151
|
Humphrey JA, Kanthasamy S, Coughlin P, Coll AP, Robinson AAH. Outcome of trans-metatarsal amputations in patients with diabetes mellitus. Foot (Edinb) 2019; 40:22-26. [PMID: 31054475 DOI: 10.1016/j.foot.2019.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 04/05/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND This retrospective case series reports the reoperation rate, survival rate and mobility status in patients with diabetes mellitus who had undergone a trans-metatarsal amputation (TMA) managed within a diabetic foot care service. METHODS Forty-one consecutive patients (37 men, 4 women) underwent a TMA with primary wound closure between January 2008 and December 2017. Eighty-eight per cent (36/41) of the patients were followed-up for a mean of 2.3 years. The outcomes were retrospectively reviewed. RESULTS Four (11%) of the 36 patients required reoperation, including three (8%) major amputations. All of the patients requiring a reoperation had peripheral vascular disease. Eleven patients died giving a four-year survival rate of 69% (25/36). Of the surviving patients who had not required revision to a major amputation 96% (21/22) were fully mobile in bespoke orthoses. A third used a walking cane. CONCLUSION This study shows that a TMA with primary wound closure in patients with diabetes mellitus, is effective for limb salvage with low reoperation and major amputation rates. A well healed TMA stump provides independent mobility in the majority of patients. The failures occurred in patients with peripheral vascular disease who, even after percutaneous trans-luminal angioplasty, had a 19% major amputation rate. LEVEL OF EVIDENCE Level IV, retrospective case series.
Collapse
Affiliation(s)
- Joel A Humphrey
- Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Senthooran Kanthasamy
- Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Patrick Coughlin
- Department of Vascular Surgery, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anthony P Coll
- Wolfson Diabetes and Endocrine Clinic, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Andrew A H Robinson
- Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| |
Collapse
|
152
|
Kerr M, Barron E, Chadwick P, Evans T, Kong WM, Rayman G, Sutton-Smith M, Todd G, Young B, Jeffcoate WJ. The cost of diabetic foot ulcers and amputations to the National Health Service in England. Diabet Med 2019; 36:995-1002. [PMID: 31004370 DOI: 10.1111/dme.13973] [Citation(s) in RCA: 198] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2019] [Indexed: 01/30/2023]
Abstract
AIM To estimate the healthcare costs of diabetic foot disease in England. METHODS Patient-level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014-2015. RESULTS The cost of health care for ulceration and amputation in diabetes in 2014-2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration. CONCLUSIONS Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one-third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.
Collapse
Affiliation(s)
- M Kerr
- Insight Health Economics Ltd, London, UK
| | - E Barron
- Public Health England, London, UK
| | | | - T Evans
- Public Health England, London, UK
| | - W M Kong
- London North West University Healthcare NHS Trust, London, UK
| | - G Rayman
- Ipswich Hospital NHS Trust, Ipswich, UK
| | - M Sutton-Smith
- London North West University Healthcare NHS Trust, London, UK
| | - G Todd
- London North West University Healthcare NHS Trust, London, UK
| | - B Young
- National Diabetes Audit, London, UK
| | - W J Jeffcoate
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
153
|
Lazzarini PA, van Netten JJ, Fitridge RA, Griffiths I, Kinnear EM, Malone M, Perrin BM, Prentice J, Wraight PR. Pathway to ending avoidable diabetes-related amputations in Australia. Med J Aust 2019; 209:288-290. [PMID: 30257626 DOI: 10.5694/mja17.01198] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/09/2018] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Ian Griffiths
- Wound Management Innovation Cooperative Research Centre, Brisbane, QLD
| | | | | | - Byron M Perrin
- La Trobe Rural Health School, La Trobe University, Bendigo, VIC
| | - Jenny Prentice
- Wound Management Innovation Cooperative Research Centre, Brisbane, QLD
| | | |
Collapse
|
154
|
NLRP3 activation induced by neutrophil extracellular traps sustains inflammatory response in the diabetic wound. Clin Sci (Lond) 2019; 133:565-582. [PMID: 30626731 DOI: 10.1042/cs20180600] [Citation(s) in RCA: 102] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 12/13/2018] [Accepted: 01/08/2019] [Indexed: 01/04/2023]
Abstract
Persistent inflammatory response in the diabetic wound impairs the healing process, resulting in significant morbidity and mortality. Mounting evidence indicate that the activation of Nod-like receptor protein (NLRP) 3 inflammasome in macrophages (MΦ) contributes to the sustained inflammatory response and impaired wound healing associated with diabetes. However, the main trigger of NLRP3 inflammasome in the wounds is not known. Neutrophils, as sentinels of the innate immune system and key stimulators of MΦ, are immune cells that play the main role in the early phase of healing. Neutrophils release extracellular traps (NETs) as defense against pathogens. On the other hand, NETs induce tissue damage. NETs have been detected in the diabetic wound and implicated in the impaired healing process, but the mechanism of NETs suspend wound healing and its role in fostering inflammatory dysregulation are elusive. Here, we report that NLRP3 and NETs production are elevated in human and rat diabetic wounds. NETs overproduced in the diabetic wounds triggered NLRP3 inflammasome activation and IL-1β release in MΦ. Furthermore, NETs up-regulated NLRP3 and pro-IL-1β levels via the TLR-4/TLR-9/NF-κB signaling pathway. They also elicited the generation of reactive oxygen species, which facilitated the association between NLRP3 and thioredoxin-interacting protein, and activated the NLRP3 inflammasome. In addition, NET digestion by DNase I alleviated the activation of NLRP3 inflammasome, regulated the immune cell infiltration, and accelerated wound healing in diabetic rat model. These findings illustrate a new mechanism by which NETs contribute to the activation of NLRP3 inflammasome and sustained inflammatory response in the diabetic wound.
