Lower-extremity amputations in diabetic and nondiabetic patients. A population-based study in eastern Finland

[Incidence of amputaciones of the lower extremities in the population with diabetes mellitus in Málaga (1996-1997)]

OBJECTIVE

To find the frequency of amputations of lower limbs (ALL) with the aim of designing a programme to prevent ALL in people with diabetes mellitus (DM).

DESIGN

Retrospective observation study.

SETTING

Population study in Malaga and its province.

PATIENTS

The clinical records of everyone with ALL in public or subsidized hospitals in the province of Malaga between January 1 1996 and December 31 1997 were reviewed. Traumatic or tumoural ALL were excluded. Cumulative incidence, relative risk (RR) of ALL and the mortality rate of people with DM were calculated.

RESULTS

449 ALL took place during the period studied, 316 (70.3%) in people with DM and 133 (29.6%) in people not suffering DM. The incidence of ALL per 100,000 people and per year was 6.3 (CI: 4.7-7.8) in the population without DM and 136.1 (CI: 114.9-157.3) in people with DM. The RR of ALL was 21.6 (CI: 17.6-26.4) for the population with DM, with differences between men and women (16.8 vs. 36.1, respectively). Mean age of ALL was significantly greater (p < 0.05) for the population with DM (70.0 +/- 10.2 vs. 68.9 +/- 15.9 years old). Older ALL were more numerous in both women and men in the two groups studied. The mortality rate, complications and mean stay in hospital were greater in the population with DM.

CONCLUSIONS

This study confirmed the greater risk of ALL run by people with DM. The incidence of ALL in this study was less than in countries of Northern Europe, the USA and Australia, but more than in any study published before in Spain.

Hyperglycemia as a risk factor for cardiovascular disease in type 2 diabetes

According to several prospective population-based studies, glycemic control influences the risk for cardiovascular disease, including coronary heart disease, independently of conventional risk factors in patients with type 2 diabetes. Recent clinical trials, particularly the United Kingdom Prospective Diabetes Study, have shown that microvascular complications and macrovascular complications, although to a lesser extent, can be prevented in patients with type 2 diabetes with correction of glycemic control. However, in the treatment and prevention of cardiovascular disease in type 2 diabetes, all known cardiovascular risk factors should be attacked simultaneously.

Epidemiology of lower limb amputees in Southern Finland in 1995 and trends since 1984

The purpose of this study was to look at the current epidemiological trends of lower limb amputees in 1995 and the trends since 1984 in the area of Southern Finland with 1.3 million inhabitants. During the one-year period, the lower limb amputation was performed on 366 patients. The overall amputation rate has been unchanged since 1984 being 28.0 per 100,000 inhabitants in 1995. The mean age was 71.4 years. The overall amputation rate was 28.0 per 100,000 inhabitants. Of the 366 patients in the study 30% had arteriosclerosis without diabetes mellitus and 49% had diabetes. Diabetes mellitus has become the most common cause of amputation since 1985. Tumours were the cause in 2% and trauma in 4%. The most common unilateral amputations were trans-femoral amputations (29%) followed by trans-tibial amputations (28%) and toe amputations (24%). The unilateral trans-tibial/trans-femoral ratio was 0.54 in 1984 and 0.95 in 1995. The one-year mortality rate was 39% in 1984 and 40% in 1995. The rate of amputation has been relatively constant over the last ten years. The age related incidence in the older age groups has also been unchanged over the last ten years. Better control of diabetes and prophylactic foot care of diabetics can have a positive contribution in prevention of lower limb amputations. The current rehabilitation and prosthetic services of the lower limb amputees can be planned in the south of Finland on the basis of the incidence of 28 per 100,000 inhabitants.

Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population-based 7-year follow-up study

OBJECTIVES

The aim of the study was to find factors predicting lower extremity amputation in patients with type 1 or type 2 diabetes mellitus through a 7-year follow-up period.

DESIGN

Follow-up study.

SUBJECTS

Altogether 733 diabetic patients. aged 10-79 years, were drawn from the national drug reimbursement register.

METHODS

At baseline, the patients underwent a podiatric, circulatory and neurophysiological examination. Seven years later a follow-up study was performed based on clinical and register data. Patient data for those who died during the follow-up were collected from hospital records and death certificates. All amputations were recorded. The patients with amputation were compared with the other patients and also, in a case-control manner, by taking three nonamputated patients matched by sex, type of diabetes, and age for each patient with amputation.

