, as either sports practices or work activities in which low temperatures are a constant (ski patrols, mountain guides, avalanche forecasters, workers in the cold chain, etc.). Clinical experience with humans shows a limited reversibility of injuries via potential tissue regeneration, which can be fostered with optimal medical management. Data were collected from 92 frostbitten patients in order to evaluate factors that represent a risk of amputation after severe frostbite. Mountain range, years of expertise in winter mountaineering, time elapsed before rewarming and especially altitude were the most important factors for a poor prognosis.
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Affiliation(s)
- Anna Carceller
- Secció de Fisiologia, Departament de Biologia Cel·lular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain.
- Medical Commission of the International Federation for Climbing and Mountaineering (UIAA MedCom), CH 3000 Bern, Switzerland.
| | - Casimiro Javierre
- Departament de Ciències Fisiològiques, Facultat de Medicina, Universitat de Barcelona, 08907 Barcelona, Spain.
| | - Martín Ríos
- Secció d'Estadística, Departament de Genètica, Estadística i Microbiologia, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain.
| | - Ginés Viscor
- Secció de Fisiologia, Departament de Biologia Cel·lular, Fisiologia i Immunologia, Facultat de Biologia, Universitat de Barcelona, 08028 Barcelona, Spain.
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118
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Abstract
Sodium glucose co-transporter 2 inhibitors (SGLT2is) are the first class of glucose lowering agent to be shown to reduce cardiovascular events. They are generally well tolerated with infrequent serious adverse events. The most frequent side effect is genital mycotic infections with candida species that are usually mild to moderate in severity, easily treated and infrequently recur. Urinary tract infections, although common in patients with diabetes, have not been shown to be increased in controlled studies with SGLT2i. Hypoglycaemia can occur when an SGLT2i is added to agents that cause hypoglycaemia, such as insulin or sulphonylureas. Volume depletion and hypotension is infrequent and can be minimized by adjusting diuretic and antihypertensive treatment in patients at risk. Acute renal failure or kidney injury was observed in early observational studies. However, in randomized controlled trials (RCTs) and in more recent observational studies a decreased incidence of acute kidney injury was observed in SGLT2-treated patients compared to those receiving either placebo or another class of glucose lowering agents. An increased incidence of amputation (largely feet and toes) was observed in the RCT with canagliflozin but not with the other SGLT2i. Observational studies have shown either an increased risk of amputation with other agents whereas another study showed no increase. Although the increased risk of amputation is very low, avoidance of SGLT2i in patients at high risk seems prudent. Increased incidence of fractures was observed with canagliflozin but not with SGLT2i nor in a meta-analysis that included canagliflozin, empagliflozin and dapagliflozin. No increased incidence of cancer has been observed in either RCTs or observational studies.
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Affiliation(s)
- David Fitchett
- Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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119
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Abstract
OBJECTIVE To determine whether tibial neurolysis performed as a surgical intervention for patients with diabetic neuropathy and superimposed tibial nerve compression in the prevention of the diabetic foot is cost-effective when compared with the current prevention programme. DESIGN A baseline analysis was built on a 5-year model to determine the cumulative incidence of foot ulcers and amputations with each strategy. Subsequently, a cost-effectiveness analysis and cohort-level Markov simulations were conducted with a model composed of 20 6-month cycles. A sensitivity analysis was also performed. SETTING A Markov model was used to simulate the effects of standard prevention compared with tibial neurolysis on the long-term costs associated with foot ulcers and amputations. This model included eight health states. PARTICIPANTS Each cohort includes simulated patients with diabetic neuropathy at different levels of risk of developing foot ulcers and amputations. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was the long-term trends concerning the development of ulcers and amputations with each strategy. The secondary outcome measures were quality adjusted life years (QALYs), incremental cost-effectiveness and net monetary benefits of the optimal strategy. RESULTS When compared with standard prevention, for a patient population of 10 000, surgery prevented a simulated total of 1447 ulcers and 409 amputations over a period of 5 years. In a subsequent analysis that consisted of 20 6-month cycles (10 years), the incremental cost of tibial neurolysis compared with current prevention was $12 772.28; the incremental effectiveness was 0.41 QALYs and the incremental cost-effectiveness ratio was $31 330.78. Survival was 73% for those receiving medical prevention compared with 95% for those undergoing surgery. CONCLUSION These results suggest that among patients with diabetic neuropathy and superimposed nerve compression, surgery is more effective at preventing serious comorbidities and is associated with a higher survival over time. It also generated greater long-term economic benefits.
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Affiliation(s)
- Samuel Sarmiento
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James A Pierre
- Department of Anesthesiology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin D Frick
- Johns Hopkins University Carey Business School, Baltimore, Maryland, USA
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Sarfo-Kantanka O, Sarfo FS, Kyei I, Agyemang C, Mbanya JC. Incidence and determinants of diabetes-related lower limb amputations in Ghana, 2010-2015- a retrospective cohort study. BMC Endocr Disord 2019; 19:27. [PMID: 30823912 PMCID: PMC6397489 DOI: 10.1186/s12902-019-0353-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 02/21/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Diabetes-related lower limb amputations (LLA) are associated with significant morbidity and mortality. Although the incidence has decreased over the past two decades in most High-Income Countries, the situation in Low-Middle Income Countries (LMIC), especially those in sub-Saharan Africa (SSA) is not clear. We have determined the incidence and determinants of diabetes-related LLA in Ghana. METHODS This was a tertiary-care-based retrospective cohort study involving patients enrolled in the diabetes clinic of Komfo Anokye Teaching Hospital, Ghana from 1st January 2010 to 31st December 2015 after a median follow-up of 4.2 years. Demographic characteristics and clinical variables at baseline were recorded. The primary outcome was new diabetes-related LLA in each year under study. Cox proportional hazard regression models were used to describe the associations of diabetes-related LLA. RESULTS The mean age at enrolment for the cohort was 55.9 ± 14.6 years, with a female preponderance (62.1%). The average incidence rate of diabetes-related LLA was 2.4 (95% CI:1.84-5.61) per 1000 follow-up years: increasing from 0.6% (95% CI:0.21-2.21) per 1000 follow up years in 2010 to 10.9% (95% CI:6.22-12.44) per 1000 follow-up years in 2015. Diabetes-related LLA was associated with increased age at enrollment (for every 10 year increase in age: HR: 1.11, CI: 1.06-1.22, p < 0.001), male gender (HR: 3.50, CI:2.88-5.23, p < 0.01), type 2 diabetes (HR 3.21, CI: 2.58-10.6, p < 0.001), high Body Mass Index (HR: 3.2, CI: 2.51-7.25 p < 0.001), poor glycemic control (for a percent increase in HbA1c, HR:1.11, CI:1.05-1.25, p = 0.03), hypertension (HR:1.14, CI:1.12-3.21 p < 0.001), peripheral sensory neuropathy (HR:6.56 CI:6.21-8.52 p < 0.001) and peripheral vascular disease (HR: 7.73 CI: 4.39-9.53, p < 0.001). CONCLUSION The study confirms a high incidence of diabetes related-LLA in Ghana. Interventions aimed at addressing systemic and patient-level barriers to good vascular risk factor control and proper foot care for diabetics should be introduced in LMICs to stem the tide of the increasing incidence of LLA.
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Affiliation(s)
- Osei Sarfo-Kantanka
- Komfo Anokye Teaching Hospital, Endocrine and Diabetes Unit, P.O Box 1934, Kumasi, Ghana
| | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Endocrine and Diabetes Unit, P.O Box 1934, Kumasi, Ghana
- Department of Medicine, Komfo Anokye Teaching Hospital/ School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Ishmael Kyei
- Komfo Anokye Teaching Hospital, Endocrine and Diabetes Unit, P.O Box 1934, Kumasi, Ghana
| | - Charles Agyemang
- Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jean Claude Mbanya
- Faculty of Medicine and Department of Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
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Zubair M, Ahmad J. Transcutaneous oxygen pressure (TcPO 2) and ulcer outcome in diabetic patients: Is there any correlation? Diabetes Metab Syndr 2019; 13:953-958. [PMID: 31336550 DOI: 10.1016/j.dsx.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/18/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Due to poor blood circulation, the prevalence of foot ulcer is extensively reported among diabetic patients. Diabetic neuropathy is the critical factor of diabetes that can affect the nerves. OBJECTIVE To examine the outcomes and correlation between TcPO2 and ulcer outcomes among diabetic patients. MATERIAL AND METHODS A prospective cohort design has been employed to compare and correlate TcPO2 group with ulcer outcomes. A total of 192 patients were enrolled, who underwent diagnosis for ulcer outcome. Descriptive analysis and Pearson Correlation were used for data analysis via SPSS version 20. RESULTS The prevalence of minor amputation among diabetic patients in 25-40 mmHg 75 (85.22%) and >40 mmhG 73 (84.88%) group is reported for ulcer outcome. Mostly diabetic patients were healed with intact skin (male = 36, female = 73), and improved ulcer healing (male = 23, female = 43). Correlation between ulcer size (p = .016), ABI (p = .044), TBI (p = .000), Adiponectin (p = .009), HbA1c (p = .033), and S. creatinine (p = .025) was significant with TcpO2 group. CONCLUSIONS The study concluded that there is a positive and significant correlation between TcPO2 group and ulcer outcome. There is a positive association between TcPO2 baseline and degree of ulcer healing with intact skin.
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Affiliation(s)
- Mohammad Zubair
- Department of Medical Microbiology, Faculty of Medicine, University of Tabuk, Tabuk, 71491, Saudi Arabia.
| | - Jamal Ahmad
- Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India
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Hu WS, Lin CL. A nationwide cohort study of the role of CHADS 2 score in predicting lower extremity amputation and death among patients with peripheral arterial occlusive disease. Aging Male 2019; 22:39-44. [PMID: 29580119 DOI: 10.1080/13685538.2018.1454420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVES The current study aimed to explore whether the CHADS2 score was predictive of lower extremity amputation (LEA) and death in people with peripheral arterial occlusive disease (PAOD). METHODS This nationwide cohort came from Taiwan, with 16,888 PAOD patients, from 2000 through 2011, extracted from the Longitudinal Health Insurance Database 2000. Cox proportional hazard regression models were employed to identify the LEA and mortality risk according to CHADS2 score. The discriminatory properties of the score in predicting the outcomes were quantified by the area under the receiver operating characteristic curve (AUROC) and the Cox C-index. RESULTS The AUROC of the CHADS2 score in predicting LEA and death were 0.75 (95% CI = 0.73-0.77) and 0.70 (95% CI = 0.69-0.71), respectively. The CHADS2 score had an acceptable stratification capacity for LEA (C-index = 0.79) and death (C-index = 0.76) based on Cox-regression analysis. CONCLUSIONS This study correlates the CHADS2 score with risk of developing LEA and death in patients with PAOD. The acceptable discriminative power of the score diversifies its predictive role in this population.