Collapse
|
155
|
Parker CN, Van Netten JJ, Parker TJ, Jia L, Corcoran H, Garrett M, Kwok CF, Nather A, Que MT, Srisawasdi G, Wraight P, Lazzarini PA. Differences between national and international guidelines for the management of diabetic foot disease. Diabetes Metab Res Rev 2019; 35:e3101. [PMID: 30468566 DOI: 10.1002/dmrr.3101] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/13/2018] [Accepted: 11/18/2018] [Indexed: 01/13/2023]
Abstract
AIM No studies have investigated if national guidelines to manage diabetic foot disease differ from international guidelines. This study aimed to compare guidelines of Western Pacific nations with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. METHODS The 77 recommendations in five chapters of the 2015 IWGDF guidance documents were used as the international gold standard reference. The IWGDF national representative(s) from 12 Western Pacific nations were invited to submit their nation's diabetic foot guideline(s). Four investigators rated information in the national guidelines as "similar," "partially similar," "not similar," or "different" when compared with IWGDF recommendations. National representative(s) reviewed findings. Disagreements in ratings were discussed until consensus agreement achieved. RESULTS Eight of 12 nations (67%) responded: Australia, China, New Zealand, Taiwan, and Thailand provided national guidelines; Singapore provided the Association of Southeast Asian Nations guidelines; and Hong Kong and the Philippines advised no formal national diabetic foot guidelines existed. The six national guidelines included were 39% similar/partially similar, 58% not similar, and 2% different compared with the IWGDF recommendations. Within individual IWGDF chapters, the six national guidelines were similar/partially similar with 53% of recommendations for the IWGDF prevention chapter, 42% for wound healing, 40% for infection, 40% for peripheral artery disease, and 20% for offloading. CONCLUSIONS National diabetic foot disease guidelines from a large and diverse region of the world showed limited similarity to recommendations made by international guidelines. Differences between recommendations may contribute to differences in national diabetic foot disease outcomes and burdens.
Collapse
Affiliation(s)
- Christina N Parker
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- School of Nursing, Queensland University of Technology, Brisbane, Australia
| | - Jaap J Van Netten
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Department of Rehabilitation Medicine, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Tony J Parker
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- School of Biomedical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Limin Jia
- Department of Endocrinology, Ningxia People's Hospital, Yinchuan, China
| | - Heidi Corcoran
- Podiatry Department, Tuen Mun Hospital, New Territories West Cluster, Hong Kong Hospital Authority, Tuen Mun, Hong Kong
| | - Michele Garrett
- Podiatry SIG, New Zealand Society for the Study of Diabetes, Auckland, New Zealand
- Diabetes Service, Waitemata District Health Board, Auckland, New Zealand
| | - Ching F Kwok
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan ROC
| | - Aziz Nather
- Department of Orthopaedic Surgery, National University Hospital, Singapore
| | - Ma Teresa Que
- Diabetes Foot Clinic, East Avenue Medical Center, Quezon City, Philippines
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Siriraj Hospital, Bangkok, Thailand
| | - Paul Wraight
- Diabetic Foot Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Peter A Lazzarini
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology, Brisbane, Australia
- Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, Australia
| |
Collapse
|
156
|
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: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [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.
Collapse
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
| |
Collapse
|
157
|
Li S, Wang C, Wang B, Liu L, Tang L, Liu D, Yang G, Zhang L. Efficacy of low-level light therapy for treatment of diabetic foot ulcer: A systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2018; 143:215-224. [PMID: 30009935 DOI: 10.1016/j.diabres.2018.07.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Revised: 05/17/2018] [Accepted: 07/05/2018] [Indexed: 12/20/2022]
Abstract
AIMS The goal of this systematic review and meta-analysis based on seven Randomized control trials (RCTs) is to examine whether Low-level light therapy (LLLT) is effective at healing diabetic foot ulcer (DFU) and to provide evidence-based recommendations and clinical guidelines for the future clinical treatment of DFUs. METHODS Medline, Embase, Scopus, Cochrane Library, and Web of Science databases were searched for studies published up to June 30, 2017, without language or data restrictions. RCTs that investigated the use of LLLT for DFU treatment were included. Standard methods of meta-analysis were performed to evaluate outcomes of LLLT on the healing of DFU. RESULTS Seven RCTs involving 194 participants were eligible for this systematic review and meta-analysis. The results of meta-analysis showed that LLLT has emerged as a potential noninvasive treatment for DFUs, as LLLT was found to effectively reduce the ulcer area [weighted mean difference (WMD) 34.18, 95% confidence intervals (CI) 19.38-48.99, P < 0.00001], improve the complete healing rate [odds ratio (OR) 6.72, 95% CI 1.99-22.64, P = 0.002]. Qualitative analysis of the included RCTs found that LLLT also played a role in the treatment of DFUs through promoting rapid granulation formation and shortening ulcer closure time, as well as alleviating foot ulcer pain. None of the treatment-related adverse event was reported. CONCLUSIONS LLLT was recognized as a potential method in the comprehensive treatment of DFUs. Further well designed and high-quality studies are required to confirm the role of LLLT in the management of DFUs.
Collapse
Affiliation(s)
- Shengbing Li
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Cong Wang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Bo Wang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Li Liu
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Liang Tang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Dongfang Liu
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Gangyi Yang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China
| | - Lili Zhang
- Department of Endocrinology, The Second Affiliated Hospital, Chongqing Medical University, 400010 Chongqing, China.
| |
Collapse
|
158
|
Del Core MA, Ahn J, Lewis RB, Raspovic KM, Lalli TAJ, Wukich DK. The Evaluation and Treatment of Diabetic Foot Ulcers and Diabetic Foot Infections. FOOT & ANKLE ORTHOPAEDICS 2018. [DOI: 10.1177/2473011418788864] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Diabetic foot ulcers and infections are common complications of diabetic foot disease. Additionally, these complications are a common cause of morbidity and impose a substantial burden to the patient and society. It is imperative to understand the major contributing factors, namely, diabetic neuropathy, peripheral arterial disease, and immune system dysfunction in order to guide treatment. Management of diabetic foot disease begins with a detailed history and thorough physical examination. This examination should focus on the manifestations of diabetic neuropathy and peripheral arterial disease, and, in particular, any evidence of diabetic foot ulcers or infection. Prevention strategies should include a multi-disciplinary approach centered on patient education.
Collapse
Affiliation(s)
- Michael A. Del Core
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Junho Ahn
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Robert B. Lewis
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Katherine M. Raspovic
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Trapper A. J. Lalli
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Dane K. Wukich
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
159
|
Rigato M, Pizzol D, Tiago A, Putoto G, Avogaro A, Fadini GP. Characteristics, prevalence, and outcomes of diabetic foot ulcers in Africa. A systemic review and meta-analysis. Diabetes Res Clin Pract 2018; 142:63-73. [PMID: 29807105 DOI: 10.1016/j.diabres.2018.05.016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/22/2018] [Accepted: 05/09/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Among non-communicable diseases, diabetes represents a growing public health problem in Africa, where diabetes-related needs remain mostly unmet and the disabling features of foot are worsened by hygienic, cultural, and healthcare issues. We aimed to review clinical characteristics, prevalence, and outcomes of patients with diabetic foot ulcer in Africa. METHODS We searched the literature for cross-sectional and longitudinal studies reporting the characteristics of patients with diabetic foot in African countries, with a particular focus on ulcer prevalence, amputation rate, and mortality. FINDINGS Fifty-five full-text papers and ten abstracts were retrieved, reporting data from 19 African countries on 56,173 diabetic patients. According to the data collected, the overall prevalence of foot ulcers was 13% and increased over time, especially since 2001. Approximately 15% of patients with foot lesions underwent major amputation and 14.2% died during hospitalization. In patients with diabetic ulcers, insulin therapy was uncommon and neuropathy was the most common predisposing factor, but the prevalence of peripheral arterial disease correlated with amputation rates. Amputation and mortality decreased over time, probably as result of the implementation of screening programs in the last ten years. Mortality was directly related to previous amputation. INTERPRETATION The diabetic foot disease in Africa is a growing problem and is burden by high rate of in-hospital mortality. Educational interventions and screening programs including evaluation of the vascular status may play a crucial role to counter diabetic foot disease in Africa.