RESULTS

The number of amputations was 25 in the sample. Compared with all patients without amputation, patients with amputation differed in altogether 24 variables concerning diabetes and its complications. Compared with the matched non-amputated patients, the amputated patients had longer duration of diabetes, lower ankle/brachial pressure index (ABI), more often history of retinopathy, nephropathy, and hypertension, more often visual handicap, elevated serum creatinine level, abnormal neurophysiological indices and electrophysiological findings. In the logistic regression analysis, vibration perception threshold, low ABI, history of retinopathy, visual handicap, and male sex were independently associated with lower extremity amputation.

CONCLUSIONS

Lower extremity amputations were strongly associated with retinopathy, nephropathy, and neuropathy. The presence of any of these complications should lead to intensified actions in order to prevent amputations. As far as arterial circulation is concerned, claudication or absent peripheral pulses were not good predictors of amputation, whereas low ABI, despite its known weaknesses, was a reliable indicator of future amputation.

Prandial glucose regulation and cardiovascular disease in type 2 diabetes

Type 2 diabetes is associated with an increased risk for cardiovascular disease. In recent years, prospective studies have indicated that, in addition to conventional risk factors, glycaemic control of diabetes predicts cardiovascular disease in both middle-aged and elderly patients with Type 2 diabetes. However, there are no consistent data from different studies to indicate that postprandial glucose is a better predictor for cardiovascular risk than fasting glucose level. Although no clinical trials are available to show that improving glycaemic control prevents cardiovascular mortality and morbidity, recent studies imply that hyperglycaemia in patients with Type 2 diabetes should be treated more intensively than recommended by current guidelines

Epidemiology of risk factors for cardiovascular disease in diabetes and impaired glucose tolerance

Diabetes mellitus is a strong risk factor for all manifestations of atherosclerotic vascular disease, coronary heart disease (CHD), cerebrovascular disease and peripheral vascular disease. Diabetes can be classified into two main subtypes, insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus (NIDDM). This review focuses only on NIDDM. Also, in impaired glucose tolerance (IGT), a precursor stage of diabetes, the risk of macrovascular disease is substantially increased. NIDDM and IGT are known to be associated with several adverse cardiovascular risk factors, including hypertension, obesity, central obesity, hyperinsulinemia and serum lipid and lipoprotein abnormalities, characterized mainly by elevated serum total triglycerides and low high-density lipoprotein cholesterol. Practically no information is available on the role of different cardiovascular risk factors to predict macrovascular complications in subjects with IGT. The role of different cardiovascular risk factors with respect to the risk of CHD, stroke and peripheral vascular disease will be discussed.

Low prevalence of long-term complications in non-insulin-dependent diabetes mellitus in France: a multicenter study. CODIAB-INSERM-ZENECA Pharma Study Group

The aim of this study was to assess the prevalence of long-term complications in a large sample of French NIDDM patients. Therefore, 427 NIDDM patients 35-74 years old were recruited in ten centers. Standardized clinical criteria and central reading for retinal and electrocardiographic changes were used to assess the presence of complications. The prevalence rates of complications were 29.7% and 3.3% for background and proliferative retinopathy; 21.8%, 6.1%, and 2.8% for microalbuminuria, proteinuria, and renal insufficiency; 19.9 and 11.7% for asymptomatic and symptomatic pheripheral neuropathy; 8.2% for orthostatic hypotension; 10.1% and 8.4% for angina pectoris and myocardial infarction; and 13.1% and 6.3% for mild and moderate to severe peripheral vascular disease, respectively. In conclusion, prevalence rates in this study were lower than in most studies from other countries.

Risk factors for lower limb complications in diabetic patients. The Italian Study Group for the Implementation of the St. Vincent Declaration

Diabetic lower extremity complications may be influenced by a number of factors, including those related to the interaction between patients and the health-care system. Our objective is to identify risk factors for the development of lower limb complications, by looking for classical clinical variables and those related to quality of care. A case-control study was carried out between December 1993 and June 1994 by interviewing 348 patients with lower-limb diabetic complications and 1050 controls enrolled from 35 diabetes outpatient clinics and 49 general practitioner's offices in Italy. Among sociodemographic characteristics associated with increased risk of lower limb complications were male gender [odds ratio (OR) = 2.5, confidence interval (CI) 1.6-3.9], age between 50 and 70 years as opposed to younger than 50 (OR = 3.6, CI 2.1-6.3) and being single as opposed to married (OR = 1.4, CI 1.1-1.8). Among clinical variables, treatment with insulin for IDDM and NIDDM patients was an important predictor of lower extremity complications compared to NIDDM patients not being treated with insulin. Cardio-cerebrovascular disease and presence of diabetic neuropathy were associated with a higher risk of being a case (OR = 1.4, CI 1.2-1.8 and OR = 3.0, CI 2.1-4.2, respectively). Patients who needed help to reach the health facility before the onset of the complications and those who did not attend health facilities regularly were more liable to develop complications (OR = 1.5, CI 1.1-2.2 and OR = 2.0, CI 1.3-3.0, respectively). Patients who had never received educational intervention had a threefold risk of being a case as compared to those who received health information regularly. The study identifies factors most likely to be related to adverse outcome and permits to discriminate between avoidable and unavoidable factors.