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Affiliation(s)
- Wei-Syun Hu
- a School of Medicine, College of Medicine , China Medical University , Taichung , Taiwan
- b Division of Cardiovascular Medicine, Department of Medicine , China Medical University Hospital , Taichung , Taiwan
| | - Cheng-Li Lin
- c Management Office for Health Data , China Medical University Hospital , Taichung , Taiwan
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Abstract
BACKGROUND Diabetes mellitus signifies a major public health threat worldwide. Type 2 diabetes has been reported as the fourth leading cause of death and has affected 15.5% of the adult population in Guyana, South America. Diabetes has also led to major lower extremity amputation at the only referral public hospital in Guyana. Diabetic foot and related complications are known to be multifactorial. CONCLUSION In this review, we highlight the information on the diabetic foot and related complications with an emphasis on Guyanese background.
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Affiliation(s)
- Rajini Kurup
- Faculty of Health Sciences, University of Guyana, Georgetown, South America, Guyana.
| | - Abdullah Adil Ansari
- Faculty of Health Sciences, University of Guyana, Georgetown, South America, Guyana.
| | - Jaipaul Singh
- School of Pharmacy and Forensic and Investigative Sciences, University of South Lancashire, Preston, Lancashire, United Kingdom.
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Abstract
BACKGROUND AND AIM Diabetic foot is a major comorbidity of diabetes, with 15-25% of diabetic patients developing diabetic foot ulcer during their lifetime. Other major diabetic foot complications include cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis. Dry gangrene involves tissue necrosis due to chronic ischemia whereby the tissue becomes numb, dry, wrinkled, and dead. Although diabetic foot complications have been extensively studied in literature, there is limited data on the management of dry gangrene. METHODS We report a case series of 12 patients with diabetes-related dry gangrene in the toes, initially planned to be managed conservatively with autoamputation. RESULTS One patient had an autoamputation, while eight patients underwent surgical amputations (six major amputations, two minor amputations) for better clinical outcomes. Two patients died, while no change was observed in one patient even after 12 months of follow-up. CONCLUSION Managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes and should be practiced cautiously on a case-by-case basis. Early surgical intervention should be opted to improve patients' quality of life.
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Affiliation(s)
- Abdullah Al Wahbi
- King Saud University for Health Sciences, Division of Vascular Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
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Abstract
OBJECTIVE To characterize indications for and clinical outcomes of limb amputation in goats and sheep. DESIGN Retrospective case series and observational study. ANIMALS Goats (n = 15) and sheep (7) that underwent partial or complete limb amputation at the University of California-Davis Veterinary Medical Teaching Hospital from January 1, 1985, through December 31, 2015. PROCEDURES Medical records of qualifying goats and sheep were reviewed and data extracted regarding signalment, use of animal, characteristics of the amputated limb, duration of hospitalization, outcome, and surgery-associated complications. The Fisher exact test was performed to compare postsurgical complication rates between various groups. RESULTS Reasons for limb amputation included trauma (ie, fracture, dog bite, and wire-fence injury) and infectious or degenerative disease (ie, osteomyelitis and osteoarthritis). Median (range) hospitalization period for goats and sheep was 7.5 days (1 to 63 days) and 8 days (3 to 20 days), respectively. Most (7/9) of the postsurgical complications were noticed > 2 months after amputation and included uncoordinated gait, tendon breakdown and laxity of the contralateral limb, chronic lameness, surgical site infection, chronic intermittent pain, and angular limb deformity. No association was identified between postsurgical complication rate in goats and body weight category (< 20 vs ≥ 20 kg [44 lb]), age category (< 2 vs ≥ 2 years), and amputated limb type (forelimb vs hind limb). CONCLUSIONS AND CLINICAL RELEVANCE Clinical outcomes for goats and sheep following limb amputation varied and were seemingly case dependent. Amputation should be considered when preservation of the whole limb is not possible. Veterinarians should advise owners that limb amputation may result in various complications and recommend aftercare treatment such as physiotherapy.
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Gariani K, Lebowitz D, von Dach E, Kressmann B, Lipsky BA, Uçkay I. Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors. Diabetes Obes Metab 2019; 21:244-251. [PMID: 30129109 DOI: 10.1111/dom.13507] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/30/2018] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Abstract
AIM To determine the most appropriate duration of antibiotic therapy for diabetic foot infections (DFIs). METHODS Using a clinical pathway for adult patients with DFIs (retrospective cohort analysis), we created a cluster-controlled Cox regression model to assess factors related to remission of infection, emphasizing antibiotic-related variables. We excluded total amputations as a result of DFI and DFI episodes with a follow-up time of <2 months. RESULTS Among 1018 DFI episodes in 482 patients, we identified 392 episodes of osteomyelitis, 626 soft tissue infections, 246 large abscesses, 322 episodes of cellulitis and 335 episodes of necrosis; 313 cases involved revascularization. Patients underwent surgical debridement for 824 episodes (81%), of which 596 (59%) required amputation. The median total duration of antibiotic therapy was 20 days. After a median follow-up of 3 years, 251 of the episodes (24.7%) were followed by ≥1 additional episode(s). Comparing patients with and without additional episodes, risk of recurrence was lower in those who underwent amputation, had type 1 diabetes, or underwent revascularization. On multivariate analysis including the entire study population, risk of remission was inversely associated with type 1 diabetes (hazard ratio [HR] 0.3, 95% confidence interval [CI] 0.2-0.6). Neither duration of antibiotic therapy nor parenteral treatment affected risk of recurrence (HR 1.0, 95% CI 0.99-1.01 for both). Similarly, neither >3 weeks versus <3 weeks of therapy, nor >1 week versus <1 week of intravenous treatment affected recurrence. In stratified analyses for both soft tissue DFIs or osteomyelitis separately, we did not observe associations of antibiotic duration with microbiological or clinical recurrences of DFI. The HRs were 1.0 (95% CI 0.6-1.8) for an antibiotic duration >3 weeks overall and 0.6 (95% CI 0.2-1.3) for osteomyelitis cases only. Plotting of duration of antibiotic therapy failed to identify any optimal threshold for preventing recurrences. CONCLUSIONS Our analysis found no threshold for the optimal duration or route of administration of antibiotic therapy to prevent recurrences of DFI. These limited data might support possibly shorter treatment duration for patients with DFI.
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Affiliation(s)
- Karim Gariani
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Service of Diabetology and Endocrinology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dan Lebowitz
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Harris CM, Abougergi MS, Wright SM. Clinical outcomes among morbidly obese patients hospitalized with diabetic foot complications. Clin Obes 2019; 9:e12285. [PMID: 30288938 DOI: 10.1111/cob.12285] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 08/15/2018] [Accepted: 08/26/2018] [Indexed: 11/29/2022]
Abstract
The aim of the study is to investigate effects of morbid obesity on patients hospitalized with diabetic foot ulcers and infections (DFU/Is). This retrospective cohort study of hospitalized adults investigated patients with a principal diagnosis of DFU/Is, and compared outcomes based on weight. The primary outcome was lower limb amputations. Secondary outcomes included in-hospital mortality, morbidity (sepsis and discharge disposition), resource utilization (length of stay [LOS] and total hospitalization charges). Multivariate analyses adjusted for confounders. A total of 31 730 admissions were included; 14% were morbidly obese. Patients with morbid obesity had overall lower rates of amputations (adjusted odds ratio [aOR]: 0.60; 95% confidence interval [CI]: 0.45-0.80). There was no difference in mortality rates between those who were morbidly obese and the non-morbidly obese patients (aOR: 3.89 [95% CI: 0.79-19.30]). Combined data from 2010 to 2014 have found higher odds of sepsis in morbidly obese patients compared with non-morbidly obese patients after adjusting for confounders (aOR: 1.49 [1.09-2.02], P = 0.01). Patients with morbid obesity were less likely to be discharged to home (aOR: 0.82 [95% CI: 0.70-0.95]), had longer LOS (adjusted mean difference [aMD]: 0.47 [95% CI: 0.13-0.81]) and higher hospital charges (aMD: $3205 [95% CI: $3373-$6037]). Despite having lower amputation rates compared to those who are not morbidly obese, patients with morbid obesity hospitalized for DFU/Is succumbed to sepsis more frequently and had less favourable utilization metrics. Specialized care pathways may be needed to enhance the value of care delivered to this high-risk population.
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Affiliation(s)
- Che Matthew Harris
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Marwan S Abougergi
- Department on Internal Medicine, Division of Gastroenterology, University of South Carolina School of Medicine, Columbia, South Carolina, USA
- Catalyst Medical Consulting, Simpsonville, South Carolina, USA
| | - Scott Mitchell Wright
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Young K, Aquilina A, Chesser TJS, Costa ML, Hettiaratchy S, Kelly MB, Moran CG, Pallister I, Woodford M. Open tibial fractures in major trauma centres: A national prospective cohort study of current practice. Injury 2019; 50:497-502. [PMID: 30401540 DOI: 10.1016/j.injury.2018.10.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 10/27/2018] [Indexed: 02/02/2023]
Abstract
AIMS To assess current national practice in the management of severe open tibial fractures against national standards, using data collected by the Trauma and Audit Research Network. MATERIALS AND METHODS Demographic, injury-specific, and outcome data were obtained for all grade IIIB/C fractures admitted to Major Trauma Centres in England from October 2014 to January 2016. RESULTS Data was available for 646 patients with recorded grade IIIB/C fractures. The male to female ratio was 2.3:1, mean age 47 years. 77% received antibiotics within 3 h of admission, 82% were debrided within 24 h. Soft tissue coverage was achieved within 72 h of admission in 71%. The amputation rate was 8.7%. 4.3% of patients required further theatre visits for infection during the index admission. The timing of antibiotics and surgery could not be correlated with returns to theatre for early infection. There were significant differences in the management and outcomes of patients aged 65 and over, with an increase in mortality and amputation rates. CONCLUSIONS Good outcomes are reported from the management of IIIB/C fractures in Major Trauma Centres in England. Overall compliance with national standards is particularly poor in the elderly. Compliance did not appear to affect rates of returning to theatre or early infection. Appropriately applied patient reported outcome measures are needed to enhance the evidence-base for management of these injuries.