Collapse
Affiliation(s)
- Mauro Rigato
- Department of Medicine, University of Padova, Padova, Italy
| | | | | | | | - Angelo Avogaro
- Department of Medicine, University of Padova, Padova, Italy
| | | |
Collapse
|
160
|
Kim YK, Lee HS, Ryu JJ, In Lee H, Seo SG. Sarcopenia increases the risk for mortality in patients who undergo amputation for diabetic foot. J Foot Ankle Res 2018; 11:32. [PMID: 29946364 PMCID: PMC6006937 DOI: 10.1186/s13047-018-0274-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 06/05/2018] [Indexed: 12/25/2022] Open
Abstract
Background Although there have been reports that diabetes affects the prevalence of sarcopenia, no studies have examined the relationship between sarcopenia and mortality in patients undergoing leg amputation. The purpose of this study is to determine whether sarcopenia affects the mortality rate of patients undergoing diabetic foot amputation. Methods From among patients who underwent limb amputation for diabetes complications, this study included 167 patients who underwent abdominal CT within 1 year of amputation. We defined sarcopenia using sex-specific cut-off points for the L3 skeletal muscle index. The 5-year survival rate was analyzed. All patients were divided into two groups and compared according to the presence of sarcopenia. The mortality rate according to sarcopenia was assessed via the Kaplan-Meier method and log-rank test. Uni- and multivariate Cox regression analyses evaluated factors associated with survival rate. Results Among the total of 167 patients, the overall 5-year mortality rate was 52.7%. Of the 112 patients with sarcopenia, the 5-year mortality rate was 60.7%. Of the 55 patients without sarcopenia, the 5-year mortality rate was 36.4%. Kaplan-Meier analysis showed a high mortality of the sarcopenia group in the univariate (p = 0.016) and multivariate (p = 0.047) analysis. Conclusions Our study is the first to analyze the relationship between diabetic amputation and sarcopenia. Sarcopenia increases the risk of mortality in patients who undergo amputation for diabetic foot. Therefore, patients with diabetes should be careful to prevent sarcopenia with enough regular exercise as well as prevent diabetic foot disease.
Collapse
Affiliation(s)
- You Keun Kim
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Ho Seong Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Jae Jung Ryu
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Hye In Lee
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea
| | - Sang Gyo Seo
- 1Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Olympic-ro 43 gil 88, Seoul, 05505 Republic of Korea.,2Diabetes Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| |
Collapse
|
161
|
Matos M, Mendes R, Silva AB, Sousa N. Physical activity and exercise on diabetic foot related outcomes: A systematic review. Diabetes Res Clin Pract 2018; 139:81-90. [PMID: 29477503 DOI: 10.1016/j.diabres.2018.02.020] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 02/01/2018] [Accepted: 02/13/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetic foot is one of the most common complications of diabetes. It has the potential risk of pathologic consequences including infection, ulceration and amputation, but a growing body of evidence suggests that physical activity and exercise may improve diabetic foot outcomes. OBJECTIVE To analyze de effects of exercise and physical activity interventions on diabetic foot outcomes. METHODS A comprehensive and systematic search was conducted according to PRISMA recommendations. Only controlled clinical trials with patients with diabetes were included. RESULTS Six studies, involving 418 patients with diabetes, were included. Two studies used only aerobic exercise; two studies combined aerobic, resistance and balance exercise; and two studies combined aerobic and balance exercise by Thai Chin Chuan methods. Physical activity and exercise significantly improved nerve velocity conduction, peripheral sensory function and foot peak pressure distribution. Moreover, the ulcers incidence rate per year was lower in the intervention groups, compared with the controls [0.02 vs. 0.12]. CONCLUSION This review suggests evidence that physical activity and exercise is an effective non-pharmacological intervention to improve diabetic foot related outcomes. Combined multi-disciplinary treatments are more effective in the prevention of foot complications in patients with diabetes.
Collapse
Affiliation(s)
- Monica Matos
- Research Center in Sports Sciences, Health Sciences and Human Development, Vila Real, Portugal.
| | - Romeu Mendes
- University of Trás-os-Montes e Alto Douro, Vila Real, Portugal; Public Health Unit, ACES Douro I - Marão e Douro Norte, Vila Real, Portugal; EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal.
| | - André B Silva
- Centro Hospitalar Tondela Viseu, Ophthalmology Department, Viseu, Portugal.
| | - Nelson Sousa
- Research Center in Sports Sciences, Health Sciences and Human Development, Vila Real, Portugal; University of Trás-os-Montes e Alto Douro, Vila Real, Portugal.
| |
Collapse
|
162
|
Vas PRJ, Edmonds M, Kavarthapu V, Rashid H, Ahluwalia R, Pankhurst C, Papanas N. The Diabetic Foot Attack: “’Tis Too Late to Retreat!”. INT J LOW EXTR WOUND 2018; 17:7-13. [DOI: 10.1177/1534734618755582] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The “diabetic foot attack” is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of “time is tissue” and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.