Methodological issues affect variability in reported incidence of lower extremity amputations due to diabetes

The aim of this study is to evaluate the influence of different methodological techniques commonly utilized to identify the incidence of diabetes related lower extremity amputations. Medical records for each hospitalization for an amputation in 1993 in six metropolitan statistical areas in South Texas were abstracted. Every hospitalization, amputation and amputee was identified to allow separate analysis. Furthermore, data was categorized by ethnicity, level and age. Diabetes was verified using WHO criteria. Incidence rates were calculated per 10,000 diabetic patients at risk per year, both diagnosed only (DO) and diagnosed and undiagnosed combined (DUC). In total 1922 amputations were carried out during 1228 hospitalizations for 1043 amputees. The incidence rates per 10,000 diabetic patients (DO) were: 157.6 amputations, 101.2 hospitalizations and 87.0 amputees. When calculated using the DUC population at risk the rates were: 92.8 amputations, 59.6 hospitalizations and 51.2 amputees. Trends were found to be similar when analyzed by gender and ethnicity. The variability detected using of different methodological techniques to determine incidence rates is considerable and may have significant consequences when rates from different studies are compared.

Epidemiology of lower limb amputees in the north of The Netherlands: aetiology, discharge destination and prosthetic use

The aim of this study was to give a retrospective review of all lower limb amputations performed in the 3 northern provinces of the Netherlands in 1991-1992. Assembled data were compared with the existing information in the National Medical Register (NMR) over the same period. With the participation of all regional hospitals, 473 lower limb amputations from transpelvic to transmetatarsal level were identified. Of the amputations 94% were performed for vascular pathology, 3% for trauma, and 3% for oncologic reasons. After surgery a prosthesis was provided to 48% of the amputees. The actual number of performed amputations exceeds the number of amputations registered by the NMR by 9%. Incidence rates of lower limb amputations in the Netherlands are 18-20/100,000 over the last 12 years. These numbers are lower than in other areas and no sharp decrease in frequency compared with other countries in Western Europe.

Daily functioning of the lower extremity amputee: an overview of the literature

The aim of this paper is to review the existing literature on the incidence, morbidity and mortality of lower limb amputation. The functional level of the lower limb amputee and the predictive factors for functioning with a prosthesis are reviewed, both for unilateral and for bilateral amputees. The reported incidence of lower extremity amputation (LEA) varies considerably between different Western countries. The mean survival of LEA patients ranges between two and five years. Assessment of functional outcome is carried out differently. Studies are not comparable and most concern selected groups of amputees. Increasing age, concurrent disease and poor compliance are prognostic factors for a low functional level. For optimal planning of rehabilitation it is necessary to study a complete cohort of amputees with respect to these prognostic factors.

The impact of diabetes-related lower-extremity amputations in The Netherlands

The purpose of this study is to identify the incidence of diabetes-related lower-extremity amputations in the Netherlands. We used discharge records from SIG Health Care Information for every hospitalization for a lower-extremity amputation in all hospitals in the Netherlands in 1992. Age- and gender-specific population figures and diagnosed cases of diabetes were obtained from the Central Bureau of Statistics. Age- and gender-adjusted amputation incidences were identified at four different levels (toe, foot, leg, and thigh). Multiple amputations were analyzed by the highest level. Of all lower-extremity amputations, 1,575 (47%) were in persons with diabetes mellitus. Age- and gender-adjusted lower-extremity amputation rates per 10,000 persons with diabetes by level were the following: toe 12.39, foot 2.42, leg 7.82, thigh 2.54, and total 25.17. People with diabetes were 20.3 times more likely to experience a lower-extremity amputation than people without diabetes. Males were at a significantly higher risk of experiencing an amputation than females. There was a significant increase in the age-specific incidence of amputations as age increased. The most common amputation procedure performed was the toe amputation. There was a significant increase in thigh amputations as age increased, indicating that as people get older they suffer higher levels of amputations. Although the incidence of lower-extremity amputations was lower than previous reports, they still have a serious impact on the health-care system in the Netherlands.

