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Zhang Y, Liu H, Yang Y, Feng C, Cui L. Incidence and risk factors for amputation in Chinese patients with diabetic foot ulcers: a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2024; 15:1405301. [PMID: 39280008 PMCID: PMC11393406 DOI: 10.3389/fendo.2024.1405301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 08/15/2024] [Indexed: 09/18/2024] Open
Abstract
Objective This study aimed to comprehensively analyze the incidence of amputation in Chinese patients with diabetic foot ulcers (DFUs). Methods The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were used. The CNKI, Wanfang Data, VIP, PubMed, Web of Science, and Embase databases were searched to collect relevant literature on the incidence of amputation in Chinese patients with DFUs. Two researchers independently screened the literature, extracted data, and evaluated the risk of bias. The data were systematically analyzed using Stata 17.0 software to determine the incidence of amputation in this patient population. Results A total of 25 papers were included in the study, revealing an incidence of amputation in Chinese patients with DFUs of 22.4% (95% confidence interval: 18.3-26.5%). The subgroup analysis revealed that a history of ulcers, Wagner grade >3, and diabetic peripheral vascular disease were the primary risk factors associated with a higher incidence of amputation in Chinese patients with DFUs (P<0.05). Among Chinese patients with DFUs, the amputation group and the non-amputation group showed significant differences in body mass index, duration of DFUs, total cholesterol, triglyceride, fasting blood glucose, white blood cell count, hemoglobin A1c, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high-sensitivity C-reactive protein, and uric acid (P<0.05). Conclusion The high incidence of amputation among Chinese patients with DFUs indicates that interventions should be implemented to prevent or minimize amputations. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42023463976.
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Affiliation(s)
- Yujie Zhang
- School of Humanities and Management, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Hui Liu
- Department of Quality Management, Jining N0.1 People's Hospital, Jining, Shandong, China
| | - Yadi Yang
- Department of Quality Management, Jining N0.1 People's Hospital, Jining, Shandong, China
| | - Chaochen Feng
- Department of Quality Management, Jining N0.1 People's Hospital, Jining, Shandong, China
| | - Liwei Cui
- Department of Quality Management, Jining N0.1 People's Hospital, Jining, Shandong, China
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2
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Highton P, Jeffers S, Butt A, O'Mahoney L, Jenkins S, Abdala R, Haddon L, Gillies C, Curtis F, Hadjiconstantinou M, Khunti K. Patient-reported outcomes in diabetes-related foot conditions: Is patient experience influenced by ethnicity? A mixed-methods systematic review. Diabet Med 2024:e15420. [PMID: 39102339 DOI: 10.1111/dme.15420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/24/2024] [Accepted: 07/27/2024] [Indexed: 08/07/2024]
Abstract
AIMS Research in diabetes-related foot conditions (DRFC) often focuses on ulcer-related care, whilst the patient experience and influence of sociodemographic factors are under-researched. This systematic review investigated patient-reported outcomes and experience in people with DRFC. METHODS Multiple databases were searched from inception to 16 August 2023. All original articles that assessed any patient-reported outcome or experience in DRFC and reported participant ethnicity were included. Data were synthesized using a sequential contingent approach. Study quality was assessed using study design-specific tools. RESULTS Twenty-three studies were included (11 qualitative, 11 quantitative and one mixed-methods). DRFC had a largely negative impact on various life dimensions, including social and daily life, work, emotional and psychological well-being, necessitating dependence on others in the form of emotional, social and/or religious support, which were experienced differently by different groups. Patient DRFC knowledge and self-care habits were typically suboptimal, and levels of hope and feeling of control over their condition varied between groups. Outcomes varied slightly between ethnicities across studies, with some ethnicity-specific themes identified such as beliefs about disease cause and footwear habits. Quantitative and qualitative findings were mostly congruent. CONCLUSIONS DRFC profoundly and negatively impacts patient-reported outcomes and experience, with limited evidence suggesting an influence of ethnicity.
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Affiliation(s)
- Patrick Highton
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Shavez Jeffers
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Ayesha Butt
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Lauren O'Mahoney
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Sian Jenkins
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | - Ruksar Abdala
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Louise Haddon
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Clare Gillies
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Applied Research Collaboration East Midlands, Leicester, UK
| | - Ffion Curtis
- Liverpool Reviews & Implementation Group (LRiG), University of Liverpool, Liverpool, UK
| | - Michelle Hadjiconstantinou
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Leicester Biomedical Research Centre, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
- National Institute for Health and Care Research Applied Research Collaboration East Midlands, Leicester, UK
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3
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Sebastian-Valles F, Martínez-Alfonso J, Arranz Martin JA, Jiménez-Díaz J, Hernando Alday I, Navas-Moreno V, Joya TA, Fandiño García MDM, Román Gómez GL, Garai Hierro J, Lander Lobariñas LE, Martínez de Icaya P, Sampedro-Nuñez MA, Martínez-Vizcaíno V, Marazuela M. Impact of socioeconomic status on chronic control and complications of type 1 diabetes mellitus in users of glucose flash systems: a follow-up study. BMC Med 2024; 22:37. [PMID: 38273326 PMCID: PMC10809494 DOI: 10.1186/s12916-024-03254-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND This study investigates the association between socioeconomic status (SES) and glycemic control in individuals with type 1 diabetes (T1D) using flash glucose monitoring (FGM) devices within a public health system where these technologies are freely available and utilized according to recommended guidelines. METHODS A follow-up study of 1060 adults (mean age 47.4 ± 15.0 years, 49.0% women) with T1D, receiving care at three Spanish university hospitals that regularly employ the FGM system. SES was assessed using the Spanish Deprivation Index and the average annual net income per person. Glycemic data were collected over a 14-day follow-up period, including baseline glycated hemoglobin (HbA1c) levels prior to sensor placement, the last available HbA1c levels, and FGM-derived glucose metrics. Individuals with sensor usage time < 70% were excluded. Chronic micro and macrovascular complications related to diabetes were documented. Regression models, adjusted for clinical variables, were employed to determine the impact of SES on optimal sensor control (defined as time in range (TIR) ≥ 70% with time below range < 4%) and disease complications. RESULTS The average follow-up was of 2 years. The mean TIR and the percentage of individuals with optimal control were higher in individuals in the highest SES quartile (64.9% ± 17.8% and 27.9%, respectively) compared to those in the lowest SES quartile (57.8 ± 17.4% and 12.1%) (p < 0.001). Regression models showed a higher risk of suboptimal control (OR 2.27, p < 0.001) and ischemic heart disease and/or stroke (OR 3.59, p = 0.005) in the lowest SES quartile. No association was observed between SES and the risk of diabetic nephropathy and retinopathy. FGM system improved HbA1c levels across all SES quartiles. Although individuals in the highest SES quartile still achieved a significantly lower value at the end of the follow-up 55 mmol/mol (7.2%) compared to those in the lowest SES quartile 60 mmol/mol (7.6%) (p < 0.001), the significant disparities in this parameter between the various SES groups were significantly reduced after FGM technology use. CONCLUSIONS Socioeconomic status plays a significant role in glycemic control and complications in individuals with T1D, extending beyond access to technology and its proper utilization. The free utilization of FGM technology helps alleviate the impact of social inequalities on glycemic control.