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Affiliation(s)
- K Young
- Queen Victoria Hospital, East Grinstead, RH19 3DZ, UK.
| | - A Aquilina
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - T J S Chesser
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - M L Costa
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - S Hettiaratchy
- St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, W2 1NY, UK
| | - M B Kelly
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB, UK
| | - C G Moran
- Queens Medical Centre, Nottingham University Hospitals, Nottingham, NG7 2UH, UK
| | | | - M Woodford
- Trauma Audit and Research, University of Manchester, Salford Royal Hospitals NHS Foundation Trust, Salford, M6 8HD, UK
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Vinkel J, Lohse N, Hyldegaard O. The clinical use of hyperbaric oxygen in the treatment of Danish patients with diabetic foot ulcers. Dan Med J 2019; 66:A5528. [PMID: 30722823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Patients with diabetic foot ulcers (DFU) suffer from diabetes-related complications and comor-bidities. Hyperbaric oxygen therapy (HBOT) is a treatment modality with limited capacity used in the treatment of DFUs. It is important to ensure that HBOT is offered to patients who are suitable for this treatment regarding effect, compliance and life expectancy. The objective of the present study was to describe the population of patients with DFU who were referred to HBOT in Denmark in the 1999-2016 period. METHODS All patients with DFU who were treated at the HBOT chamber in Copenhagen during the study period were considered. Patients with an invalid social security number or an incorrect diagnosis were excluded. Data on comor-bidities, amputation and death were extracted from the Danish National patient Registry and the Danish Civil Registration System. Continuous data were described as median values and binary data were described as proportions. The probability estimate for survival and amputation was investigated by constructing Kaplan-Meier curves. RESULTS The cohort included 148 patients. Patients were mainly referred from the Capital Region (92%) and multi-disciplinary wound care centres were the primary referring departments (67%). Comorbidity rates were high with an initial median Charlson Comorbidity Index score of five. The five-year amputation and mortality estimates after referral were 73.5% and 51.8%, respectively. CONCLUSIONS The study showed that Danish DFU patients who are offered HBOT are in advanced stages of their disease, and the referral hinges on local factors such as geography and the referring source rather than on standardised procedures. FUNDING none. TRIAL REGISTRATION not relevant.
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Nazri MY, Aminudin CA, Ahmad FS, Mohd Jazlan MA, Jamalludin Ab R, Ramli M. Quality of life of diabetes amputees following major and minor lower limb amputations. Med J Malaysia 2019; 74:25-29. [PMID: 30846658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Minor amputation was performed as a salvage procedure because most of the patients were not able to ambulate and become dependent following major amputation. Minor amputation is defined as amputation at the level of ankle joint and below while major amputation is defines by amputation above the ankle joint. The aim of this study was to compare the quality of life among diabetes patients following major and minor amputations. METHODS A total of 94 diabetes patients were reviewed six months following amputation. Their walking ability, dependency status and quality of life were evaluated, using the Malay translated version of the Short Form Health Survey 36 (SF-36) questionnaire. RESULTS During the follow up only three patients (8.3%) following major amputation were dependant compared to 30 patients (51.7%) following minor amputation. Forty-nine (84.5%) of minor amputation and only 15 (41.7%) of major amputation patients were ambulating independently. Patients with minor amputation have significantly better Physical functioning, Role - physical, General health, Role - emotional, and Mental health score (p<0.001). However, they have worse BP and SF score than those following major amputation (p<0.001). The VT score of both groups were not significantly different. CONCLUSION Patients with minor amputation are more independent, ambulatory and had better quality of life than those with major amputation. Despite the risk of persistent infection and amputation stump complication, minor amputation should be attempted in diabetes patients.
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Affiliation(s)
- M Y Nazri
- International Islamic University of Malaysia, Kulliyyah of Medicine, Department of Orthopaedic, Traumatology and Rehabilitation, Kuantan, Pahang, Malaysia.
| | - C A Aminudin
- International Islamic University of Malaysia, Kulliyyah of Medicine, Department of Orthopaedic, Traumatology and Rehabilitation, Kuantan, Pahang, Malaysia
| | - F S Ahmad
- International Islamic University of Malaysia, Kulliyyah of Medicine, Department of Orthopaedic, Traumatology and Rehabilitation, Kuantan, Pahang, Malaysia
| | - M A Mohd Jazlan
- Queen Elizabeth Hospital, Department of Orthopaedic, Kota Kinabalu, Sabah, Malaysia
| | - R Jamalludin Ab
- International Islamic University of Malaysia, Kulliyyah of Medicine, Department of Community Medicine, Kuantan, Pahang, Malaysia
| | - M Ramli
- International Islamic University of Malaysia, Kulliyyah of Medicine, Department of Psychiatry, Kuantan, Pahang, Malaysia
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Jeyaraman K, Berhane T, Hamilton M, Chandra AP, Falhammar H. Mortality in patients with diabetic foot ulcer: a retrospective study of 513 cases from a single Centre in the Northern Territory of Australia. BMC Endocr Disord 2019; 19:1. [PMID: 30606164 PMCID: PMC6318899 DOI: 10.1186/s12902-018-0327-2] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 12/14/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFU) are a common problem in longstanding diabetes. However, mortality outcomes in Australian patients with DFU are still unclear. METHODS All patients with DFU presenting for the first time to the Multi-Disciplinary Foot Clinic (MDFC) at Royal Darwin Hospital, Northern Territory Australia, between January 2003 and June 2015 were included in this study. These patients were followed until 2017, or death. Individual patient data was extracted from hospital and primary care information systems. Kaplan-Meier survival curves were developed. The association between various risk factors and mortality was analysed using Cox regression. RESULTS In total 666 subjects were screened, and 513 were included in the final analysis. Of these subjects, 247 were Indigenous and 266 were non-Indigenous. The median follow-up period was 5.8 years (IQR, 3.1-9.8). The mean age at inclusion was 59.9 ± 12.3 years and 62.8% were males. The majority (93.6%) had type 2 diabetes and the median diabetes duration was 7 years (IQR, 3-12). There were 199 deaths, with a 5-year-mortality rate of 24.6%, and a 10-year-mortality rate of 45.4%. The mean age at death was 64.6 ± 11.8 years. In a multivariate analysis, the following variables were associated with mortality (adjusted HR, 95% CI): age 1.04 (1.02-1.05, P < 0.001); chronic kidney disease 1.22 (1.11-1.33, P < 0.001), and plasma albumin 0.96 (0.94-0.99, P < 0.05). The most common causes of death were chronic kidney disease (24.6%), cardiovascular events (19.6%), sepsis (15.6%), respiratory failure (10.0%), malignancy (9.5%) and multi-organ failure (5.0%). CONCLUSION Patients with DFU have high mortality. Age, chronic kidney disease, and low albumin levels increase the risk of mortality. Strategies should focus on ulcer prevention and aggressive risk factor reduction.
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Affiliation(s)
- Kanakamani Jeyaraman
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory Australia
| | - Thomas Berhane
- Department of Prosthetics and Orthotics, Royal Darwin Hospital, Darwin, Northern Territory Australia
| | - Mark Hamilton
- Department of Vascular Surgery, Royal Darwin Hospital, Darwin, Northern Territory Australia
- Menzies School of Health Research, Darwin, NT Australia
| | - Abhilash P. Chandra
- Department of Vascular Surgery, Royal Darwin Hospital, Darwin, Northern Territory Australia
- Menzies School of Health Research, Darwin, NT Australia
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory Australia
- Menzies School of Health Research, Darwin, NT Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Zubair M, Malik A, Ahmad J. Correlation of HbA1c and S. creatinine along with microbiological profiling of infected ulcers; cases of diabetic patients. Diabetes Metab Syndr 2019; 13:30-34. [PMID: 30641715 DOI: 10.1016/j.dsx.2018.08.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 08/09/2018] [Indexed: 01/01/2023]
Abstract
STATEMENT OF THE PROBLEM The rate of diabetes mellitus is increasing globally as a result of increased levels of blood glucose. The elevated blood glucose level results due to impairment in the production and action of insulin. An increase in glycated hemoglobin is associated with higher blood glucose levels that further results in nephropathy, neuropathy, retinopathy, and cardiovascular disease. Therefore, the study has investigated the correlation between HbA1c and creatinine levels among diabetic patients, suffering from foot ulcerations. METHODS A prospective cohort hospital based-study has retrieved hospital records of patients during January 2009 and February 2015. A total of 192 patients, admitted in the Rajiv Gandhi Centre for Diabetes and Endocrinology, of Jawaharlal Nehru Medical College Hospital, Aligarh Muslim University, Aligarh, India were recruited. RESULTS It has been examined that there is a positive correlation between ulcer duration and BMI, amputation rate and BMI, gender and BMI, hospital stay and BMI, HbA1c and BMI, Hb and BMI and triglyceride and BMI at 5% level of significance. CONCLUSION Findings have shown positive association with gender, diabetes duration, ulcer size, grade of ulcer, amputation rate, hospital stay, Hb, SGOT/AST and triglyceride.
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Affiliation(s)
- Mohammad Zubair
- Department of Medical Microbiology, Faculty of Medicine, University of Tabuk, Tabuk, 71491, Saudi Arabia; Former PDF, Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India.
| | - Abida Malik
- Former Chairperson, Department of Medical Microbiology, Former Dean, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India
| | - Jamal Ahmad
- Former Director, Rajiv Gandhi Centre for Diabetes and Endocrinology, Former Dean, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India.