Regional variation in the incidence of diabetes-related amputations in The Netherlands

The purpose of this study is to identify the incidence of diabetes-related lower extremity amputations in 27 health regions in the Netherlands. A secondary database was used that contains all hospitalizations for a lower extremity amputation in the Netherlands in 1991 and 1992, recorded separately for 27 health regions. The age-adjusted incidence lower extremity amputations per 10,000 diabetic patients in the Netherlands was 25.05, and among the regions it ranged from 10.15 to 44.64. In the non-diabetic population, the age-adjusted incidence in the Netherlands was 1.24 and ranged by region from 0.77 to 1.77. Overall, diabetic males had higher age-adjusted incidence rates than diabetic females, although in four health regions the situation was reversed. In the Netherlands, there was an increasing incidence of diabetes-related lower extremity amputation as age increased: < 45 years, 11.15; 45-64 years, 33.84; 65-74 years, 61.22; and 75 + years, 107.92 (P < 0.001). This continued to be a significant phenomenon for every health region (P < 0.001). This study found a wide range in the incidence of diabetes related lower extremity amputations in the 27 health regions in the Netherlands. A possible explanation could be differences in the severity of diabetes, in local treatment philosophies or the availability of subspecialties.

Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?

The purpose of this retrospective study was to evaluate the changes in diabetes-related lower extremity amputations following the implementation of a multidisciplinary programme for prevention and treatment of diabetic foot ulcers in a 0.2 million population with a 2.4% prevalence of diabetes. All diabetes-related primary amputations from toe to hip from 1 January 1982 to 31 December 1993 were included. In 294 diabetic patients, 387 primary major (above the ankle) or minor (through or below the ankle) amputations were performed, constituting 48% of all lower extremity amputations. The annual number of amputations at all levels decreased from 38 to 21, equalling a decrease of incidence from 19.1 to 9.4/100,000 inhabitants (p = 0.001). The incidence of major amputations decreased by 78% from 16/1 to 3.6/100,000 inhabitants (p < 0.001). The absolute number of amputations with a final level below the ankle showed no increase, but their proportion increased from 28 to 53% (p < 0.001) and the reamputation rate decreased from 36 to 22% (p < 0.05) between the first and last 3-year period. Thus, a substantial long-term decrease in the incidence of major amputations was seen as well as a decrease in the total incidence of amputations in diabetic patients. Seventy-one per cent of the amputations were precipitated by a foot ulcer. These findings indicate that a multidisciplinary approach plays an important role to reduce and maintain a low incidence of major amputations in diabetic patients.

Human sciatic nerve phospholipid profiles from non-diabetes mellitus, non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus individuals. A 31P NMR spectroscopy study

1. Human sciatic nerve phospholipids obtained from non-diabetes mellitus (NDM), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) patients, after lower extremity amputation, were studied by 31P NMR spectrometry. 2. Nine phospholipids resonances in NDM and NIDDM groups were identified as followed: Ethanolamine plasmalogen (Eplas, Chemical shift = 0.07 delta); phosphatidylethanolamine (PE, 0.03 delta); phosphatidylserine (PS, -0.05 delta); sphingomyelin (SM, -0.09 delta); lysophosphatidylcholine (LPC, -0.28 delta); phosphatidylinositol (PI, -0.30 delta); alkylacylphosphorylcholine (A1.PC, -0.78 delta); phosphatidylcholine (PC -0.84 delta), and an unknown resonance (U, 0.13 delta). 3. In the IDDM group a resonance of lysophosphatidylinositol (LPI, 0.01 delta) was detected in addition to the nine phospholipids listed above. 4. IDDM showed that PI and A1.PC were elevated and U was lower when compared with NDM; also, Eplas was lower when compared with NIDDM. PC was elevated and PS was lower when compared with both NDM and NIDDM. 5. Indices calculated from this data, showed that the choline ratio and choline/ethanolamine ratio were elevated; while ethanolamine ratio, and myelin ratio were lower in IDDM group, when compared with both NDM and NIDDM groups. 6. Inactivation of the cholineacethyltransferase enzyme (ChAT) and enhancement of the phospholipidmethyltransferase enzyme (PLMT), secondary to an insulin deficiency, are proposed as an interpretation of these findings.