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Affiliation(s)
- Fernando Sebastian-Valles
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain.
| | - Julia Martínez-Alfonso
- Department of Family and Community Medicine, Centro de Salud Daroca, 28006, Madrid, Spain
| | - Jose Alfonso Arranz Martin
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | - Jessica Jiménez-Díaz
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, 28194, Madrid, Spain
| | - Iñigo Hernando Alday
- Department of Endocrinology and Nutrition, Hospital Universitario Basurto, 48013, Bilbao, Spain
| | - Victor Navas-Moreno
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | - Teresa Armenta Joya
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | | | - Gisela Liz Román Gómez
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, Leganés, 28194, Madrid, Spain
| | - Jon Garai Hierro
- Department of Endocrinology and Nutrition, Hospital Universitario Basurto, 48013, Bilbao, Spain
| | | | | | - Miguel Antonio Sampedro-Nuñez
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
| | - Vicente Martínez-Vizcaíno
- Health and Social Care Research Center, Universidad de Castilla-La Mancha, 16071, Cuenca, Spain
- Facultad de Ciencias de La Salud, Universidad Autónoma de Chile, Talca, Chile
| | - Mónica Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria de La Princesa, Universidad Autónoma de Madrid, 28006, Madrid, Spain
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Jeyaparam S, Agha-Jaffar R, Mullins E, Pinho-Gomes AC, Khunti K, Robinson S. Retrospective cohort study of the association between socioeconomic deprivation and incidence of gestational diabetes and perinatal outcomes. BMC Public Health 2024; 24:184. [PMID: 38225599 PMCID: PMC10790393 DOI: 10.1186/s12889-023-17261-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 11/18/2023] [Indexed: 01/17/2024] Open
Abstract
INTRODUCTION Socioeconomic disparities have been shown to correlate with perinatal mortality and the incidence of type 2 diabetes. Few studies have explored the relationship between deprivation and the incidence of gestational diabetes (GDM). We aimed to identify the relationship between deprivation and incidence of GDM, after adjusting for age, BMI, and ethnicity. We also examined for relationships between deprivation and perinatal outcomes. METHODS A retrospective cohort analysis of 23,490 pregnancies from a major National Health Service Trust in Northwest London was conducted. The 2019 English Indices of Multiple Deprivation was used to identify the deprivation rank and decile for each postcode. Birthweight centile was calculated from absolute birthweight after adjusting for ethnicity, maternal height, maternal weight, parity, sex and outcome (live birth/stillbirth). Logistic regression and Kendall's Tau were used to identify relationships between variables. RESULTS After controlling for age, BMI & ethnicity, Index of Multiple Deprivation postcode decile was not associated with an increased risk of developing gestational diabetes. Each increase in decile of deprivation was associated with an increase in birthweight centile by 0.471 (p < 0.001). After adjusting for confounders, age was associated with a 7.1% increased GDM risk (OR: 1.076, p < 0.001); BMI increased risk by 5.81% (OR: 1.059, p < 0.001). There was no significant correlation between Index of Multiple Deprivation rank and perinatal outcomes. DISCUSSION Our analysis demonstrates that socioeconomic deprivation was not associated with incidence of GDM or adverse perinatal outcomes. Factors such as genetic predisposition and lifestyle habits may likely play a larger role in the development of GDM compared to socioeconomic deprivation alone.
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Affiliation(s)
- Srirangan Jeyaparam
- Department of Metabolism, Digestion & Reproduction, Imperial College London, London, UK.
| | - Rochan Agha-Jaffar
- Department of Metabolism, Digestion & Reproduction, Imperial College London, London, UK
- Department of Metabolic Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Edward Mullins
- Department of Obstetrics & Gynaecology, Imperial College Healthcare NHS Trust, London, UK
- The George Institute for Global Health, London, UK
| | | | | | - Stephen Robinson
- Department of Metabolic Medicine, Imperial College Healthcare NHS Trust, London, UK
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5
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Erandathi MA, Wang WYC, Mayo M, Lee CC. Comprehensive Factors for Predicting the Complications of DiabetesMellitus: A Systematic Review. Curr Diabetes Rev 2024; 20:e040124225240. [PMID: 38178670 PMCID: PMC11327746 DOI: 10.2174/0115733998271863231116062601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND This article focuses on extracting a standard feature set for predicting the complications of diabetes mellitus by systematically reviewing the literature. It is conducted and reported by following the guidelines of PRISMA, a well-known systematic review and meta-analysis method. The research articles included in this study are extracted using the search engine "Web of Science" over eight years. The most common complications of diabetes, diabetic neuropathy, retinopathy, nephropathy, and cardiovascular diseases are considered in the study. METHOD The features used to predict the complications are identified and categorised by scrutinising the standards of electronic health records. RESULT Overall, 102 research articles have been reviewed, resulting in 59 frequent features being identified. Nineteen attributes are recognised as a standard in all four considered complications, which are age, gender, ethnicity, weight, height, BMI, smoking history, HbA1c, SBP, eGFR, DBP, HDL, LDL, total cholesterol, triglyceride, use of insulin, duration of diabetes, family history of CVD, and diabetes. The existence of a well-accepted and updated feature set for health analytics models to predict the complications of diabetes mellitus is a vital and contemporary requirement. A widely accepted feature set is beneficial for benchmarking the risk factors of complications of diabetes. CONCLUSION This study is a thorough literature review to provide a clear state of the art for academicians, clinicians, and other stakeholders regarding the risk factors and their importance.