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Atosona A, Larbie C. Prevalence and Determinants of Diabetic Foot Ulcers and Lower Extremity Amputations in Three Selected Tertiary Hospitals in Ghana. J Diabetes Res 2019; 2019:7132861. [PMID: 30886869 PMCID: PMC6388336 DOI: 10.1155/2019/7132861] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/06/2019] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The occurrence and complications of diabetes are increasing worldwide. This study examined the prevalence and determinants of diabetic foot ulcers and lower extremity amputations in three selected tertiary hospitals in Ghana. METHODS A cross-sectional multicenter study involving 100 subjects was carried out. Subjects were selected through simple random sampling from three selected tertiary hospitals in Ghana. A structured questionnaire was used to document information on sociodemographic, medical history, lifestyle, and physical characteristics of subjects. Foot ulcers and lower extremity amputations were also investigated. Total cholesterol, triglycerides, low-density lipoproteins, high-density lipoproteins, serum urea, serum creatinine, and estimated glomerular filtration rate of subjects were assessed. Data analysis was done using SPSS version 22. RESULTS The study revealed that 31% and 69% were males and females, respectively, with a mean age of 53.8 ± 13.8 years. Among the patients, 11% had diabetic foot ulcers whilst 3% had lower extremity amputations. In the multivariate binary logistic regression analysis, previous history of foot ulcers (OR = 40.4, 95% CI = 5.5-299.9) and foot deformities (OR = 14.4, 95% CI = 1.3-161.2) were identified as independent predictors of diabetic foot ulcers. Foot deformity (p = 0.043) and serum urea (p = 0.002) were associated with diabetic lower extremity amputations in the univariate analysis. CONCLUSION This study showed that the prevalences of diabetic foot ulcers and lower extremity amputations are high among diabetes patients. Foot deformities and previous history of foot ulcers are determinants of diabetic foot ulcers. Foot deformity and serum urea are associated with diabetic lower extremity amputations.
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Affiliation(s)
- Ambrose Atosona
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
- Department of Nutritional Sciences, University for Development Studies, Tamale Campus, Ghana
| | - Christopher Larbie
- Department of Biochemistry and Biotechnology, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Meloni M, Izzo V, Giurato L, Brocco E, Ferrannini M, Gandini R, Uccioli L. Procalcitonin Is a Prognostic Marker of Hospital Outcomes in Patients with Critical Limb Ischemia and Diabetic Foot Infection. J Diabetes Res 2019; 2019:4312737. [PMID: 31485450 PMCID: PMC6710766 DOI: 10.1155/2019/4312737] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 08/02/2019] [Indexed: 11/17/2022] Open
Abstract
AIM To evaluate the prognostic role of procalcitonin (PCT) in patients with diabetic foot infection (DFI) and critical limb ischemia (CLI). MATERIALS AND METHODS The study group was composed of diabetic patients with DFI and CLI. All patients were treated according to a preset limb salvage protocol which includes revascularization, wound debridement, antibiotic therapy, and offloading. Inflammatory markers, including PCT, were evaluated at admission. Only positive values of PCT, greater than 0.5 ng/ml, were considered. Hospital outcomes were categorized as limb salvage (discharge with preserved limb), major amputation (amputation above the ankle), and mortality. RESULTS Eighty-six patients were included. The mean age was 67.3 ± 11.4 years, 80.7% were male, 95.1% had type 2 diabetes, and the mean diabetes duration was 20.5 ± 11.1 with a mean HbA1c of 67 ± 16 mmol/mol. 66/86 (76.8%) of patients had limb salvage, 7/86 (8.1%) had major amputation, and 13/86 (15.1%) died. Patients with positive PCT baseline values in comparison to those with normal values showed a lower rate of limb salvage (30.4 versus 93.6%, p = 0.0001), a higher rate of major amputation (13 versus 6.3%, p = 0.3), and a higher rate of hospital mortality (56.5 versus 0%, p < 0.0001). At the multivariate analysis of independent predictors found at univariate analysis, positive PCT was an independent predictor of major amputation [OR 3.3 (CI 95% 2.0-5.3), p = 0.0001] and mortality [OR 4.1 (CI 95% 2.2-8.3), p < 0.0001]. DISCUSSION Positive PCT at admission increased the risk of major amputation and mortality in hospital patients with DFI and CLI.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Valentina Izzo
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Laura Giurato
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Enrico Brocco
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Piazza Cristoforo Colombo 1, 35031, Abano Terme, Padua, Italy
| | - Michele Ferrannini
- Division of Hypertension and Nephrology, Department of Systems Medicine, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Roberto Gandini
- Department of Interventional Radiology, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Luigi Uccioli
- Diabetic Foot Unit, Department of Systems Medicine, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
- Diabetic Foot Unit, Foot and Ankle Clinic, Abano Terme Polyclinic, Piazza Cristoforo Colombo 1, 35031, Abano Terme, Padua, Italy
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Ólafsdóttir AF, Svensson AM, Pivodic A, Gudbjörnsdottir S, Nyström T, Wedel H, Rosengren A, Lind M. Excess risk of lower extremity amputations in people with type 1 diabetes compared with the general population: amputations and type 1 diabetes. BMJ Open Diabetes Res Care 2019; 7:e000602. [PMID: 31114696 PMCID: PMC6501853 DOI: 10.1136/bmjdrc-2018-000602] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 01/04/2019] [Accepted: 01/29/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE This study investigates how the excess risk of lower extremity amputations (amputations) in people with type 1 diabetes mellitus (DM) differs from the general population by diabetes duration, glycemic control, and renal complications. RESEARCH DESIGN AND METHODS We analyzed data from people with type 1 DM from the Swedish National Diabetes Register without prior amputation from January 1998 to December 2013. Each person (n=36 872) was randomly matched with five controls by sex, age, and county (n=184 360) from the population without diabetes. All were followed until first amputation, death or end of follow-up. RESULTS The overall adjusted HR for all amputation was 40.1 (95% CI 32.8 to 49.1) for type 1 DM versus controls. HR increased with longer diabetes duration. The incidence of amputation/1000 patient-years was 3.18 (95% CI 2.99 to 3.38) for type 1 DM and 0.07 (95% CI 0.05 to 0.08) for controls. The incidence decreased from 1998-2001 (3.09, 95% CI 2.56 to 3.62) to 2011-2013 (2.64, 95% CI 2.31 to 2.98). The HR for major amputations was lower than for minor amputations and decreased over the time period (p=0.0045). Worsening in glycemic control among patients with diabetes led to increased risk for amputation with an HR of 1.80 (95% CI 1.72 to 1.88) per 10 mmol/mol (1%) increase in hemoglobin A1c. CONCLUSIONS Although the absolute risk of amputation is relatively low, the overall excess risk was 40 times that of controls. Excess risk was substantially lower for those with good glycemic control and without renal complications, but excess risk still existed and is greatest for minor amputations.
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Affiliation(s)
- Arndís Finna Ólafsdóttir
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers in Region Västra Götaland, Gothenburg, Sweden
| | | | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Centre of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Thomas Nyström
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Hans Wedel
- Department of Health Metrics, Health Metrics Sahlgrenska Academy, Gothenburg, Sweden
| | - Annika Rosengren
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
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Lin CW, Armstrong DG, Lin CH, Liu PH, Hung SY, Lee SR, Huang CH, Huang YY. Nationwide trends in the epidemiology of diabetic foot complications and lower-extremity amputation over an 8-year period. BMJ Open Diabetes Res Care 2019; 7:e000795. [PMID: 31749971 PMCID: PMC6827817 DOI: 10.1136/bmjdrc-2019-000795] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 09/12/2019] [Accepted: 09/24/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To study the prevalence and trends of lower extremity complications of diabetes over an 8-year period in a single nation. RESEARCH DESIGN AND METHODS Nationwide data for people with type 2 diabetes (T2D) and diabetic foot complications (DFCs) were analyzed over an 8-year period (2007-2014) from National Health Insurance Research Database using the International Classification of Diseases, Ninth Revision disease coding. The DFCs were defined as ulcers, infections, gangrene, and hospitalization for peripheral arterial disease (PAD). Trends of patient characteristics, foot presentation, and the execution of major procedures were studied, including lower-extremity amputations (LEAs). RESULTS Along with the T2D population increasing over time, the absolute number of people with DFCs increased by 33.4%, but retained a prevalence of around 2% per year. The annual incident of LEAs decreased from 2.85 to 2.06 per 1000 T2D population (p=0.001) with the major LEA proportion decreasing from 56.2% to 47.4% (p<0.001).The mean age of patients increased from 65.3 to 66.3 years and most of the associated comorbidities of diabetes were increased. For example, end-stage renal disease increased from 4.9% to 7.7% (p=0.008). The incidence of gangrene on presentation decreased from 14.7% to 11.3% (p<0.001) with a concomitant increase in vascular interventions (6.2% to 19.5%, p<0.001). CONCLUSIONS DFCs remain a sustained major medical problem. These nationwide long-term data suggest trends toward older people with greater comorbidities such as PAD and renal disease. Nevertheless, promising trends of reducing gangrene on presentation paired with increases in vascular interventions support continued vigilance and rapid, coordinated interdisciplinary diabetic foot care.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, California, USA
| | - Chia-Hung Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Pi-Hua Liu
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Shu-Ru Lee
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital Linkou Main Branch, Taoyuan, Taiwan
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Kool B, Ipil M, McCool J. Diabetes Mellitus-related Foot Surgeries in the Republic of the Marshall Islands in Micronesia. Hawaii J Med Public Health 2019; 78:13-18. [PMID: 30697470 PMCID: PMC6333959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Diabetes Mellitus (DM) is the leading cause of morbidity and mortality in the Republic of the Marshall Islands (RMI), a small Pacific nation located in Micronesia (population 53,184). Although generally preventable, diabetic foot disease is among the most frequently reported complication of DM globally and in the RMI. Over 25% of people with DM globally will have at least one DM-related foot ulcer, which may require surgical intervention. The purpose of this study is to determine the incidence of DM-related foot surgeries at the Leroij Atama Zedkaia Majuro Hospital, the main tertiary referral centre for the RMI, and where 90% of all DM-related foot surgeries in the country are conducted. A retrospective review of surgical and clinical records at Majuro Hospital for the 12-month period January 2015 to December 2015 was conducted to determine the incidence and characteristics of DM-related foot surgeries (foot ulcer debridement or lower limb amputation [LLA]). DM-related foot surgery was the fourth most common surgical procedure conducted in the RMI during the 12-month period reviewed. Four percent of people with DM presenting to the Majuro Hospital during the review period required DM-related foot surgery. The incidence of DM-related major LLAs was 103 per 100,000 population. As age increased, so did the proportion of patients requiring DM-related foot surgery. Eighty six percent of those requiring surgery were 50 years and older, and the majority were male (54.6%). The incidence of DM-related foot surgeries in the RMI remains high by international standards. The study findings confirm the need to address the burden of DM in the RMI and support the country's NCD Crisis Action Plan.