Collapse
|
163
|
Gurney JK, Stanley J, York S, Rosenbaum D, Sarfati D. Risk of lower limb amputation in a national prevalent cohort of patients with diabetes. Diabetologia 2018; 61:626-635. [PMID: 29101423 DOI: 10.1007/s00125-017-4488-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
AIMS/HYPOTHESIS Lower limb amputation is a serious complication of diabetes mellitus. Understanding how amputation risk differs by population subgroups is crucial in terms of directing preventive strategies. In this study, we describe those factors that impact amputation risk in the entire prevalent diabetic population of New Zealand. METHODS A national prevalent cohort of 217,207 individuals with diabetes in 2010 were followed up until the end of 2013 for lower limb amputations, and 2014 for mortality. Inpatient hospitalisation data were used to define lower limb amputation using ICD-10 codes. Cox proportional hazards models were used to describe relative hazard of amputation over the follow-up period. RESULTS A total of 784 individuals (3.6 cases/1000 individuals) underwent a major (above-ankle) lower limb amputation during follow-up, while 1217 (5.6/1000) underwent a minor (below ankle) amputation. The risk of major and minor amputation was 39% and 77% greater for men than women, respectively (adjusted HR: major amputation 1.39, 95% CI 1.20, 1.61; minor amputation 1.77, 95% CI 1.56, 2.00). Indigenous Māori were at 65% greater risk of above-knee amputation compared with the European/Other diabetic population (HR 1.65, 95% CI 1.37, 1.97). Amputation risk increased with increasing comorbidity burden, and peripheral vascular disease conferred the greatest independent risk of all comorbid conditions. Prior minor amputation increased the risk of subsequent major amputation by tenfold (HR 10.04, 95% CI 7.83, 12.87), and increased the risk of another minor amputation by 20-fold (HR 21.39, 95% CI 17.89, 25.57). Death was common among the total cohort, but particularly among those who underwent amputation, with more than half of those who underwent a major amputation dying within 3 years of their procedure (57%). CONCLUSIONS/INTERPRETATION Using a large, well-defined, national prevalent cohort of people with diabetes, we found that being male, indigenous Māori, living in deprivation, having a high comorbidity burden and/or having a previous amputation were strongly associated with subsequent risk of lower limb amputation. The use of this prevalent cohort strengthens the value of our estimates in terms of applicability to the general population, and highlights the subgroups at greatest risk of lower limb amputation.
Collapse
Affiliation(s)
- Jason K Gurney
- Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, 23a Mein St, Newtown, Wellington, New Zealand.
| | - James Stanley
- Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, 23a Mein St, Newtown, Wellington, New Zealand
| | - Steve York
- High Risk Foot Clinic, Northland District Health Board, Whangarei, New Zealand
| | - Dieter Rosenbaum
- Movement Analysis Lab, University Hospital Muenster, Muenster, Germany
| | - Diana Sarfati
- Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, 23a Mein St, Newtown, Wellington, New Zealand
| |
Collapse
|
164
|
van Netten JJ, Lazzarini PA, Armstrong DG, Bus SA, Fitridge R, Harding K, Kinnear E, Malone M, Menz HB, Perrin BM, Postema K, Prentice J, Schott KH, Wraight PR. Diabetic Foot Australia guideline on footwear for people with diabetes. J Foot Ankle Res 2018; 11:2. [PMID: 29371890 PMCID: PMC5769299 DOI: 10.1186/s13047-017-0244-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 12/27/2017] [Indexed: 12/21/2022] Open
Abstract
Background The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes. Methods We reviewed new footwear publications, (inter)national guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations. Result We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate- or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate- or high-risk of foot ulceration to wear their footwear at all times, both indoors and outdoors. (6) Motivate people with diabetes at intermediate- or high-risk of foot ulceration (or their relatives and caregivers) to check their footwear, each time before wearing, to ensure that there are no foreign objects in, or penetrating, the footwear; and check their feet, each time their footwear is removed, to ensure there are no signs of abnormal pressure, trauma or ulceration. (7) For people with a foot deformity or pre-ulcerative lesion, consider prescribing medical grade footwear, which may include custom-made in-shoe orthoses or insoles. (8) For people with a healed plantar foot ulcer, prescribe medical grade footwear with custom-made in-shoe orthoses or insoles with a demonstrated plantar pressure relieving effect at high-risk areas. (9) Review prescribed footwear every three months to ensure it still fits adequately, protects, and supports the foot. (10) For people with a plantar diabetic foot ulcer, footwear is not specifically recommended for treatment; prescribe appropriate offloading devices to heal these ulcers. Conclusions This guideline contains 10 key recommendations to guide health professionals in selecting the most appropriate footwear to meet the specific foot risk needs of an individual with diabetes.
Collapse
Affiliation(s)
- Jaap J van Netten
- 1School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD Australia.,Diabetic Foot Australia, Brisbane, QLD Australia.,Wound Management Innovation Cooperative Research Centre, Brisbane, QLD Australia
| | - Peter A Lazzarini
- 1School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD Australia.,Diabetic Foot Australia, Brisbane, QLD Australia.,Wound Management Innovation Cooperative Research Centre, Brisbane, QLD Australia.,Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD Australia
| | - David G Armstrong
- 5Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, AZ USA
| | - Sicco A Bus
- Department of Rehabilitation, Academic Medical Center, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Robert Fitridge
- Diabetic Foot Australia, Brisbane, QLD Australia.,7Vascular Surgery, The University of Adelaide, Adelaide, South Australia Australia
| | - Keith Harding
- 8University Dean of Clinical Innovation, Professor of Wound Healing Research, Cardiff University, Cardiff, UK
| | - Ewan Kinnear
- Diabetic Foot Australia, Brisbane, QLD Australia.,Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD Australia
| | - Matthew Malone
- Diabetic Foot Australia, Brisbane, QLD Australia.,9High Risk Foot Service, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW Australia
| | - Hylton B Menz
- 10Discipline of Podiatry, School of Allied Health, College of Science, Health and Engineering, La Trobe University, Bundoora, VIC Australia
| | - Byron M Perrin
- Diabetic Foot Australia, Brisbane, QLD Australia.,11La Trobe Rural Health School, College of Science, Health and Engineering, La Trobe University, Bendigo, VIC Australia
| | - Klaas Postema
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, the Netherlands
| | - Jenny Prentice
- Diabetic Foot Australia, Brisbane, QLD Australia.,Wound Consultant, Trojan Health, Perth, WA Australia
| | - Karl-Heinz Schott
- 14School of Health and Human Sciences (Pedorthics) Southern Cross University Gold Coast Campus, Bilinga, QLD Australia
| | - Paul R Wraight
- Diabetic Foot Australia, Brisbane, QLD Australia.,15Diabetic Foot Unit, Royal Melbourne Hospital, Melbourne, VIC Australia
| |
Collapse
|
165
|
Thurber EG, Kisuule F, Humbyrd C, Townsend J. Inpatient Management of Diabetic Foot Infections: A Review of the Guidelines for Hospitalists. J Hosp Med 2017; 12:994-1000. [PMID: 29236099 DOI: 10.12788/jhm.2842] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Diabetic foot infections (DFIs) are common and represent the leading cause for hospitalization among diabetic complications. Without proper management, DFIs may lead to amputation, which is associated with a decreased quality of life and increased mortality. However, there is currently significant variation in the management of DFIs, and many providers fail to perform critical prevention and assessment measures. In this review, we will provide an overview of the diagnosis, management, and discharge planning of hospitalized patients with DFIs to guide hospitalists in the optimal inpatient care of patients with this condition.