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Affiliation(s)
| | | | | | - Ching-Chi Lee
- National Chen Kung University Hospital, Tainan, Taiwan
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6
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Kaltalioglu K. Sinapic acid-loaded gel accelerates diabetic wound healing process by promoting re-epithelialization and attenuating oxidative stress in rats. Biomed Pharmacother 2023; 163:114788. [PMID: 37105076 DOI: 10.1016/j.biopha.2023.114788] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 04/29/2023] Open
Abstract
Impaired wound healing is a critical health concern for individuals with diabetes. Sinapic acid, a phyto-compound, has wound-healing potential owing to its various bioactivities. In this study, we explored the wound-healing ability of sinapic acid in diabetes. Full-thickness excisional wounds were created in streptozotocin-induced diabetic rats. Sinapic acid-loaded gels (1%, 2%, and 3%) were prepared and applied topically to diabetic skin wounds. On day 7 post-wounding, rats were sacrificed, and macroscopic, histopathological, and oxidative markers of wound healing activity were evaluated in the collected wound tissues. Sinapic acid-loaded gels showed better recovery in re-epithelialization (p < 0.05) and angiogenesis (p < 0.05) compared to the negative control group. Sinapic acid-loaded gels (1%, 2%, and 3%) showed 87.46%, 79.53%, and 68.78% wound contraction, respectively. They increased collagen content (28.05 ± 1.66, 17.30 ± 2.19, and 11.64 ± 1.25, respectively) and decreased malondialdehyde (MDA) levels (17.49 ± 1.61, 18.44 ± 1.24, and 19.16 ± 1.77, respectively) compared to the negative control group (6.76 ± 0.89, and 43.58 ± 3.70, respectively) (p < 0.05). Moreover, sinapic acid-loaded gel groups demonstrated enhanced antioxidant capacity (approximately 2-2.5-fold) compared to the negative control group (p < 0.05). Sinapic acid 1% loaded gel showed the best effect on the diabetic healing process, whereas sinapic acid 2% loaded gel and reference drug showed similar effects. The results of this study, for the first time, suggest that the topical application of sinapic acid can promote diabetic wound healing, especially at low doses.
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Affiliation(s)
- Kaan Kaltalioglu
- Espiye Vocational School, Giresun University, 28600 Giresun, Turkey.
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7
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Holland D, Heald AH, Hanna FFW, Stedman M, Wu P, Sim J, Duff CJ, Duce H, Green L, Scargill J, Howe JD, Robinson S, Halsall I, Gaskell N, Davison A, Simms M, Denny A, Langan M, Fryer AA. The Effect of the COVID-19 Pandemic on HbA1c Testing: Prioritization of High-Risk Cases and Impact of Social Deprivation. Diabetes Ther 2023; 14:691-707. [PMID: 36814045 PMCID: PMC9946287 DOI: 10.1007/s13300-023-01380-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Studies show that the COVID-19 pandemic disproportionately affected people with diabetes and those from disadvantaged backgrounds. During the first 6 months of the UK lockdown, > 6.6 M glycated haemoglobin (HbA1c) tests were missed. We now report variability in the recovery of HbA1c testing, and its association with diabetes control and demographic characteristics. METHODS In a service evaluation, we examined HbA1c testing across ten UK sites (representing 9.9% of England's population) from January 2019 to December 2021. We compared monthly requests from April 2020 to those in the equivalent 2019 months. We examined effects of (i) HbA1c level, (ii) between-practice variability, and (iii) practice demographics. RESULTS In April 2020, monthly requests dropped to 7.9-18.1% of 2019 volumes. By July 2020, testing had recovered to 61.7-86.9% of 2019 levels. During April-June 2020, we observed a 5.1-fold variation in the reduction of HbA1c testing between general practices (12.4-63.8% of 2019 levels). There was evidence of limited prioritization of testing for patients with HbA1c > 86 mmol/mol during April-June 2020 (4.6% of total tests vs. 2.6% during 2019). Testing in areas with the highest social disadvantage was lower during the first lockdown (April-June 2020; trend test p < 0.001) and two subsequent periods (July-September and October-December 2020; both p < 0.001). By February 2021, testing in the highest deprivation group had a cumulative fall in testing of 34.9% of 2019 levels versus 24.6% in those in the lowest group. CONCLUSION Our findings highlight that the pandemic response had a major impact on diabetes monitoring and screening. Despite limited test prioritization in the > 86 mmol/mol group, this failed to acknowledge that those in the 59-86 mmol/mol group require consistent monitoring to achieve the best outcomes. Our findings provide additional evidence that those from poorer backgrounds were disproportionately disadvantaged. Healthcare services should redress this health inequality.
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Affiliation(s)
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, The Northern Care Alliance NHS Foundation Trust, Salford, UK
- The School of Medicine and Manchester Academic Health Sciences Centre, The University of Manchester, Manchester, UK
| | - Fahmy F W Hanna
- Department of Diabetes and Endocrinology, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
- Centre for Health & Development, Staffordshire University, Staffordshire, UK
| | | | - Pensée Wu
- Department of Obstetrics & Gynaecology, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Julius Sim
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
| | - Christopher J Duff
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
| | - Helen Duce
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
| | - Lewis Green
- Department of Clinical Biochemistry, St. Helens & Knowsley Teaching Hospitals NHS Trust, Whiston Hospital, Prescot, UK
| | - Jonathan Scargill
- Department of Clinical Biochemistry, The Royal Oldham Hospital, The Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Jonathon D Howe
- Department of Clinical Biochemistry, Salford Royal Hospital, The Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Sarah Robinson
- Department of Clinical Biochemistry, North Midlands and Cheshire Pathology Services, University Hospitals of North Midlands NHS Trust, Stoke-On-Trent, Staffordshire, UK
| | - Ian Halsall
- Department of Clinical Biochemistry, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Neil Gaskell
- Department of Pathology, Warrington & Halton Teaching Hospitals NHS Foundation Trust, Warrington, UK
| | - Andrew Davison
- Department of Clinical Biochemistry & Metabolic Medicine, Liverpool Clinical Laboratories, Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
| | - Mark Simms
- Department of Clinical Biochemistry, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Angela Denny
- Department of Clinical Biochemistry, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, Wirral, UK
| | - Martin Langan
- Pathology Directorate, Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Anthony A Fryer
- School of Medicine, Keele University, Keele, Staffordshire, ST5 5BG, UK.
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Taylor L, Gangnon R, Powell WR, Kramer J, Kind AJH, Bartels CM, Brennan MB. Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study. BMJ Open Diabetes Res Care 2023; 11:11/2/e003185. [PMID: 37072336 PMCID: PMC10124219 DOI: 10.1136/bmjdrc-2022-003185] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/28/2023] [Indexed: 04/19/2023] Open
Abstract
INTRODUCTION Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion. RESEARCH DESIGN AND METHODS This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black. RESULTS Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black. CONCLUSIONS A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.