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Affiliation(s)
- Bridget Kool
- Section of Epidemiology and Biostatistics, the University of Auckland, Auckland New Zealand
| | - Maybelline Ipil
- Section of Epidemiology and Biostatistics, the University of Auckland, Auckland New Zealand
| | - Judith McCool
- Section of Epidemiology and Biostatistics, the University of Auckland, Auckland New Zealand
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Schmidt BM, Holmes CM, Ye W, Pop-Busui R. A Tale of Two Eras: Mining Big Data from Electronic Health Records to Determine Limb Salvage Rates with Podiatry. Curr Diabetes Rev 2019; 15:497-502. [PMID: 30332970 PMCID: PMC6531350 DOI: 10.2174/1573399814666181017104818] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 09/24/2018] [Accepted: 10/11/2018] [Indexed: 01/22/2023]
Abstract
AIMS/HYPOTHESIS Diabetic foot complications remain very prevalent in the US and worldwide, and a major risk for devastating amputations. We evaluated the impact of establishing a fully integrated and specialized Podiatry service into a large tertiary academic health system to implement structured and targeted preventative foot care on limb salvage rates. METHODS Cross-sectional cohorts' data mining analysis was conducted of all encounters for diabetes and any foot complications between 2000-2005 and 2010-2015, preceding and after full implementation of podiatry service, respectively. The primary outcome was the change in major non-traumatic lower extremity amputations. Secondary outcomes included minor non-traumatic lower extremity amputations, other diabetic foot complications, limb salvage procedures as documented by procedural coding, and location (outpatient, inpatient, ED) of service rendered. RESULTS We analyzed 100 million patient encounters that met the above criteria. Compared with the initial cohort, integration of specialized podiatry services resulted in a significant decrease in the number of major amputations from 127 to 85/year (p<0.05), and halved the amputations rate from 0.004% to 0.002% (p<0.05). Rates of minor lower extremity amputations remained unchanged (p>0.10), while the rates of preventative procedures including foot ulcer debridement doubled (0.0002% to 0.0004% ; p<0.03). Diagnoses of diabetic foot complications increased significantly (p<0.05) and shifted toward the outpatient setting. CONCLUSION Full integration of specialized Podiatry service led to a significant decrease in major amputation rates, supporting teamwork between podiatry and diabetes health-care providers is essential to performing timely diabetic foot complications management, preventative procedures leading to limb salvage, and a shift in the care location.
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Affiliation(s)
- Brian M. Schmidt
- Department of Internal Medicine, Michigan Medicine, Division of Metabolism, Endocrinology, and Diabetes. Dom-ino’s Farms (Lobby C, Suite I300) 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48I06, USA
- Address correspondence to this author at the Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Lobby C, Ann Arbor, Michigan 48106, USA;
| | - Crystal M. Holmes
- Department of Internal Medicine, Michigan Medicine, Division of Metabolism, Endocrinology, and Diabetes. Dom-ino’s Farms (Lobby C, Suite I300) 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48I06, USA
| | - Wen Ye
- University of Michigan School of Public Health, M25I5 SPHII, I4I5 Washington Heights Ann Arbor, Michigan 48I09, USA
| | - Rodica Pop-Busui
- Department of Internal Medicine, Michigan Medicine, Division of Metabolism, Endocrinology, and Diabetes. Dom-ino’s Farms (Lobby C, Suite I300) 24 Frank Lloyd Wright Drive Ann Arbor, Michigan 48I06, USA
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Hsu CC, Kwan GNC, Singh D, Rophael JA, Anthony C, van Driel ML. Angioplasty versus stenting for infrapopliteal arterial lesions in chronic limb-threatening ischaemia. Cochrane Database Syst Rev 2018; 12:CD009195. [PMID: 30536919 PMCID: PMC6517022 DOI: 10.1002/14651858.cd009195.pub2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chronic limb-threatening ischaemia (CLTI) is a manifestation of peripheral arterial disease (PAD) that includes chronic ischaemic rest pain or ischaemic skin lesions, ulcers, or gangrene for longer than two weeks. The severity of the disease depends on the extent of arterial stenosis and the availability of collateral circulation. Treatment for CLTI aims to relieve ischaemic pain, heal ischaemic ulcers, prevent limb loss, improve quality of life, and prolong survival. CLTI due to occlusive disease in the infrapopliteal arterial circulation (below-knee circulation) can be treated via an endovascular technique by a balloon opening the narrowed vessel, so called angioplasty, with or without the additional deployment of a scaffold made of metal alloy or other material, so called stenting. Endovascular interventions in the infrapopliteal vasculature may improve symptoms in patients with CLTI by re-establishing in-line blood flow to the foot. Controversy remains as to whether a balloon should be used alone to open the vessel, or whether a stent should also be deployed. OBJECTIVES To determine the efficacy and safety of percutaneous transluminal angioplasty (PTA) alone versus PTA with stenting of infrapopliteal arterial lesions (anterior tibial artery, posterior tibial artery, fibular artery (formerly known as peroneal artery), and common tibioperoneal trunk) for patients with chronic limb-threatening ischaemia (CLTI). SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, and AMED databases, as well as World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 25 June 2018. We applied no language restrictions. SELECTION CRITERIA We planned to include randomised or quasi-randomised controlled trials comparing PTA versus PTA with a stent and including patients aged 18 years or over with CLTI. We defined CLTI as Fontaine stage III (ischaemic rest pain) and IV (ischaemic ulcers or gangrene) or consistent with Rutherford category 4 (ischaemic rest pain), 5 (minor tissue loss), and 6 (major tissue loss), with stenotic (> 50% luminal loss) or occluded infrapopliteal artery, including tibiofibular trunk, anterior tibial artery, posterior tibial artery, and fibular artery. We included all types of stents irrespective of design (e.g. bare-metal, drug-eluting, bio-absorbable). DATA COLLECTION AND ANALYSIS Two review authors (CC-TH and GNCK) independently selected suitable trials, assessed trial quality, and extracted data. An additional third review author (MLvD) assessed trial quality and, when necessary, acted as arbiter for study selection and data extraction. Outcomes included technical success of the procedure, procedural complications, patency, major amputation, and mortality. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS We included in the review seven trials with 542 participants. One trial randomised limbs to undergo PTA alone or PTA with stent placement, and the remaining studies randomised participants. Five trials with 476 participants show that the technical success rate was greater in the stent group than in the angioplasty group (odds ratio (OR) 3.00, 95% confidence interval (CI) 1.14 to 7.93; 476 lesions; 5 studies; I² = 23%). Meta-analysis of three eligible trials with 456 participants did not show a clear difference in short-term (within six months) patency between infrapopliteal arterial lesions treated with PTA and those treated with PTA and stenting (OR 0.88, 95% CI 0.37 to 2.11; 456 lesions; 3 studies; I² = 77%). Results also did not show clear differences between treatment groups in procedure complication rate (OR 0.87, 95% CI 0.01 to 53.60; 360 participants; 5 studies; I² = 85%), rate of major amputations at 12 months (OR 1.34, 95% CI 0.56 to 3.22; 306 participants; 4 studies; I² = 0%), and rate of mortality at 12 months (OR 0.71, 95% CI 0.43 to 1.17; 497 participants; 6 studies; I² = 0%). Heterogeneity between studies was high for the outcomes procedure complications and primary patency. The overall methodological quality of the trials included in this review was moderate due to selection and performance bias. Studies used different regimens for pretreatment and post-treatment antiplatelet/anticoagulant medication. We downgraded the certainty of the overall evidence for all outcomes by one level to moderate due to inconsistency of results across studies and large confidence intervals (small numbers of trials and participants). AUTHORS' CONCLUSIONS Trials show that the immediate technical success rate of restoring luminal patency is higher in the stent group but reveal no clear differences in short-term patency at six months between infrapopliteal arterial lesions treated with PTA with stenting versus those treated with PTA without stenting. We ascertained no clear differences between groups in periprocedural complications, major amputation, and mortality. However, use of different regimens for pretreatment and post-treatment antiplatelet/anticoagulant medication and the duration of its use within and between trials may have influenced the outcomes. Limited currently available data suggest that high-quality evidence is insufficient to show that PTA with stent insertion is superior to use of standard PTA alone without stenting for treatment of infrapopliteal arterial lesions. Further studies should standardise the use of antiplatelets/anticoagulants before and after the intervention to improve the comparability of the two treatments.
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Affiliation(s)
- Charlie C‐T Hsu
- Gold Coast University HospitalDepartment of Medical Imaging1 Hospital BlvdSouthportQueenslandAustralia4215
| | - Gigi NC Kwan
- Gold Coast University HospitalDepartment of Medical Imaging1 Hospital BlvdSouthportQueenslandAustralia4215
| | - Dalveer Singh
- Qscan Radiology ClinicsSouthportAustralia
- The University of QueenslandFaculty of MedicineBrisbaneQueenslandAustralia
| | - John A Rophael
- University of MelbourneDepartment of Surgery ‐ St Vincent's Hospital41 Victoria ParadeFitzroyVictoriaAustralia3065
| | - Chris Anthony
- St Vincent's Hospital390 Victoria StreetDarlinghurst, SydneyNSWAustralia2010
| | - Mieke L van Driel
- The University of QueenslandPrimary Care Clinical Unit, Faculty of MedicineBrisbaneQueenslandAustralia4029
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Moussa Pacha H, Mallipeddi VP, Afzal N, Moon S, Kaggal VC, Kalra M, Oderich GS, Wennberg PW, Rooke TW, Scott CG, Kullo IJ, McBane RD, Nishimura RA, Chaudhry R, Liu H, Arruda-Olson AM. Association of Ankle-Brachial Indices With Limb Revascularization or Amputation in Patients With Peripheral Artery Disease. JAMA Netw Open 2018; 1:e185547. [PMID: 30646276 PMCID: PMC6324363 DOI: 10.1001/jamanetworkopen.2018.5547] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE The prevalence and morbidity of peripheral artery disease (PAD) are high, with limb outcomes including revascularization and amputation. In community-dwelling patients with PAD, the role of noninvasive evaluation for risk assessment and rates of limb outcomes have not been established to date. OBJECTIVE To evaluate whether ankle-brachial indices are associated with limb outcomes in community-dwelling patients with PAD. DESIGN, SETTING, AND PARTICIPANTS A population-based, observational, test-based cohort study of patients was performed from January 1, 1998, to December 31, 2014. Data analysis was conducted from July 15 to December 15, 2017. Participants included a community-based cohort of 1413 patients with PAD from Olmsted County, Minnesota, identified by validated algorithms deployed to electronic health records. Automated algorithms identified limb outcomes used to build Cox proportional hazards regression models. Ankle-brachial indices and presence of poorly compressible arteries were electronically identified from digital data sets. Guideline-recommended management strategies within 6 months of diagnosis were also electronically retrieved, including therapy with statins, antiplatelet agents, angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, and smoking abstention. MAIN OUTCOMES AND MEASURES Ankle-brachial index (index ≤0.9 indicates PAD; <.05, severe PAD; and ≥1.40, poorly compressible arteries) and limb revascularization or amputation. RESULTS Of 1413 patients, 633 (44.8%) were women; mean (SD) age was 70.8 (13.3) years. A total of 283 patients (20.0%) had severe PAD (ankle-brachial indices <0.5) and 350 (24.8%) had poorly compressible arteries (ankle-brachial indices ≥1.4); 780 (55.2%) individuals with less than severe disease formed the reference group. Only 32 of 283 patients (11.3%) with severe disease and 68 of 350 patients (19.4%) with poorly compressible arteries were receiving 4 guideline-recommended management strategies. In the severe disease subgroup, the 1-year event rate for revascularization was 32.4% (90 events); in individuals with poorly compressible arteries, the 1-year amputation rate was 13.9% (47 events). In models adjusted for age, sex, and critical limb ischemia, poorly compressible arteries were associated with amputation (hazard ratio [HR], 3.12; 95% CI, 2.16-4.50; P < .001) but not revascularization (HR, 0.91; 95% CI, 0.69-1.20; P = .49). In contrast, severe disease was associated with revascularization (HR, 2.69; 95% CI, 2.15-3.37; P < .001) but not amputation (HR, 1.30; 95% CI, 0.82-2.07; P = .27). CONCLUSIONS AND RELEVANCE Community-dwelling patients with severe PAD or poorly compressible arteries have high rates of revascularization or limb loss, respectively. Guideline-recommended management strategies for secondary risk prevention are underused in the community.