Collapse
Affiliation(s)
- Emilia G Thurber
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Flora Kisuule
- Division of Hospital Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Casey Humbyrd
- Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland USA
| | - Jennifer Townsend
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| |
Collapse
|
166
|
Boodoo C, Perry JA, Hunter PJ, Duta DI, Newhook SCP, Leung G, Cross K. Views of Patients on Using mHealth to Monitor and Prevent Diabetic Foot Ulcers: Qualitative Study. JMIR Diabetes 2017; 2:e22. [PMID: 30291089 PMCID: PMC6238864 DOI: 10.2196/diabetes.8505] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 08/28/2017] [Accepted: 08/29/2017] [Indexed: 01/15/2023] Open
Abstract
Background People with diabetes are at risk for diabetic foot ulcers (DFUs), which can lead to limb loss and a significant decrease in quality of life. Evidence suggests that mHealth can be an effective tool in diabetes self-management. mHealth presents an opportunity for the prevention and monitoring of DFUs. However, there is a paucity of research that explores its effectiveness in the DFU patient population, as well as the views and attitudes of these patients toward technology and mHealth. Objective This study aimed to explore the views, attitudes, and experiences of a diabetic patient population with or at risk of DFUs regarding technology, mHealth, and the diabetic foot. Methods We used a qualitative research approach using in-depth interviews with 8 patients with DFUs. Questions were structured around experience with technology, current health practices related to diabetic foot care, and thoughts on using an mHealth device that prevents and monitors DFUs. We transcribed and thematically analyzed all interviews. Results All patients had positive responses for an mHealth intervention aimed at preventing and monitoring DFUs. We found 4 themes in the data: diversity in use of technology, feet-checking habits, 2-way communication with health care professionals (HCPs), and functionality. There were varying levels of familiarity with and dependence on technology within this patient population. These relationships correlated with distinct generations found in North America, including baby boomers and Generation X. Furthermore, we found that most patients performed daily feet checks to monitor any changes in health. However, some did not perform feet checks prior to the development of a DFU. Patients expressed interest in 2-way communication with HCPs that would allow for easier appointment scheduling, sharing of medical data, decreased number of visits, and use of alerts for when medical attention is required. Patients also identified conditions of functionality for the mHealth intervention. These included consideration of debilitating complications because of diabetes, such as retinopathy and decreased mobility; ease of use of the intervention; and implementation of virtual communities to support continued use of the intervention. Conclusions Our patient population expressed an interest in mHealth for preventing and monitoring DFUs, although some participants were not frequent users of technology. mHealth continues to show potential in improving patient outcomes, and this study provides a foundation for designing interventions specific to a DFU population. Further research is needed to confirm these findings.
Collapse
Affiliation(s)
- Chris Boodoo
- Department of Medical Imaging, St Michael's Hospital, Toronto, ON, Canada
| | - Julie Ann Perry
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Paul John Hunter
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada
| | - Dragos Ioan Duta
- Department of Medical Imaging, St Michael's Hospital, Toronto, ON, Canada
| | | | - General Leung
- Department of Medical Imaging, St Michael's Hospital, Toronto, ON, Canada.,Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.,Department of Medical Imaging, University of Toronto, Toronto, ON, Canada.,Institute of Biomedical Engineering Science & Technology, Ryerson University, Toronto, ON, Canada
| | - Karen Cross
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, ON, Canada.,Institute of Biomedical Engineering Science & Technology, Ryerson University, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
167
|
van Netten JJ, Baba M, Lazzarini PA. Epidemiology of diabetic foot disease and diabetes-related lower-extremity amputation in Australia: a systematic review protocol. Syst Rev 2017; 6:101. [PMID: 28521817 PMCID: PMC5437559 DOI: 10.1186/s13643-017-0488-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/28/2017] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Diabetic foot disease is associated with major morbidity, mortality, costs, and reduction of a person's quality of life. Investigating the epidemiology of diabetic foot disease is the backbone of diabetic foot research and clinical practice, yet the full burden of diabetic foot disease in Australia is unknown. This study aims to describe the protocol for a systematic review of the epidemiology of diabetic foot disease and diabetes-related lower-extremity amputation in Australia. METHODS-SEARCH The systematic review will be performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed and EMBASE will be searched for publications in any language and without restrictions to date. Two independent investigators will screen publications for eligibility, with publications reporting Australian population-based incidence or prevalence of diabetic foot disease or diabetes-related lower-extremity amputation to be included. Additionally, a forward literature search will be performed in Google Scholar, and a grey literature search will be performed to identify government publications. METHODS-ASSESSMENT Quality assessment will be performed using customised checklists. The summary statistic used for each study will be an incidence or prevalence proportion of diabetic foot disease or diabetes-related lower-extremity amputation. The standard error for each proportion will be calculated. A meta-analysis will be performed when three or more publications of adequate quality, reporting on similar outcomes and in similar populations, are identified. DISCUSSION The results of this systematic review can be used to adequately inform stakeholders in the field of diabetic foot disease on the extent of the problem in incidence and prevalence of diabetic foot disease in Australia, and to help guide appropriate use of resources to reduce the burden of this disease. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016050740.
Collapse
Affiliation(s)
- Jaap J. van Netten
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD Australia
- Diabetic Foot Australia, West End, QLD 4101 Australia
- Wound Management Innovation Cooperative Research Centre, Brisbane, QLD Australia
| | | | - Peter A. Lazzarini
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD Australia
- Diabetic Foot Australia, West End, QLD 4101 Australia
- Wound Management Innovation Cooperative Research Centre, Brisbane, QLD Australia
- Department of Podiatry, Metro North Hospital & Health Service, Queensland Health, Brisbane, QLD Australia
| |
Collapse
|
168
|
Rubio JA, Jiménez S, Álvarez J. Clinical characteristics and mortality in patients treated in a Multidisciplinary Diabetic Foot Unit. ACTA ACUST UNITED AC 2017; 64:241-249. [PMID: 28495319 DOI: 10.1016/j.endinu.2017.02.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 02/23/2017] [Accepted: 02/27/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND OBJECTIVE This study reviews the clinical characteristics of patients with diabetic foot ulcer treated in a Multidisciplinary Diabetic Foot Unit (MDFU) and analyzes the mortality and factors associated with its survival. MATERIAL AND METHODS Data from all patients who attended the MDFU for the first time for a diabetic foot ulcer during the 2008-2014 period were analized. The patients were followed until their death or until June 30, 2016, for up to 8 years. RESULTS A total of 345 patients were included, with a median age (P25-P75) of 71 (61.5-80) years, and 321 (93%) had type 2 diabetes. They were characterized as patients with inadequate glycemic control, 48% had HbA1c ≥ 8% and high prevalence of chronic complications: 60.2% retinopathy, 43.8% nephropathy and 47.2% ischemic heart disease and/or cerebrovascular disease. A total of 126 (36.5%) patients died and 69 (54.8%) were due to cardiovascular disease. Survival measured by Kaplan-Meier declined over time to 69, 60 and 45% at 3, 5 and 7 years respectively. Cox's multivariate regression analysis showed the following variables associated with mortality, HR (95% CI): age 1.08 (1.05-1.11); previous amputation 2.24 (1.34-3.73); active smoking 2.10 (1.12-3.97); cerebrovascular disease 1.75 (1.05-2.92); renal dysfunction 1.65 (1.04-2.61) and ischemic heart disease 1.60 (1.01-2.51). CONCLUSIONS Patients with diabetic foot ulcer are characterized by high morbidity and mortality, with cardiovascular disease being the most frequent cause of death. It is necessary to pay more attention to this risk group, tailoring objectives and treatments to their situation and life expectancy.