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Affiliation(s)
- Lindsay Taylor
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Ronald Gangnon
- Population Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - W Ryan Powell
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | - Joseph Kramer
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | - Amy J H Kind
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- University of Wisconsin Center for Health Disparities Research, Madison, Wisconsin, USA
| | | | - Meghan B Brennan
- Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
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9
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Oliveira-Cortez A, Rodrigues Ferreira I, Luíza Nunes Abreu C, de Oliveira Bosco Y, Kümmel Duarte C, Nogueira Cortez D. Incidence of the first diabetic foot ulcer: A systematic review and meta-analysis. Diabetes Res Clin Pract 2023; 198:110594. [PMID: 36842478 DOI: 10.1016/j.diabres.2023.110594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/21/2023] [Indexed: 02/28/2023]
Abstract
AIM Investigate the incidence of the first diabetic foot ulcer. METHOD This is a systematic review with meta-analysis of cohort studies following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and using RevMan software. A systematic search of Medline databases via PubMed, Embase, Lilacs, Scopus databases, and Web of Science was performed until July 2021. In addition to investigating the incidence of the first diabetic foot ulcer, the influence of the variables of the Human Development Index (HDI), glycated hemoglobin, and follow-up time of the participants on the incidence of the first diabetic foot ulcer (DFU) was analyzed through meta-regression. For the meta-analysis of cumulative incidence and possible variable associations, RevMan software was used in the Metaprop data package with 95% confidence interval (CI). RESULTS A total of 9,772 articles were identified out of which 87 were selected and 12 studies ultimately included in the systematic review and meta-analysis. The meta-analysis of cumulative incidence was 5.65% (95% CI: 4.20; 7.57). By meta-regression, a significant inverse association was identified between DFU incidence and HDI (estimate - 2.38; 95% CI - 4.10--0.67; p = 0.01). CONCLUSION The study presents the cumulative incidence for the first DFU, an inexistent datum in the national and international literature, and the HDI was inversely associated with the incidence of DFU.
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Affiliation(s)
- Andreza Oliveira-Cortez
- Nursing Department, Federal University of São João del-Rei/Centro Oeste Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour district. Zip Code: 35501-296. Divinópolis, Brazil
| | - Isabela Rodrigues Ferreira
- Nursing Department, Postgraduate Nursing Program, Federal University of São João del-Rei/Centro Oeste Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour district. Zip Code: 35501-296. Divinópolis, Brazil
| | - Carolina Luíza Nunes Abreu
- Nursing Department, Federal University of São João del-Rei/Centro Oeste Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour district. Zip Code: 35501-296. Divinópolis, Brazil
| | - Yvina de Oliveira Bosco
- Nursing Department, Federal University of São João del-Rei/Centro Oeste Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour district. Zip Code: 35501-296. Divinópolis, Brazil
| | - Camila Kümmel Duarte
- Nutrition Department, Postgraduate Nutrition and Health Program, Federal University of Minas Gerais, Belo Horizonte, Brazil Prof. Alfredo Balena Street, 190, Santa Efigênia district. Zip Code: 30130-100. Belo Horizonte, Brazil
| | - Daniel Nogueira Cortez
- Nursing Department, Postgraduate Nursing Program, Federal University of São João del-Rei/Centro Oeste Campus, Sebastião Gonçalves Coelho Street, 400, Chanadour district. Zip Code: 35501-296. Divinópolis, Brazil.
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10
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Blong J, Sharpe A, Cairney-Hill J, Gorman A, Allen M, Haycocks S, Stedman M, Robinson A, Heald AH, Gee E. Saving the foot: Simple orthopaedic surgical intervention demonstrates improved outcomes and reduced costs. Foot Ankle Surg 2023; 29:218-222. [PMID: 36646595 DOI: 10.1016/j.fas.2023.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 12/08/2022] [Accepted: 01/08/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Forefoot ulceration in diabetes requires significant resources, with high cost and low rates of success. The authors present the results of tendon procedures (percutaneous toe tenotomy and percutaneous tendo-achilles lengthening) under local anaesthetic to adjust mechanics in patients with diabetic neuropathic forefoot ulceration. METHODS Retrospective review of electronic patient record of 19 patients (22 feet) undergoing local anaesthetic tendon procedures between April 2019 and April 2021 with a 12 month follow up period. Size of ulcer, rate of ulcer healing, complication rates and ulcer recurrence were recorded and compared to a population of conservatively-managed patients (14 patients, 15 feet) treated prior to the introduction of tendon procedures. All clinical information obtained from electronic patient records. RESULTS All patients undergoing tendon procedures achieved complete ulcer healing at a mean time of 3.3 weeks for toe tip ulcers (after toe tenotomy) and 4.5 weeks for metatarsal head ulcers (after Achilles lengthening). There were no admissions for diabetic foot sepsis, reduced recurrence, reduced amputation rates and no mortality. Of the conservatively managed cohort, only 3 of the 15 achieved ulcer resolution without recurrence within the 12 month study period. The cohort managed conservatively had an average cost of £ 9902 per patient, per annum. The intervention cost was £ 1211 per patient, saving an average of £ 8691 per patient, per annum with ulcer resolution (88 % reduction in costs). CONCLUSION Significant patient benefit, reduction in resource use and cost saving was seen with this simple intervention, which merits full evaluation in a clinical trial. LEVEL OF EVIDENCE Level-IV.
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Affiliation(s)
- Jessica Blong
- Department of Trauma and Orthopaedic Surgery, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Andrew Sharpe
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Jess Cairney-Hill
- Department of Trauma and Orthopaedic Surgery, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Andy Gorman
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Matthew Allen
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Samantha Haycocks
- Department of Podiatry, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Mike Stedman
- Res Consortium, Fosse House, East Anton Court, Icknield Way, Andover SP10 5RG, UK.
| | - Adam Robinson
- Endocrine Medicine, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Adrian H Heald
- Endocrine Medicine, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
| | - Edward Gee
- Department of Trauma and Orthopaedic Surgery, Salford Royal Hospital, Stott Ln, Salford M6 8HD, UK.
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11
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Lin S, Wang Q, Huang X, Feng J, Wang Y, Shao T, Deng X, Cao Y, Chen X, Zhou M, Zhao C. Wounds under diabetic milieu: The role of immune cellar components and signaling pathways. Biomed Pharmacother 2023; 157:114052. [PMID: 36462313 DOI: 10.1016/j.biopha.2022.114052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/19/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022] Open
Abstract
A major challenge in the field of diabetic wound healing is to confirm the body's intrinsic mechanism that could sense the immune system damage promptly and protect the wound from non-healing. Accumulating literature indicates that macrophage, a contributor to prolonged inflammation occurring at the wound site, might play such a role in hindering wound healing. Likewise, other immune cell dysfunctions, such as persistent neutrophils and T cell infection, may also lead to persistent oxidative stress and inflammatory reaction during diabetic wound healing. In this article, we discuss recent advances in the immune cellular components in wounds under the diabetic milieu, and the role of key signaling mechanisms that compromise the function of immune cells leading to persistent wound non-healing.
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Affiliation(s)
- Siyuan Lin
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China; Institute for Interdisciplinary Medicine Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China; School of Public Health, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Qixue Wang
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China; Institute for Interdisciplinary Medicine Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China
| | - Xiaoting Huang
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Jiawei Feng
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Yuqing Wang
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Tengteng Shao
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Xiaofei Deng
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Yemin Cao
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China
| | - Xinghua Chen
- Jinshan Hospital Affiliated to Fudan University, Shanghai, China.
| | - Mingmei Zhou
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China; Institute for Interdisciplinary Medicine Sciences, Shanghai University of Traditional Chinese Medicine, Shanghai 201203, China.
| | - Cheng Zhao
- Shanghai Traditional Chinese Medicine Integrated Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai 200082, China.