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Affiliation(s)
- Homam Moussa Pacha
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Vishnu P. Mallipeddi
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Naveed Afzal
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Sungrim Moon
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Vinod C. Kaggal
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Manju Kalra
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Gustavo S. Oderich
- Division of Vascular Surgery, Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Paul W. Wennberg
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Thom W. Rooke
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Christopher G. Scott
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Iftikhar J. Kullo
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Robert D. McBane
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Rick A. Nishimura
- Department of Cardiovascular Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Rajeev Chaudhry
- Division of Primary Care Medicine and Center of Translational Informatics and Knowledge Management, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
| | - Hongfang Liu
- Department of Health Sciences Research, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
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Le Joncour A, Soudet S, Dupont A, Espitia O, Koskas F, Cluzel P, Hatron PY, Emmerich J, Cacoub P, Resche‐Rigon M, Lambert M, Saadoun D. Long-Term Outcome and Prognostic Factors of Complications in Thromboangiitis Obliterans (Buerger's Disease): A Multicenter Study of 224 Patients. J Am Heart Assoc 2018; 7:e010677. [PMID: 30571594 PMCID: PMC6405548 DOI: 10.1161/jaha.118.010677] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/08/2018] [Indexed: 01/04/2023]
Abstract
Background Data regarding long-term outcome of patients with thromboangiitis obliterans are lacking and most series come from India and Japan. In this study, we assess long-term outcome and prognostic factors in a large cohort of thromboangiitis obliterans. Methods and Results Retrospective multicenter study of characteristics and outcomes of 224 thromboangiitis obliterans patients fulfilling Papa's criteria were analyzed. Factors associated with vascular events and amputations were identified. The median age at diagnosis was 38.5 (32-46) years, 51 (23.8%) patients were female, and 81.7% were whites. After a mean follow-up of 5.7 years, vascular events were observed in 58.9%, amputations in 21.4%, and death in 1.4%. The 5-, 10-, and 15-year vascular event-free survival and amputation-free survival were 41% and 85%, 23% and 74%, and 19% and 66%, respectively. Ethnic group (nonwhite) (hazard ratio 2.35 [1.30-4.27] P=0.005) and limb infection at diagnosis (hazard ratio 3.29 [1.02-10.6] P=0.045) were independent factors of vascular event-free survival. Factor associated with amputation was limb infection (hazard ratio 12.1 [3.5-42.1], P<0.001). Patients who stopped their tobacco consumption had lower risk of amputation ( P=0.001) than those who continued. Conclusions This nationwide study shows that 34% of thromboangiitis obliterans patients will experience an amputation within 15 years from diagnosis. We identified high-risk patients for vascular complications and amputations.
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Affiliation(s)
- Alexandre Le Joncour
- UPMC Univ Paris 06UMR 7211, and Inflammation‐Immunopathology‐Biotherapy Department (DHU i2B)Sorbonne UniversitésParisFrance
- UMR_S 959INSERMParisFrance
- Department of Internal Medicine and Clinical ImmunologyAP‐HPGroupe Hospitalier Pitié‐SalpêtrièreParisFrance
- Centre national de référence des maladies Autoimmunes Systémiques raresCentre National de Référence Des Maladies Autoinflammatoires et de l'AmyloseFrance
| | - Simon Soudet
- Département de Médecine Interne et Immunologie CliniqueCHU LilleLilleFrance
- Centre National de Référence des Maladies Autoimmunes et Systémiques Rares (Sclérodermie)France
| | - Axelle Dupont
- Service de Biostatistique et Information médicaleAPHPHôpital Saint‐LouisParisFrance
| | | | - Fabien Koskas
- Service de chirurgie vasculaireGroupe Hospitalier Pitié‐SalpétrièreParisFrance
| | - Philippe Cluzel
- Service d'Imagerie CardiovasculaireInstitut de cardiologieGroupe Hospitalier Pitié‐SalpétrièreParisFrance
| | - Pierre Yves Hatron
- Département de Médecine Interne et Immunologie CliniqueCHU LilleLilleFrance
- Centre National de Référence des Maladies Autoimmunes et Systémiques Rares (Sclérodermie)France
| | - Joseph Emmerich
- Department of Vascular Medicine and CardiologyUniversity Hospital Hotel DieuUniversity Paris‐DescartesParisFrance
| | - Patrice Cacoub
- UPMC Univ Paris 06UMR 7211, and Inflammation‐Immunopathology‐Biotherapy Department (DHU i2B)Sorbonne UniversitésParisFrance
- UMR_S 959INSERMParisFrance
- Department of Internal Medicine and Clinical ImmunologyAP‐HPGroupe Hospitalier Pitié‐SalpêtrièreParisFrance
- Centre national de référence des maladies Autoimmunes Systémiques raresCentre National de Référence Des Maladies Autoinflammatoires et de l'AmyloseFrance
| | | | - Marc Lambert
- Département de Médecine Interne et Immunologie CliniqueCHU LilleLilleFrance
- Centre National de Référence des Maladies Autoimmunes et Systémiques Rares (Sclérodermie)France
| | - David Saadoun
- UPMC Univ Paris 06UMR 7211, and Inflammation‐Immunopathology‐Biotherapy Department (DHU i2B)Sorbonne UniversitésParisFrance
- UMR_S 959INSERMParisFrance
- Department of Internal Medicine and Clinical ImmunologyAP‐HPGroupe Hospitalier Pitié‐SalpêtrièreParisFrance
- Centre national de référence des maladies Autoimmunes Systémiques raresCentre National de Référence Des Maladies Autoinflammatoires et de l'AmyloseFrance
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De Ayala-Hillman R, Crespo-Martínez NA, García-Rodríguez O, Ramos-Meléndez EO, Rodriguez-Ortiz P. Traumatic Vascular Injury and its Management with Temporary Intravascular Shunts: A Puerto Rico Trauma Hospital's Experience. P R Health Sci J 2018; 37:220-223. [PMID: 30548058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Temporary intravascular shunts (TIVSs) are commonly used as a damagecontrol procedure in trauma settings. Currently, there is scarce literature in the civilian field, and what there is is limited to large trauma centers with multiple resources. Therefore, we aimed to describe TIVS usage, and the outcomes of that usage, at Puerto Rico Trauma Hospital. MATERIALS AND METHODS This is a case series conducted from 2009 to 2013 with 32 patients who suffered vascular trauma, of which 13 needed TIVSs. Data related to age, trauma mechanism, injured vessel, type of shunt, Glasgow Coma Scale, vital signs, and mortality were collected. The analysis was carried out using descriptive statistics. This protocol was approved by the IRB of the Medical Sciences Campus. RESULTS The most frequent mechanism of injury was a gunshot (11/13; 84.6%). The most commonly injured vessel was the superficial femoral artery. Indwelling time ranged from 6 to 96 hours. Only 2 of the 13 (15.4%) patients with shunts reported thrombosis. Furthermore, we performed 4 (30.7% of the patients) prophylactic fasciotomies and 4 (30.7% of the patients) amputations; 4 of the 13 (30.7%) patients died from unrelated causes. CONCLUSION Our results are consistent with those in the literature, which supports our contention that a TIVS can be an effective component of damage-control vascular surgery and can, in both military and civilian settings, aid in extremity amputation prevention. Furthermore, it has been established that a TIVS can be fashioned from any available hollow tube. However, further research is needed to evaluate the safety of an improvised catheter of this nature.
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Affiliation(s)
- Rafael De Ayala-Hillman
- Department of Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | | | | | - Ediel O Ramos-Meléndez
- Department of Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR
| | - Pablo Rodriguez-Ortiz
- Department of Surgery, School of Medicine, University of Puerto Rico Medical Sciences Campus, San Juan, PR; Puerto Rico Trauma Hospital, Puerto Rico Medical Center, San Juan, PR
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Adimadhyam S, Lee TA, Calip GS, Smith Marsh DE, Layden BT, Schumock GT. Risk of amputations associated with SGLT2 inhibitors compared to DPP-4 inhibitors: A propensity-matched cohort study. Diabetes Obes Metab 2018; 20:2792-2799. [PMID: 29971914 DOI: 10.1111/dom.13459] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 06/20/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
AIM To determine the risk of amputations associated with sodium-glucose co-transporter-2 inhibitors (SGLT2i) relative to dipeptidyl peptidase-4 inhibitors (DPP4i). MATERIALS AND METHODS We conducted an active comparator, new user cohort study using data from the Truven Health MarketScan (2009-2015) databases. Patients aged ≥18 years newly initiating SGLT2i or DPP4i between April 1, 2013 and March 31, 2015 were included. Patients were matched 1:1 on high dimensional propensity scores and followed until the earliest of any amputation, treatment discontinuation, disenrollment or end of study period (December 31, 2015). Cox proportional hazards models were used to estimate hazard ratios (HR) and robust 95% confidence intervals (CI) for amputation risk. RESULTS There were 30 216 comparable patients in each arm after matching. Over a median follow-up of 0.6 years, there were 60 amputations (SGLT2i: 36; DPP4i: 24), most at the level of partial foot (75%) and associated with diabetes-related vascular disease (66.7%). The incidence of amputations was higher among SGLT2i patients (1.62 vs. 1.15 per 1000 person-years) with a HR of 1.38 (CI: 0.83-2.31). In subgroup analyses, risk differed by type of SGLT2i: canagliflozin, HR 1.15 (CI: 0.63-2.09); dapagliflozin or empagliflozin, HR 2.25 (CI: 0.78-6.47). CONCLUSION All SGLT2i had an elevated, though not statistically significant, risk for amputations.