Collapse
Affiliation(s)
- José Antonio Rubio
- Unidad de Pie Diabético, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España; Departamento de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España; Departamento de Ciencias Biomédicas, Universidad de Alcalá, Alcalá de Henares, España.
| | - Sara Jiménez
- Unidad de Pie Diabético, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España; Departamento de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España
| | - Julia Álvarez
- Unidad de Pie Diabético, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España; Departamento de Endocrinología y Nutrición, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, España; Departamento de Medicina y Especialidades Médicas, Universidad de Alcalá, Alcalá de Henares, España
| |
Collapse
|
169
|
Rossaneis MA, Haddad MDCFL, Mantovani MDF, Marcon SS, Pissinati PDSC. Foot ulceration in patients with diabetes: a risk analysis. ACTA ACUST UNITED AC 2017; 26:S6-S14. [DOI: 10.12968/bjon.2017.26.6.s6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Mariana Angela Rossaneis
- University Professor, Nursing Department, State University of Londrina, Londrina, Paraná, Brazil
| | | | | | - Sonia Silva Marcon
- Nursing Department, State University of Maringá, Maringá, Paraná, Brazil
| | | |
Collapse
|
170
|
Schaarup C, Pape-Haugaard L, Jensen MH, Laursen AC, Bermark S, Hejlesen OK. Probing community nurses' professional basis: a situational case study in diabetic foot ulcer treatment. Br J Community Nurs 2017; 22 Suppl 3:S46-S52. [PMID: 28252333 DOI: 10.12968/bjcn.2017.22.sup3.s46] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Complicated and long-lasting wound care of diabetic foot ulcers are moving from specialists in wound care at hospitals towards community nurses without specialist diabetic foot ulcer wound care knowledge. The aim of the study is to elucidate community nurses' professional basis for treating diabetic foot ulcers. A situational case study design was adopted in an archetypical Danish community nursing setting. Experience is a crucial component in the community nurses' professional basis for treating diabetic foot ulcers. Peer-to-peer training is the prevailing way to learn about diabetic foot ulcer, however, this contributes to the risk of low evidence-based practice. Finally, a frequent behaviour among the community nurses is to consult colleagues before treating the diabetic foot ulcers.
Collapse
Affiliation(s)
- Clara Schaarup
- PhD Fellow, Department of Health Science and Technology, Aalborg University, Denmark
| | - Louise Pape-Haugaard
- Associate Professor, Department of Health Science and Technology, Aalborg University, Denmark
| | | | | | - Susan Bermark
- Clinical Head Nurse, The Wound Healing Knowledge Centre, Bispebjerg Hospital
| | | |
Collapse
|
171
|
Menon AS, Dixit A, Garg MK, Girish R. Cardiac Autonomic Neuropathy in Patients with Type 2 Diabetes Mellitus at High Risk for Foot Ulcers. Indian J Endocrinol Metab 2017; 21:282-285. [PMID: 28459026 PMCID: PMC5367231 DOI: 10.4103/ijem.ijem_542_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIM To study the prevalence of cardiac autonomic neuropathy (CAN) in patients with Type 2 diabetes mellitus at high risk for foot ulcers. MATERIALS AND METHODS We screened patients attending diabetic clinic for identifying patients at high risk for foot ulcers. Those with foot risk category 1, 2 and 3 as per criteria of Foot Care Interest Group were subjected to battery of cardiovascular autonomic reflex tests. Those with one abnormal test were termed as probable CAN and those with two abnormal tests as definite CAN. Those with postural fall in blood pressure with one other abnormal test were termed to have advanced CAN. RESULTS A total of 74 patients were recruited in the study. The prevalence of abnormal cardiovascular autonomic reflex test was sustained hand grip 81%, E/I ratio 66.2%, 30:15 ratio 28.3% and orthostatic hypotension 13.5%. The prevalence of possible CAN was 31.0% (23/74) and definite CAN was 66.2% (49/74). Ten patients had advanced CAN. There was no observable difference in presence of probable or definite CAN in three risk category for foot ulcers. CONCLUSION We found a high prevalence of CAN in subgroup of diabetic patients at increased risk for foot ulcer.
Collapse
Affiliation(s)
- Anil S. Menon
- Department of Endocrinology, Command Hospital, Lucknow, Uttar Pradesh, India
| | - Abhinav Dixit
- Department of Endocrinology, Command Hospital, Lucknow, Uttar Pradesh, India
| | - M. K. Garg
- Department of Endocrinology, Command Hospital, Lucknow, Uttar Pradesh, India
| | - R. Girish
- Department of Cardiology, Command Hospital, Lucknow, Uttar Pradesh, India
| |
Collapse
|
172
|
Silva JMTSD, Haddad MDCFL, Rossaneis MA, Vannuchi MTO, Marcon SS. Factors associated with foot ulceration of people with diabetes mellitus living in rural areas. Rev Gaucha Enferm 2017; 38:e68767. [PMID: 29641685 DOI: 10.1590/1983-1447.2017.03.68767] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 04/18/2017] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze the factors associated with the risk of ulceration in the feet of people with diabetes mellitus living in rural areas. Methods This is a cross-sectional study conducted with 293 individuals with diabetes mellitus, aged 40 years or older, living in the south of Brazil, in 2014. We analyzed socioeconomic variables, clinical conditions and foot self-care. We used the Poisson multiple regression model and the Prevalence Ratio (PR) and p-value<0.05 as a measure of association. Results 43.7% of the sample presented risk of foot ulceration. The highest prevalence of foot ulceration risk was associated with people with lower purchasing power (PRadjusted=1.62/IC95%:1.52-2.22), with retinopathy (PRadjusted=1.30/IC95%:1.12-1.68) and alteration in foot moisture (PRadjusted=1.57/IC95%:1.22-2.01). We identified low education level (64.2%), high prevalence of arterial hypertension (86.3%) and onychomycosis in the feet (72%). Conclusions Diabetic patients need an assessment of the risk of foot ulceration, especially those with longer diagnosis, chronic complications and low socio-educational level.