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12
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Social Deprivation, Healthcare Access and Diabetic Foot Ulcer: A Narrative Review. J Clin Med 2022; 11:jcm11185431. [PMID: 36143078 PMCID: PMC9501414 DOI: 10.3390/jcm11185431] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/08/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
The diabetic foot ulcer (DFU) is a common and serious complication of diabetes. There is also a strong relationship between the environment of the person living with a DFU and the prognosis of the wound. Financial insecurity seems to have a major impact, but this effect can be moderated by social protection systems. Socioeconomic and socio-educational deprivations seem to have a more complex relationship with DFU risk and prognosis. The area of residence is a common scale of analysis for DFU as it highlights the effect of access to care. Yet it is important to understand other levels of analysis because some may lead to over-interpretation of the dynamics between social deprivation and DFU. Social deprivation and DFU are both complex and multifactorial notions. Thus, the strength and characteristics of the correlation between the risk and prognosis of DFU and social deprivation greatly depend not only on the way social deprivation is calculated, but also on the way questions about the social deprivation−DFU relationship are framed. This review examines this complex relationship between DFU and social deprivation at the individual level by considering the social context in which the person lives and his or her access to healthcare.
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13
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Hagde P, Pingle P, Mourya A, Katta CB, Srivastava S, Sharma R, Singh KK, Sodhi RK, Madan J. Therapeutic potential of quercetin in diabetic foot ulcer: Mechanistic insight, challenges, nanotechnology driven strategies and future prospects. J Drug Deliv Sci Technol 2022. [DOI: 10.1016/j.jddst.2022.103575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Meza-Torres B, Cunningham SG, Heiss C, Joy M, Feher M, Leese GP, de Lusignan S, Carinci F. Adherence to General Diabetes and Foot Care Processes, with Prompt Referral, Are Associated with Amputation-Free Survival in People with Type 2 Diabetes and Foot Ulcers: A Scottish National Registry Analysis. J Diabetes Res 2022; 2022:7414258. [PMID: 35746918 PMCID: PMC9213182 DOI: 10.1155/2022/7414258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 05/10/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
Aims To compare different packages of care across care providers in Scotland on foot-related outcomes. Methods A retrospective cohort study with primary and secondary care electronic health records from the Scottish Diabetes Registry, including 6,845 people with type 2 diabetes and a first foot ulcer occurring between 2013 and 2017. We assessed the association between exposure to care processes and major lower extremity amputation and death. Proportional hazards were used for time-to-event univariate and multivariate analyses, adjusting for case-mix characteristics and care processes. Results were expressed in terms of hazard ratios with 95% confidence intervals. Results 2,243 (32.7%) subjects had a major amputation or death. Exposure to all nine care processes at all ages (HR = 0.63; 95% CI: 0.58-0.69; p < .001) and higher foot care attendance in people aged >70 years (HR = 0.88; 0.78-0.99; p = .03) were associated with longer major amputation-free survival. Waiting time ≥ 12 weeks between ulceration and clinic attendance was associated with worse outcomes (HR = 1.59; 1.37-1.84; p < .001). In people > 70 years, minor amputations were associated with improved major amputation-free survival (HR = 0.69; 0.52-0.92; p = .01). Conclusions Strict adherence to a standardised package of general diabetes care before foot ulceration, timely foot care after ulceration, and specific treatment pathways were associated with longer major amputation-free survival among a large cohort of people with type 2 diabetes in Scotland, with a larger impact on older age groups.
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Affiliation(s)
- Bernardo Meza-Torres
- Department of Clinical and Experimental Medicine, University of Surrey, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Scott G. Cunningham
- Division of Population Health and Genomics, University of Dundee, Scotland, UK
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, University of Surrey, UK
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Graham P. Leese
- Division of Population Health and Genomics, University of Dundee, Scotland, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Fabrizio Carinci
- Department of Statistical Sciences, University of Bologna, Italy
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15
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Bonnet JB, Nicolet G, Papinaud L, Avignon A, Duflos C, Sultan A. Effects of social deprivation and healthcare access on major amputation following a diabetic foot ulcer in a French administrative area: Analysis using the French claim data. Diabet Med 2022; 39:e14820. [PMID: 35213066 DOI: 10.1111/dme.14820] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 02/22/2022] [Indexed: 11/28/2022]
Abstract
AIM The link between social deprivation and the development of diabetic foot ulcer (DFU) is still widely debated. The study objective was to evaluate the relationship between lower limb amputation, social deprivation level, and inequalities in access to care service among people with DFU. This regional pilot study was conducted at the living area level and based on the French National Health Data System (SNDS). METHODS We conducted a retrospective cohort study using hospital and primary care claim data in the Languedoc-Roussillon region. DFUs were determined using an original algorithm of care consumption or hospital diagnosis. The primary end point was amputation at 1 year. Secondary end points were mortality at 1 year and impact of potential access to care on amputation. RESULTS We included 15,507 people from 2015 to 2017. Amputation and mortality rates were 17.5 and 117 per 1000 person-years. The least precarious living areas showed better prognoses (relative risk = 0.46; 95% CI 0.27-0.66). Territorial accessibility to a private-practice nurse, unlike physician accessibility, was associated with better results on major outcomes (p = 0.004). CONCLUSION This is the first study using SNDS to study the care pathway of DFU management within and outside the hospital. High social deprivation in a living areas seems to be associated with more major amputations after a DFU.