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Affiliation(s)
- Sruthi Adimadhyam
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Todd A Lee
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, University of Illinois at Chicago, Chicago, Illinois
- Epidemiology Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Daphne E Smith Marsh
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
| | - Brian T Layden
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Jesse Brown Veterans Medical Center, Chicago, Illinois
| | - Glen T Schumock
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois
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Gouta EL, Khalfallah M, Dougaz W, Samaali I, Nouira R, Bouasker I, Dziri C. Morbidity and mortality of infected diabetic foot managed in general surgical department. Tunis Med 2018; 96:875-883. [PMID: 31131868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Foot ulcers are diabetes-related complications which occur in 10%-25% in diabetic patients. They are an important cause of morbidity and mortality in diabetes. This retrospective study aimed to assess, using an administrative database, the morbidity and the mortality risk of infected diabetic ulcers. METHODS It's a retrospective study enrolling 644 patients operated on for a diabetic foot between January 1st, 2012 and December 31st, 2016 in the surgical department B of Charles Nicolle's Hospital. Logistic regression identified independent predictive factors of major amputation, morbidity and mortality. RESULTS This retrospective study showed that "Cardiac failure" (OR=5.00, 95%CI [1.08 23.25], p=0.039), "Admission in the ICU in the first 48h" (OR=12.76, 95%CI [4.92 33.33], p<0.001) and "Major amputation" (OR=6.40, 95%CI [2.41 16.94], p<0.001) were considered as independent predictive factors of mortality. As concerns morbidity, Cardiac failure (OR=0.163, 95%CI [0.055 0.479], p=0.001) and organ failure at admission (OR=0.017, 95%CI [0.004 0.066], p=0.017) were predictive factors of admission in the ICU during the first 48 hours. Besides, advanced age (OR=1.033, 95%CI [1.014 1.052], p=0.001), Pre-operative stay (OR=1.093, 95%CI [1.039 1.151], p=0.001) and admission in the ICU during the first 48 hours (OR=0.142, 95%CI [0.071 0.285], p<0.001) were predictive factors of major amputation. Moreover, Cardiac failure (OR=0.517, 95%CI [0.298 0.896], p=0.019), admission in the ICU during the first 48 hours (OR=0.176, 95%CI [0.088 0.354], p<0.001) and Pre-operative stay (OR=1.083, 95%CI [1.033 1.134], p=0.001) were predictive variables of complicated post-operative course. Admission in the ICU during the first 48h (OR=0.140, 95%CI [0.48 0.405], p<0.001), major amputation (OR=0.170, 95%CI [0.76 0.379], p<0.001), and number of ICU stays (OR=3.341, 95%CI [1.558 7.164], p=0.002) were predictive factors of medical complications. Preoperative stay (OR=1.091, 95%CI [1.038 1.147], p=0.001) was predictive of reintervention. CONCLUSIONS Our retrospective study assessed that mortality rate was inferior when the patient didn't have amputation, no post-operative complications and no reintervention. The main limitation of our study was the retrospective design.
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Ueda P, Svanström H, Melbye M, Eliasson B, Svensson AM, Franzén S, Gudbjörnsdottir S, Hveem K, Jonasson C, Pasternak B. Sodium glucose cotransporter 2 inhibitors and risk of serious adverse events: nationwide register based cohort study. BMJ 2018; 363:k4365. [PMID: 30429124 PMCID: PMC6233755 DOI: 10.1136/bmj.k4365] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess the association between the use of sodium glucose cotransporter 2 (SGLT2) inhibitors and seven serious adverse events of current concern. DESIGN Register based cohort study. SETTING Sweden and Denmark from July 2013 to December 2016. PARTICIPANTS A propensity score matched cohort of 17 213 new users of SGLT2 inhibitors (dapagliflozin, 61%; empagliflozin, 38%; canagliflozin, 1%) and 17 213 new users of the active comparator, glucagon-like peptide 1 (GLP1) receptor agonists. MAIN OUTCOME MEASURES The primary outcomes were lower limb amputation, bone fracture, diabetic ketoacidosis, acute kidney injury, serious urinary tract infection, venous thromboembolism, and acute pancreatitis, as identified from hospital records. Hazard ratios and 95% confidence intervals were estimated by using Cox proportional hazards models. RESULTS Use of SGLT2 inhibitors, as compared with GLP1 receptor agonists, was associated with an increased risk of lower limb amputation (incidence rate 2.7 v 1.1 events per 1000 person years, hazard ratio 2.32, 95% confidence interval 1.37 to 3.91) and diabetic ketoacidosis (1.3 v 0.6, 2.14, 1.01 to 4.52) but not with bone fracture (15.4 v 13.9, 1.11, 0.93 to 1.33), acute kidney injury (2.3 v 3.2, 0.69, 0.45 to 1.05), serious urinary tract infection (5.4 v 6.0, 0.89, 0.67 to 1.19), venous thromboembolism (4.2 v 4.1, 0.99, 0.71 to 1.38) or acute pancreatitis (1.3 v 1.2, 1.16, 0.64 to 2.12). CONCLUSIONS In this analysis of nationwide registers from two countries, use of SGLT2 inhibitors, as compared with GLP1 receptor agonists, was associated with an increased risk of lower limb amputation and diabetic ketoacidosis, but not with other serious adverse events of current concern.
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Affiliation(s)
- Peter Ueda
- Clinical Epidemiology Division, Department of Medicine, Solna, Eugeniahemmet, T2, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Henrik Svanström
- Clinical Epidemiology Division, Department of Medicine, Solna, Eugeniahemmet, T2, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
| | - Mads Melbye
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- The Swedish National Diabetes Register, Västra Götalandsregionen, Gothenburg, Sweden
| | - Stefan Franzén
- The Swedish National Diabetes Register, Västra Götalandsregionen, Gothenburg, Sweden
| | - Soffia Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- The Swedish National Diabetes Register, Västra Götalandsregionen, Gothenburg, Sweden
| | - Kristian Hveem
- KG Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology, Levanger, Norway
| | - Christian Jonasson
- KG Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Science, Norwegian University of Science and Technology, Trondheim, Norway
- HUNT Research Center, Faculty of Medicine, Norwegian University of Science and Technology, Levanger, Norway
| | - Björn Pasternak
- Clinical Epidemiology Division, Department of Medicine, Solna, Eugeniahemmet, T2, Karolinska University Hospital, 17176 Stockholm, Sweden
- Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark
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Akgül T, Sormaz İC, Aksoy M, Uçar A, Özger H, Eralp L. Results and functional outcomes of en-bloc resection and vascular reconstruction in extremity musculoskeletal tumors. Acta Orthop Traumatol Turc 2018; 52:409-414. [PMID: 30274704 PMCID: PMC6318543 DOI: 10.1016/j.aott.2018.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 08/14/2018] [Accepted: 08/29/2018] [Indexed: 01/28/2023]
Abstract
Objectives This paper aims to evaluate the extremity function and vascular outcome after limb-sparing surgery for extremity musculoskeletal tumors invading vascular structure required reconstruction. Methods Of the 507 patients with musculoskeletal tumors, who underwent surgery between 2004 and 2007, 17 (3,3%) patients with major vessel involvement were included in the study. The mean age was 37.8 ± 14.5, with a female/male ratio of 8/9. Thirteen (76.4%) patients had Stage IIb disease, and 2 (11,7%) patients had Stage III disease. In 2 (11,7%) patients have locally aggressive tumor that had Stage 3. Fifteen (88.2%) of the cases involved lower extremity, whilst 2 (11.8%) of them involved upper extremity. An arterial reconstruction was carried out in all patients. Wide tumor resection and endoprosthetic reconstruction were performed in 6 (35.2%) patients. Other 11 (65.8%) patients were treated with wide resection and soft tissue reconstruction. Postoperative data included; perioperative morbidities such as bleeding, infection, graft thrombosis, rupture, metastatic local recurrence and mortality. Ankle brachial index (ABI) and color-flow-duplex-scan (CFDS) were done at the final follow-up of the study, in order to prove the efficacy of reconstruction. Functional outcome was evaluated with International Society of Limb Salvage (ISOLS) criteria. Results The mean follow-up was of 39 months (range 3–120). Perioperative complications were arterial graft thrombosis occurred in 3 (17.6%) patients treated acutely with thrombectomy, uncontrolled deep wound infection occurred in 2 patients whom extremities were amputated. The most frequent complication after surgery was limb edema according to possibly venous and lymphatic obstruction, staged as C1, C2 and C3 disease was established in 6 patients (two patients in each group), and 1 patient was classified as C6 disease. Three (17.6%) patients had local recurrence (1/3 patient died and 2/3 (11.7%) patients underwent transfemoral amputation). At the last follow-up, 9 (52.9%) patients were alive without evidence of disease, 8 (47.1%) patients were died due to primary disease. There were 8 (47.1%) patients alive with an intact limb. Although functional outcome scores were satisfactory, emotional acceptance scores were low. The limb salvage probability was 74.0%. Conclusion Limb-sparing oncological surgery in musculoskeletal tumors with vascular invasion provides a satisfactory limb function, which may lead to an improved life quality. Arterial reconstruction has a high rate of patency in the long term. The surgeon should be aware of early perioperative complication related to vascular reconstruction and infection that effect on the rate of extremity survival. Level of evidence Level IV, Therapeutic study
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Affiliation(s)
- Turgut Akgül
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - İsmail Cem Sormaz
- Department of General Surgery, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Murat Aksoy
- Department of General Surgery, Bahcesehir University, Liv Hospital, Istanbul, Turkey.
| | - Adem Uçar
- Department of Radiology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Harzem Özger
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
| | - Levent Eralp
- Department of Orthopedics and Traumatology, Istanbul Medical Faculty, Istanbul, Turkey.