Collapse
Affiliation(s)
| | | | | | | | - Sonia Silva Marcon
- Departamento de Enfermagem, Universidade Estadual de Maringá, Maringá, Paraná, Brasil
| |
Collapse
|
173
|
Xie Y, Zhang H, Ye T, Ge S, Zhuo R, Zhu H. The Geriatric Nutritional Risk Index Independently Predicts Mortality in Diabetic Foot Ulcers Patients Undergoing Amputations. J Diabetes Res 2017; 2017:5797194. [PMID: 28164133 PMCID: PMC5253176 DOI: 10.1155/2017/5797194] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/18/2016] [Indexed: 12/30/2022] Open
Abstract
Objective. Patients with diabetic foot ulcers undergoing amputations have poor prognosis. Malnutrition usually occurs in this population and is associated with increased risk of mortality. The geriatric nutritional risk index (GNRI) is a widely used, simple, and well-established tool to assess nutritional risk. The purpose of this study was to assess the association between GNRI and all-cause mortality in diabetic foot ulcers patients undergoing minor or major amputations. Methods. This was a retrospective cohort study including 271 adult patients. Patients were divided into two groups according to a GNRI cutoff value of 92, and characteristics and mortality were compared between the two groups. Cox proportional hazard analysis was performed to explore the association between GNRI and mortality. Result. GNRI (p < 0.001), age (p < 0.001), and eGFR (p = 0.002) were independent predictors of mortality. Among a subgroup of 230 patients with minor amputation, increased age (p < 0.001), coronary artery disease (p = 0.030), and increased GNRI (p < 0.001) were major risk factors. Conclusion. GNRI on admission might be a novel clinical predictor for the incidence of death in patients with diabetic foot ulcers who were undergoing amputations.
Collapse
Affiliation(s)
- Yuanyuan Xie
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hailing Zhang
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Tingting Ye
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Shengjie Ge
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruyi Zhuo
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hong Zhu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- *Hong Zhu:
| |
Collapse
|
174
|
Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med 2016; 33:1493-1498. [PMID: 26666583 DOI: 10.1111/dme.13054] [Citation(s) in RCA: 268] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2015] [Indexed: 12/15/2022]
Abstract
AIMS The presence of diabetic foot ulcers is strongly associated with an increased risk of death. In this study, we investigate whether the effects of diabetes-associated complications can explain the apparent relationship between diabetic foot ulcers and death. METHODS We analysed data from 414 523 people with diabetes enrolled in practices associated with The Health Improvement Network in the United Kingdom. Our methods were designed to control for potential confounders in order to isolate the relationship between diabetic foot ulcers and death. Using proportional hazards models and the area under the receiver operator curve, we evaluated the effects of diabetic foot ulcers and the covariates on death. RESULTS Among the patients, 20 737 developed diabetic foot ulcers; 5.0% of people with new ulcers died within 12 months of their first foot ulcer visit and 42.2% of people with foot ulcers died within 5 years. After controlling for major known complications of diabetes that might influence mortality, the correlation between diabetic foot ulcers and death remained strong with a fully adjusted hazard ratio of 2.48 (95% confidence interval: 2.43, 2.54). Geographic variance existed but was not spatially associated. CONCLUSIONS Diabetic foot ulcers are linked to an increased risk of death. This cannot be explained by other common risk factors. These results suggest that either there are major unknown risk factors associated with both diabetic foot ulcers and death, or that diabetic foot ulceration itself is a serious threat, which seems unlikely. A diabetic foot ulcer should be seen as a major warning sign for mortality, necessitating closer medical follow-up.
Collapse
Affiliation(s)
- J W Walsh
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - O J Hoffstad
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - M O Sullivan
- Department of Chemical & Biomolecular Engineering, University of Delaware, Newark, DE, USA
| | - D J Margolis
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, PA.
| |
Collapse
|
175
|
Cheng Q, Lazzarini PA, Gibb M, Derhy PH, Kinnear EM, Burn E, Graves N, Norman RE. A cost-effectiveness analysis of optimal care for diabetic foot ulcers in Australia. Int Wound J 2016; 14:616-628. [PMID: 27489228 DOI: 10.1111/iwj.12653] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 07/01/2016] [Accepted: 07/08/2016] [Indexed: 02/01/2023] Open
Abstract
In addition to affecting quality of life, diabetic foot ulcers (DFUs) impose an economic burden on both patients and the health system. This study developed a Markov model to analyse the cost-effectiveness of implementing optimal care in comparison with the continuation of usual care for diabetic patients at high risk of DFUs in the Australian setting. The model results demonstrated overall 5-year cost savings (AUD 9100·11 for those aged 35-54, $9391·60 for those aged 55-74 and $12 394·97 for those aged 75 or older) and improved health benefits measured in quality-adjusted life years (QALYs) (0·13 QALYs, 0·13 QALYs and 0·16 QALYs, respectively) for high-risk patients receiving optimal care for DFUs compared with usual care. Total cost savings for Australia were estimated at AUD 2·7 billion over 5 years. Probabilistic sensitivity analysis showed that optimal care always had a higher probability of costing less and generating more health benefits. This study provides important evidence to inform Australian policy decisions on the efficient use of health resources and supports the implementation of evidence-based optimal care in Australia. Furthermore, this information is of great importance for comparable developed countries that could reap similar benefits from investing in these well-known evidence-based strategies.