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Affiliation(s)
- Jean-Baptiste Bonnet
- UMR 1302, Institute Desbrest of Epidemiology and Public Health, INSERM, CHU, University of Montpellier, Montpellier, France
- Endocrinology-Diabetes-Nutrition Department, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Guillaume Nicolet
- Clinical Research and Epidemiology Unit, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Laurence Papinaud
- Information Systems Unit at the Regional Medical Office of the Assurance Maladie, Montpellier, France
| | - Antoine Avignon
- UMR 1302, Institute Desbrest of Epidemiology and Public Health, INSERM, CHU, University of Montpellier, Montpellier, France
- Endocrinology-Diabetes-Nutrition Department, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Claire Duflos
- UMR 1302, Institute Desbrest of Epidemiology and Public Health, INSERM, CHU, University of Montpellier, Montpellier, France
- Clinical Research and Epidemiology Unit, CHU Montpellier, University of Montpellier, Montpellier, France
| | - Ariane Sultan
- Endocrinology-Diabetes-Nutrition Department, CHU Montpellier, University of Montpellier, Montpellier, France
- PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, Montpellier, France
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16
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Chamberlain RC, Fleetwood K, Wild SH, Colhoun HM, Lindsay RS, Petrie JR, McCrimmon RJ, Gibb F, Philip S, Sattar N, Kennon B, Leese GP. Foot Ulcer and Risk of Lower Limb Amputation or Death in People With Diabetes: A National Population-Based Retrospective Cohort Study. Diabetes Care 2022; 45:83-91. [PMID: 34782354 DOI: 10.2337/dc21-1596] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/20/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To describe incidence of foot ulceration and amputation-free survival associated with foot ulceration status in a national population-based cohort study of people with diabetes. RESEARCH DESIGN AND METHODS The study population included 233,459 people with diabetes who were alive in Scotland on 1 January 2012 identified from the national population-based register (national prevalence 4.9%). Characteristics of patients identified from linked hospital and mortality records during follow-up to the end of November 2017 were compared by outcome. Cox regression was used to assess the association between history of foot ulcer and amputation-free survival. RESULTS The population included 23,395 people with type 1 diabetes and 210,064 people with type 2 diabetes. In total there were 13,093 (5.6%) people who had a previous foot ulceration, 9,023 people who developed a first ulcer, 48,995 who died, and 2,866 who underwent minor or major amputation during follow-up. Overall incidence of first-time foot ulcers was 7.8 per 1,000 person-years (95% CI7.6-7.9) and 11.2 (11.0-11.4) for any ulcer. Risk factors for reduced amputation-free survival included social deprivation, mental illness, and being underweight in addition to conventional cardiovascular risk factors. Adjusted hazard ratios (95% CI) were 2.09 (1.89-2.31) for type 1 diabetes and 1.65 (1.60-1.70) for type 2 diabetes. CONCLUSIONS The overall incidence of foot ulceration in a population-based study of people with diabetes was 11.2 per 1,000 person-years. Foot ulceration is associated with lower amputation-free survival rate, a potential measure of effectiveness of care among people with diabetes. Mental illness and social deprivation are also highlighted as risk factors.
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Affiliation(s)
| | | | - Sarah H Wild
- 3Usher Institute, University of Edinburgh, Edinburgh, U.K
| | - Helen M Colhoun
- 4Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, U.K
| | - Robert S Lindsay
- 5Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - John R Petrie
- 6Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, U.K
| | | | - Fraser Gibb
- 8Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, U.K
| | - Sam Philip
- 9Diabetes Centre, Aberdeen Royal Infirmary, Aberdeen, U.K
| | - Naveed Sattar
- 10Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Brian Kennon
- 11Diabetes Centre, New Victoria Hospital, Glasgow, U.K
| | - Graham P Leese
- 12Department of Diabetes and Endocrinology, Ninewells Hospital, Dundee, U.K
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17
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Schofield H, Haycocks S, Robinson A, Edmonds M, Anderson SG, Heald AH. Mortality in 98 type 1 diabetes mellitus and type 2 diabetes mellitus: Foot ulcer location is an independent risk determinant. Diabet Med 2021; 38:e14568. [PMID: 33772856 DOI: 10.1111/dme.14568] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 02/18/2021] [Accepted: 03/24/2021] [Indexed: 01/01/2023]
Abstract
INTRODUCTION We previously demonstrated in both a longitudinal study and in meta-analysis (pooled relative-risk RR, 2.45) that all-cause mortality is significantly higher in people with diabetes foot ulceration (DFU) than with those without a foot ulcer. In this prospective study, we looked at the factors linked to mortality after presentation to podiatry with DFU. METHODS Ninety-eight individuals recruited consecutively from the Salford Royal Hospital Multidisciplinary Foot Clinic in Spring 2016 were followed up for up to 48 months. Data concerning health outcomes were extracted from the electronic patient record (EPR). RESULTS Seventeen people (17) had type 1 diabetes mellitus, and 81 had type 2 diabetes mellitus. Thirty-one were women. The mean age (range) was 63.6 (28-90) years with maximum diabetes duration 45 years. Mean HbA1c was 72 (95% CI: 67-77) mmol/mol; 97% had neuropathy (International Working Group on the Diabetic Foot (IWGDF) monofilament); 62% had vascular insufficiency (Doppler studies); 69% of ulcers were forefoot, and 23% of ulcers were hind foot in location. Forty of 98 (40%) patients died in follow-up with 27% of death certificates including sepsis (not foot-related) and 35% renal failure as cause of death. Multivariate regression analysis indicated a 6.3 (95% CI: 3.9-8.1) fold increased risk of death with hind foot ulcer, independent of age/BMI/gender/HbA1c/eGFR/total cholesterol level. CONCLUSION This prospective study has indicated a very high long-term mortality rate in individuals with DFU, greater for those with a hind foot ulcer and shown a close relation between risk of sepsis/renal failure and DFU mortality, highlighting again the importance of addressing all risk factors as soon as people present with a foot ulcer.
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Affiliation(s)
| | | | - Adam Robinson
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
| | | | - Simon G Anderson
- University of the West Indies, Cavehill Campus Barbados, Barbados, UK
| | - Adrian H Heald
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford, UK
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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18
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Moreno Carrillo MA, Martínez Gómez DA, Martínez González-Moro I, Lozano Guadalajara JV. [Multidisciplinary unit specialized in the treatment of diabetic foot: Evaluation and results]. Rehabilitacion (Madr) 2021; 56:56-63. [PMID: 34521549 DOI: 10.1016/j.rh.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/05/2021] [Accepted: 08/05/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In this study the evaluation of the care process of the diabetic foot will be carried out after the implementation of an intra-hospital clinical pathway and a multidisciplinary consultation. OBJECTIVES Evaluate the influence on factors related to the care, amputations, and rehabilitation of the amputee patient. METHODOLOGY Retrospective study, in which the comparison of three periods has been made. First (3years): Before the implantation of the pathway. Second (5years): After the implementation of the pathway. Third (10years): After the implementation of the consultation. RESULTS A specialized consultation in diabetic foot care contributes to a reduction in femoral and minor amputations. The assessment and treatment by rehabilitation of patients undergoing major amputation has been optimized. CONCLUSION The implantation of the pathway and consultation contributes to the preservation of the lower limb. However, the incidence remains high, suggesting that diabetic foot care remains suboptimal.