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Ryan PB, Buse JB, Schuemie MJ, DeFalco F, Yuan Z, Stang PE, Berlin JA, Rosenthal N. Comparative effectiveness of canagliflozin, SGLT2 inhibitors and non-SGLT2 inhibitors on the risk of hospitalization for heart failure and amputation in patients with type 2 diabetes mellitus: A real-world meta-analysis of 4 observational databases (OBSERVE-4D). Diabetes Obes Metab 2018; 20:2585-2597. [PMID: 29938883 PMCID: PMC6220807 DOI: 10.1111/dom.13424] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Revised: 06/01/2018] [Accepted: 06/12/2018] [Indexed: 12/16/2022]
Abstract
AIMS Sodium glucose co-transporter 2 inhibitors (SGLT2i) are indicated for treatment of type 2 diabetes mellitus (T2DM); some SGLT2i have reported cardiovascular benefit, and some have reported risk of below-knee lower extremity (BKLE) amputation. This study examined the real-world comparative effectiveness within the SGLT2i class and compared with non-SGLT2i antihyperglycaemic agents. MATERIALS AND METHODS Data from 4 large US administrative claims databases were used to characterize risk and provide population-level estimates of canagliflozin's effects on hospitalization for heart failure (HHF) and BKLE amputation vs other SGLT2i and non-SGLT2i in T2DM patients. Comparative analyses using a propensity score-adjusted new-user cohort design examined relative hazards of outcomes across all new users and a subpopulation with established cardiovascular disease. RESULTS Across the 4 databases (142 800 new users of canagliflozin, 110 897 new users of other SGLT2i, 460 885 new users of non-SGLT2i), the meta-analytic hazard ratio estimate for HHF with canagliflozin vs non-SGLT2i was 0.39 (95% CI, 0.26-0.60) in the on-treatment analysis. The estimate for BKLE amputation with canagliflozin vs non-SGLT2i was 0.75 (95% CI, 0.40-1.41) in the on-treatment analysis and 1.01 (95% CI, 0.93-1.10) in the intent-to-treat analysis. Effects in the subpopulation with established cardiovascular disease were similar for both outcomes. No consistent differences were observed between canagliflozin and other SGLT2i. CONCLUSIONS In this large comprehensive analysis, canagliflozin and other SGLT2i demonstrated HHF benefits consistent with clinical trial data, but showed no increased risk of BKLE amputation vs non-SGLT2i. HHF and BKLE amputation results were similar in the subpopulation with established cardiovascular disease. This study helps further characterize the potential benefits and harms of SGLT2i in routine clinical practice to complement evidence from clinical trials and prior observational studies.
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Affiliation(s)
| | - John B. Buse
- University of North Carolina School of Medicine, Department of MedicineChapel HillNorth Carolina
| | | | - Frank DeFalco
- Janssen Research & Development, LLCRaritanNew Jersey
| | - Zhong Yuan
- Janssen Research & Development, LLCTitusvilleNew Jersey
| | - Paul E. Stang
- Janssen Research & Development, LLCTitusvilleNew Jersey
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149
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Abstract
BACKGROUND Diabetic foot ulcers are the leading cause of non-traumatic lower extremity amputation. The aim of this study was to establish short-term predictors of lower extremity amputation (LEA) in patients with diabetic foot ulcers (DFU). METHODS A retrospective observational study was performed. Patients observed for the first time in a multidisciplinary outpatient diabetic foot clinic during 1-year were reviewed. We examined demographic and clinical data and the occurrence of LEA within 180 days. Bivariate descriptive analysis was performed and three logistic regression models were created to predict short-term LEA. RESULTS During 1-year 613 patients were observed for the first time in our diabetic foot clinic. Relevant data and eligibility was available from 479 patients with DFU; 38.41%, 40,71% and 20,88% had neuropathic, neuroischemic and ischemic ulcers, respectively. Considering a follow-up of 180 days, amputation occurred in 10.02% (n = 48) of patients: 3.13% (n = 15) major amputation and 6.89% (n = 33) minor amputation. Independent predictors of short-term LEA included moderate to severe infection [OR 5.23 (IC 95% 2.51-10.80; p < 0.001)], previous history of LEA [OR 3.93 (IC 95% 1.81-8.53; p = 0.001)], peripheral arterial disease [OR 3.51 (IC 95% 1.29-9.58; p = 0.014)] and presence of any walking disability [OR 3.35 (IC 95% 1.58-7.13; p = 0.002)]. CONCLUSION In DFU patients the risk of LEA at 180 days is associated to moderate to severe infection at the initial presentation, previous history of LEA, peripheral arterial disease and presence of any walking disability. To prevent future amputations these patients should be identified early and managed by a multidisciplinary team. LEVEL OF CLINICAL EVIDENCE Level 2.
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Affiliation(s)
- Lia Ferreira
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar do Porto, Portugal.
| | - André Carvalho
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar do Porto, Portugal
| | - Rui Carvalho
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar do Porto, Portugal
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150
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Abstract
BACKGROUND Peripheral arterial disease (PAD), caused by narrowing of the arteries in the limbs, is increasing in incidence and prevalence as our population is ageing and as diabetes is becoming more prevalent. PAD can cause pain in the limbs while walking, known as intermittent claudication, or can be more severe and cause pain while at rest, ulceration, and ultimately gangrene and limb loss. This more severe stage of PAD is known as 'critical limb ischaemia'. Treatments for PAD include medications that help to reduce the increased risk of cardiovascular events and help improve blood flow, as well as endovascular or surgical repair or bypass of the blocked arteries. However, many people are unresponsive to medications and are not suited to surgical or endovascular treatment, leaving amputation as the last option. Gene therapy is a novel approach in which genetic material encoding for proteins that may help increase revascularisation is injected into the affected limbs of patients. This type of treatment has been shown to be safe, but its efficacy, especially regarding ulcer healing, effects on quality of life, and other symptomatic outcomes remain unknown. OBJECTIVES To assess the effects of gene therapy for symptomatic peripheral arterial disease. SEARCH METHODS The Cochrane Vascular Information Specialist searched Cochrane CENTRAL, the Cochrane Vascular Specialised Register, MEDLINE Ovid, Embase Ovid, CINAHL, and AMED, along with trials registries (all searched 27 November 2017). We also checked reference lists of included studies and systematic reviews for further studies. SELECTION CRITERIA We included randomised and quasi-randomised studies that evaluated gene therapy versus no gene therapy in people with PAD. We excluded studies that evaluated direct growth hormone treatment or cell-based treatments. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, performed quality assessment, and extracted data from the included studies. We collected pertinent information on each study, as well as data for the outcomes of amputation-free survival, ulcer healing, quality of life, amputation, all-cause mortality, ankle brachial index, symptom scores, and claudication distance. MAIN RESULTS We included in this review a total of 17 studies with 1988 participants (evidence current until November 2017). Three studies limited their inclusion to people with intermittent claudication, 12 limited inclusion to people with varying levels of critical limb ischaemia, and two included people with either condition. Study investigators evaluated many different types of gene therapies, using different protocols. Most studies evaluated growth factor-encoding gene therapy, with six studies using vascular endothelial growth factor (VEGF)-encoding genes, four using hepatocyte growth factor (HGF)-encoding genes, and three using fibroblast growth factor (FGF)-encoded genes. Two studies evaluated hypoxia-inducible factor 1-alpha (HIF-1α) gene therapy, one study used a developmental endothelial locus-1 gene therapy, and the final study evaluated a stromal cell-derived factor-1 (SDF-1) gene therapy. Most studies reported outcomes after 12 months of follow-up, but follow-up ranged from three months to two years.Overall risk of bias varied between studies, with many studies not providing sufficient detail for adequate determination of low risk of bias for many domains. Two studies did not utilise a placebo control, leading to risk of performance bias. Several studies reported in previous protocols or in their Methods sections that they would report on certain outcomes for which no data were then reported, increasing risk of reporting bias. All included studies reported sponsorships from corporate entities that led to unclear risk of other bias. The overall quality of evidence ranged from moderate to very low, generally as the result of heterogeneity and imprecision, with few or no studies reporting on outcomes.Evidence suggests no clear differences for the outcomes of amputation-free survival, major amputation, and all-cause mortality between those treated with gene therapy and those not receiving this treatment (all moderate-quality evidence). Low-quality evidence suggests improvement in complete ulcer healing with gene therapy (odds ratio (OR) 2.16, 95% confidence interval (CI) 1.02 to 4.59; P = 0.04). We could not combine data on quality of life and can draw no conclusions at this time regarding this outcome (very low-quality evidence). We included one study in the meta-analysis for ankle brachial index, which showed no clear differences between treatments, but we can draw no overall association (low-quality evidence). We combined in a meta-analysis pain symptom scores as assessed by visual analogue scales from two studies and found no clear differences between treatment groups (very low-quality evidence). We carried out extensive subgroup analyses by PAD classification, dosage schedule, vector type, and gene used but identified no substantial differences. AUTHORS' CONCLUSIONS Moderate-quality evidence shows no clear differences in amputation-free survival, major amputation, and all-cause mortality between those treated with gene therapy and those not receiving gene therapy. Some evidence suggests that gene therapy may lead to improved complete ulcer healing, but this outcome needs to be explored with improved reporting of the measure, such as decreased ulcer area in cm², and better description of ulcer types and healing. Further standardised data that are amenable to meta-analysis are needed to evaluate other outcomes such as quality of life, ankle brachial index, symptom scores, and claudication distance.
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Affiliation(s)
- Rachel Forster
- University of EdinburghUsher Institute of Population Health Sciences and InformaticsEdinburghUKEH8 9AG
| | - Aaron Liew
- Newcastle UniversityInstitute of Cellular Medicine4th Floor, William Leech BuildingFramlington PlaceNewcastle upon TyneUKNE2 4HH
- National University of Ireland Galway (NUIG), Portiuncula University Hospital & Galway University Hospital, Saolta University Health Care GroupGalwayIreland
| | - Vish Bhattacharya
- Queen Elizabeth HospitalDepartment of General and Vascular SurgeryQueen Elizabeth AvenueSheriff HillGatesheadTyne and WearUKNE9 6SX
| | - James Shaw
- Newcastle UniversityInstitute of Cellular Medicine4th Floor, William Leech BuildingFramlington PlaceNewcastle upon TyneUKNE2 4HH
| | - Gerard Stansby
- Freeman HospitalNorthern Vascular CentreNewcastle upon TyneUKNE7 7DN
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