Collapse
Affiliation(s)
- Qinglu Cheng
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Peter A Lazzarini
- Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, Australia.,School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Michelle Gibb
- Wound Management Innovation Cooperative Research Centre, Brisbane, Australia
| | - Patrick H Derhy
- Healthcare Improvement Unit, Queensland Health, Brisbane, Australia
| | - Ewan M Kinnear
- Department of Podiatry, Metro North Hospital & Health Service, Brisbane, Australia
| | - Edward Burn
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Nicholas Graves
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Rosana E Norman
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.,Wound Management Innovation Cooperative Research Centre, Brisbane, Australia
| |
Collapse
|
176
|
Thorud JC, Jupiter DC, Lorenzana J, Nguyen TT, Shibuya N. Reoperation and Reamputation After Transmetatarsal Amputation: A Systematic Review and Meta-Analysis. J Foot Ankle Surg 2016; 55:1007-12. [PMID: 27475711 DOI: 10.1053/j.jfas.2016.05.011] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Indexed: 02/03/2023]
Abstract
Transmetatarsal amputations have generally been accepted as a relatively more definitive amputation compared with other lesser ray resections. However, many investigators have reported a high occurrence of more proximal amputation after transmetatarsal amputation. A systematic review was performed to evaluate the occurrence of reamputation and reoperation after transmetatarsal amputations. A search of the Medline, CINAHL, and Cochrane Central databases yielded 159 abstracts. After review, 24 reports were included in the study. A total of 391 (26.9%) reoperations were identified after 1453 transmetatarsal amputations. Any level reamputation occurred in 152 (29.7%) of 365 transmetatarsal amputations and major amputation occurred in 380 (33.2%) of 1146 transmetatarsal amputations. Using a random effects model, the reoperation rate was estimated at 24.43% (95% confidence interval 11.64% to 37.21%), the reamputation rate was estimated at 28.37% (95% confidence interval 19.56% to 37.19%), and the major amputation rate was estimated at 30.16% (95% confidence interval 23.86% to 36.47%). These findings raise questions about the conventional wisdom of performing primary transmetatarsal amputation in lieu of other minor amputations, such as partial first ray amputation, and suggest that the choice between transmetatarsal amputation and other minor amputations might be a decision that depends on very patient-specific factors.
Collapse
Affiliation(s)
| | - Daniel C Jupiter
- Assistant Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| | - Jonathan Lorenzana
- Second Year Resident, Baylor Scott & White Health, Temple, TX; Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; and Department of Surgery, Texas A&M University Health and Science Center, College of Medicine, Round Rock, TX
| | | | - Naohiro Shibuya
- Associate Professor, Department of Surgery, Texas A&M University Health Science Center, College of Medicine, Round Rock, TX; Chief, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; and Department of Surgery, Baylor Scott & White Health, Temple, TX
| |
Collapse
|
177
|
Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality After Nontraumatic Major Amputation Among Patients With Diabetes and Peripheral Vascular Disease: A Systematic Review. J Foot Ankle Surg 2016; 55:591-9. [PMID: 26898398 DOI: 10.1053/j.jfas.2016.01.012] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Indexed: 02/03/2023]
Abstract
High mortality rates have been reported after major amputations of a lower limb secondary to diabetes and peripheral vascular disease. However, the mortality rates have varied across studies. A systematic review of the 5-year mortality after nontraumatic major amputations of the lower extremity was conducted. A data search was performed of Medline using OVID, CINHAL, and Cochrane, 365 abstracts were screened, and 79 full text articles were assessed for eligibility. After review, 31 studies met the inclusion and exclusion criteria. Overall, the 5-year mortality rate was very high among patients with any amputation (major and minor combined), ranging from 53% to 100%, and in patients with major amputations, ranging from 52% to 80%. Mortality after below-the-knee amputation ranged from 40% to 82% and after above-the-knee amputation from 40% to 90%. The risk factors for increased mortality included age, renal disease, proximal amputation, and peripheral vascular disease. Although our previous systematic review of the 5-year mortality after ulceration had much lower rates of death, additional studies are warranted to determine whether amputation hastens death or is a marker for underlying disease severity.
Collapse
Affiliation(s)
- Jakob C Thorud
- Podiatrist, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Podiatrist, Department of Surgery, Baylor Scott & White Health, Temple, TX.
| | - Britton Plemmons
- Podiatrist, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Third Year Resident, Baylor Scott & White Health, Temple, TX; and Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Clifford J Buckley
- Chief, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Director, Division of Surgery, Baylor Scott & White Health, Temple, TX; and Professor, Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Naohiro Shibuya
- Associate Professor, Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX; Chief, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; and Podiatrist, Baylor Scott & White Health, Temple, TX
| | - Daniel C Jupiter
- Assistant Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
| |
Collapse
|
178
|
Walters J, Cazzell S, Pham H, Vayser D, Reyzelman A. Healing Rates in a Multicenter Assessment of a Sterile, Room Temperature, Acellular Dermal Matrix Versus Conventional Care Wound Management and an Active Comparator in the Treatment of Full-Thickness Diabetic Foot Ulcers. EPLASTY 2016; 16:e10. [PMID: 26933467 PMCID: PMC4750365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this 16-week, multicenter, randomized, controlled trial was to assess the healed ulcer rate of a human acellular dermal matrix, DermACELL, compared with conventional care and a second acellular dermal matrix, Graftjacket, in the treatment of full-thickness diabetic foot ulcers. METHODS One hundred sixty-eight patients were randomized into DermACELL, conventional care, and Graftjacket treatment arms in a 2:2:1 ratio. Patients in the acellular dermal matrix groups received either 1 or 2 applications of the graft at the discretion of the investigator. Weekly follow-up visits were conducted until the ulcer healed or the endpoint was reached. RESULTS At 16 weeks, the DermACELL arm had a significantly higher proportion of completely healed ulcers than the conventional care arm (67.9% vs 48.1%; P = .0385) and a nonsignificantly higher proportion than the Graftjacket arm (67.9% vs 47.8%; P = .1149). The DermACELL arm also exhibited a greater average percent reduction in wound area than the conventional care arm (91.4% vs 80.3%; P = .0791) and the Graftjacket arm (91.4% vs 73.5%; P = .0762). The proportion of severe adverse events and the proportion of overall early withdrawals were similar among the 3 groups based on relative population size (P ≥ .05). CONCLUSIONS The results presented here indicate that DermACELL is an appropriate clinical option in the treatment of diabetic foot ulcers, with significant increases in healing rates and rate of percentage wound closure as compared with conventional care options.
Collapse
Affiliation(s)
| | - Shawn Cazzell
- Limb Preservation Platform, Valley Vascular Surgical Associates, Fresno, Calif
| | - Hau Pham
- Boston University School of Medicine, Boston Medical Center, Boston, Mass
| | | | - Alexander Reyzelman
- California School of Podiatric Medicine at Samuel Merritt University, Oakland
- UCSF Center for Limb Preservation, San Francisco, Calif
| |
Collapse
|
179
|
Margolis DJ, Hoffstad O. Response to Comment on Hoffstad et al. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care 2015;38:1852-1857. Diabetes Care 2016; 39:e27. [PMID: 26798156 DOI: 10.2337/dci15-0025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- David J Margolis
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ole Hoffstad
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|
180
|
Margolis DJ, Hoffstad O. Response to Comment on Hoffstad et al. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care 2015;38:1852-1857. Diabetes Care 2016; 39:e8. [PMID: 26696669 DOI: 10.2337/dc15-2053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- David J Margolis
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ole Hoffstad
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| |
Collapse
|