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Affiliation(s)
- M A Moreno Carrillo
- Servicio de Rehabilitación, Hospital Universitario Morales Meseguer, Murcia, España.
| | - D A Martínez Gómez
- Servicio de Cirugía, Hospital Universitario Morales Meseguer, Murcia, España
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19
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Tamir E, Tamar M, Ayalon M, Koren S, Shohat N, Finestone AS. Effect of Mini-invasive Floating Metatarsal Osteotomy on Plantar Pressure in Patients With Diabetic Plantar Metatarsal Head Ulcers. Foot Ankle Int 2021; 42:536-543. [PMID: 33334148 PMCID: PMC8127671 DOI: 10.1177/1071100720976099] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Distal metatarsal osteotomy has been used to alleviate plantar pressure caused by anatomic deformities. This study's purpose was to examine the effect of minimally invasive floating metatarsal osteotomy on plantar pressure in patients with diabetic metatarsal head ulcers. METHODS We performed a retrospective case series of prospectively collected data on 32 patients with diabetes complicated by plantar metatarsal head ulcers without ischemia. Peak plantar pressure and pressure time integrals were examined using the Tekscan MatScan prior to surgery and 6 months following minimally invasive floating metatarsal osteotomy. Patients were followed for complications for at least 1 year. RESULTS Peak plantar pressure at the level of the osteotomized metatarsal head decreased from 338.1 to 225.4 kPa (P < .0001). The pressure time integral decreased from 82.4 to 65.0 kPa·s (P < .0001). All ulcers healed within a mean of 3.7 ± 4.2 weeks. There was 1 recurrence (under a hypertrophic callus of the osteotomy) during a median follow-up of 18.3 months (range, 12.2-27). Following surgery, adjacent sites showed increased plantar pressure and 4 patients developed transfer lesions (under an adjacent metatarsal head); all were managed successfully. There was 1 serious adverse event related to surgery (operative site infection) that resolved with antibiotics. CONCLUSION This study showed that the minimally invasive floating metatarsal osteotomy successfully reduced local plantar pressure and that the method was safe and effective, both in treatment and prevention of recurrence. LEVEL OF EVIDENCE Level III, retrospective case series of prospectively collected data.
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Affiliation(s)
- Eran Tamir
- Department of Orthopaedic Surgery, Shamir Medical Center, Zerrifin, Israel,Maccabi Health Services, Tel Aviv, Israel,The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michael Tamar
- Department of Orthopaedic Surgery, Shamir Medical Center, Zerrifin, Israel
| | - Moshe Ayalon
- The Academic College at the Wingate Institute, Netanya, Israel
| | - Shlomit Koren
- The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Diabetes Unit, Shamir Medical Center, Zerrifin, Israel
| | - Noam Shohat
- Department of Orthopaedic Surgery, Shamir Medical Center, Zerrifin, Israel,Diabetes Unit, Shamir Medical Center, Zerrifin, Israel
| | - Aharon S. Finestone
- Department of Orthopaedic Surgery, Shamir Medical Center, Zerrifin, Israel,Maccabi Health Services, Tel Aviv, Israel,The Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,Aharon S. Finestone, MD, MHA, POB 1424, Reut 7179902, Israel.
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20
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Riley J, Antza C, Kempegowda P, Subramanian A, Chandan JS, Gokhale K, Thomas N, Sainsbury C, Tahrani AA, Nirantharakumar K. Social Deprivation and Incident Diabetes-Related Foot Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study. Diabetes Care 2021; 44:731-739. [PMID: 33483358 DOI: 10.2337/dc20-1027] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 12/19/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the relationship between social deprivation and incident diabetes-related foot disease (DFD) in newly diagnosed patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A population-based open retrospective cohort study using The Health Improvement Network (1 January 2005 to 31 December 2019) was conducted. Patients with type 2 diabetes free of DFD at baseline were stratified by Townsend deprivation index, and risk of developing DFD was calculated. DFD was defined as a composite of foot ulcer (FU), Charcot arthropathy, lower-limb amputation (LLA), peripheral neuropathy (PN), peripheral vascular disease (PVD), and gangrene. RESULTS A total of 176,359 patients were eligible (56% men; mean age 62.9 [SD 13.1] years). After excluding 26,094 patients with DFD before/within 15 months of type 2 diabetes diagnosis, DFD incidentally developed in 12.1% of the study population over 3.27 years (interquartile range 1.41-5.96). Patients in the most deprived Townsend quintile had increased risk of DFD compared with those in the least deprived (adjusted hazard ratio [aHR] 1.22; 95% CI 1.16-1.29) after adjusting for sex, age at type 2 diabetes diagnosis, ethnicity, smoking, BMI, HbA1c, cardiovascular disease, hypertension, retinopathy, estimated glomerular filtration rate, insulin, glucose/lipid-lowering medication, and baseline foot risk. Patients in the most deprived Townsend quintile had higher risk of PN (aHR 1.18; 95% CI 1.11-1.25), FU (aHR 1.44; 95% CI 1.17-1.77), PVD (aHR 1.40; 95% CI 1.28-1.53), LLA (aHR 1.75; 95% CI 1.08-2.83), and gangrene (aHR 8.49; 95% CI 1.01-71.58) compared with those in the least. CONCLUSIONS Social deprivation is an independent risk factor for the development of DFD, PN, FU, PVD, LLA, and gangrene in newly diagnosed patients with type 2 diabetes. Considering the high individual and economic burdens of DFD, strategies targeting patients in socially deprived areas are needed to reduce health inequalities.
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Affiliation(s)
- Jenny Riley
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Christina Antza
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K.,Department of Diabetes and Endocrinology, University Hospitals NHS Foundation Trust, Birmingham, U.K
| | - Punith Kempegowda
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K
| | | | - Joht Singh Chandan
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | - Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
| | | | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, U.K. .,Department of Diabetes and Endocrinology, University Hospitals NHS Foundation Trust, Birmingham, U.K.,Centre of Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, U.K
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21
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Nguyen M, Wong D, Barson E, Staunton ET, Fisher CA. Psychological and Cognitive Barriers to Diabetes-Related Foot Complication Treatment: Clinicians' Perspectives. INT J LOW EXTR WOUND 2021; 21:617-631. [PMID: 33390087 DOI: 10.1177/1534734620983181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study investigated clinicians' perspectives about cognitive functioning and mental health in individuals with diabetes-related foot complications (DRFCs), and how these impact the clinicians' treatment of the patients' conditions. Psychological and cognitive impairments may be more pronounced in individuals with DRFCs compared with the general diabetes mellitus population. Understanding these factors will identify potential barriers to DRFC treatment adherence and effective disease self-management. Fourteen multidisciplinary clinicians (Meanage = 37.86 years; standard deviation = 9.26; range = 27-51) were recruited from a metropolitan hospital diabetic foot unit. Semistructured interviews were conducted with each clinician, followed by the completion of a brief quantitative questionnaire. Interview data were analyzed thematically. Six themes that encompassed factors affecting DRFC treatment were identified: (1) psychological and cognitive characteristics; (2) the person in the environment; (3) illness and self-identity; (4) burden of chronic disease; (5) engaging with treatment; and (6) the clinician and health system response. Quantitative questionnaire results coincided with qualitative findings, with endorsement of global psychological and cognitive impairment in individuals with DRFC, which considerably affected their ability to engage in treatment. From the perspectives of clinicians working with patients with DRFCs, psychological, cognitive, and social factors have a considerable influence on DRFC treatment and self-management. Further investigation of these factors and their interrelationships is necessary to enhance treatment adherence in individuals with DRFCs.
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Affiliation(s)
- Mai Nguyen
- School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, Australia
| | - Dana Wong
- School of Psychology and Public Health, La Trobe University, Bundoora, Victoria, Australia
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22
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Rossboth S, Lechleitner M, Oberaigner W. Risk factors for diabetic foot complications in type 2 diabetes-A systematic review. Endocrinol Diabetes Metab 2021; 4:e00175. [PMID: 33532615 PMCID: PMC7831214 DOI: 10.1002/edm2.175] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 07/18/2020] [Indexed: 12/14/2022] Open
Abstract
Aims With increasing numbers of patients with type 2 diabetes mellitus (T2DM) worldwide, the number of associated diabetic foot complications might also increase. This systematic review was performed to summarize published data about risk factors for the diabetic foot (DF) syndrome in order to improve the identification of high-risk patients. Materials and methods Six electronic databases were searched for publications up to August 2019 using predefined stringent inclusion and exclusion criteria. Results Of 9,476 identified articles, 31 articles from 28 different study populations fulfilled the criteria for our evaluation. The overall quality of the studies was good, and the risk of bias was low. There was large heterogeneity among the studies concerning study protocols and patient populations analysed. A total of 79 risk factors were analysed within this review. The majority of studies described a consistently positive association with different outcomes of interest related to DF for gender, peripheral neuropathy, retinopathy, nephropathy, poor glycaemic control, insulin use, duration of diabetes, smoking and height. For age, hypertension, dyslipidaemia and body mass index, the results remain inconsistent. Conclusion A most up-to-date literature review resulted in glycaemic control and smoking as the only amenable risk factors with a consistently positive association for DF. Due to the high personal and financial burden associated with DF and the large heterogeneity among included studies, additional longitudinal studies in large patient populations are necessary to identify more modifiable risk factors that can be used in the prediction and prevention of DF complications.
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Affiliation(s)
- Sophia Rossboth
- Medical Informatics and TechnologyPublic Health, Health Services Research and Health Technology AssessmentUMIT ‐ University for Health SciencesHall in TrollAustria
| | | | - Willi Oberaigner
- Medical Informatics and TechnologyPublic Health, Health Services Research and Health Technology AssessmentUMIT ‐ University for Health SciencesHall in TrollAustria
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23
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Llanera DK, Wilmington R, Shoo H, Lisboa P, Jarman I, Wong S, Nizza J, Sharma D, Kalathil D, Rajeev S, Williams S, Yadav R, Qureshi Z, Narayanan RP, Furlong N, Westall S, Nair S. Clinical Characteristics of COVID-19 Patients in a Regional Population With Diabetes Mellitus: The ACCREDIT Study. Front Endocrinol (Lausanne) 2021; 12:777130. [PMID: 35095757 PMCID: PMC8793829 DOI: 10.3389/fendo.2021.777130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/17/2021] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To identify clinical and biochemical characteristics associated with 7- & 30-day mortality and intensive care admission amongst diabetes patients admitted with COVID-19. RESEARCH DESIGN AND METHODS We conducted a cohort study collecting data from medical notes of hospitalised people with diabetes and COVID-19 in 7 hospitals within the Mersey-Cheshire region from 1 January to 30 June 2020. We also explored the impact on inpatient diabetes team resources. Univariate and multivariate logistic regression analyses were performed and optimised by splitting the dataset into a training, test, and validation sets, developing a robust predictive model for the primary outcome. RESULTS We analyzed data from 1004 diabetes patients (mean age 74.1 (± 12.6) years, predominantly men 60.7%). 45% belonged to the most deprived population quintile in the UK. Median BMI was 27.6 (IQR 23.9-32.4) kg/m2. The primary outcome (7-day mortality) occurred in 24%, increasing to 33% by day 30. Approximately one in ten patients required insulin infusion (9.8%). In univariate analyses, patients with type 2 diabetes had a higher risk of 7-day mortality [p < 0.05, OR 2.52 (1.06, 5.98)]. Patients requiring insulin infusion had a lower risk of death [p = 0.02, OR 0.5 (0.28, 0.9)]. CKD in younger patients (<70 years) had a greater risk of death [OR 2.74 (1.31-5.76)]. BMI, microvascular and macrovascular complications, HbA1c, and random non-fasting blood glucose on admission were not associated with mortality. On multivariate analysis, CRP and age remained associated with the primary outcome [OR 3.44 (2.17, 5.44)] allowing for a validated predictive model for death by day 7. CONCLUSIONS Higher CRP and advanced age were associated with and predictive of death by day 7. However, BMI, presence of diabetes complications, and glycaemic control were not. A high proportion of these patients required insulin infusion warranting increased input from the inpatient diabetes teams.
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Affiliation(s)
- Daniel Kevin Llanera
- Department of Diabetes and Endocrinology, Countess of Chester Hospital NHS Foundation Trust, Chester, United Kingdom
- *Correspondence: Daniel Kevin Llanera,
| | - Rebekah Wilmington
- Department of Diabetes and Endocrinology, Countess of Chester Hospital NHS Foundation Trust, Chester, United Kingdom
| | - Haika Shoo
- Department of Diabetes and Endocrinology, Countess of Chester Hospital NHS Foundation Trust, Chester, United Kingdom
| | - Paulo Lisboa
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ian Jarman
- School of Computer Science and Mathematics, Liverpool John Moores University, Liverpool, United Kingdom
| | - Stephanie Wong
- Department of Diabetes and Endocrinology, Arrowe Park Hospital, Birkenhead, United Kingdom
| | - Jael Nizza
- Department of Diabetes and Endocrinology, Arrowe Park Hospital, Birkenhead, United Kingdom
| | - Dushyant Sharma
- Department of Diabetes and Endocrinology, The Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Dhanya Kalathil
- Department of Diabetes and Endocrinology, The Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Surya Rajeev
- Department of Diabetes and Endocrinology, The Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - Scott Williams
- Department of Diabetes and Endocrinology, Aintree University Hospital, Liverpool, United Kingdom
| | - Rahul Yadav
- Department of Diabetes and Endocrinology, Warrington Hospital, Warrington, United Kingdom
| | - Zubair Qureshi
- Department of Diabetes and Endocrinology, Leighton Hospital, Crewe, United Kingdom
| | | | - Niall Furlong
- Department of Diabetes and Endocrinology, Whiston Hospital, Prescot, United Kingdom
| | - Sam Westall
- Department of Diabetes and Endocrinology, Whiston Hospital, Prescot, United Kingdom
| | - Sunil Nair
- Department of Diabetes and Endocrinology, Countess of Chester Hospital NHS Foundation Trust, Chester, United Kingdom
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24
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Zhang GQ, Canner JK, Haut E, Sherman RL, Abularrage CJ, Hicks CW. Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes. J Surg Res 2020; 258:38-46. [PMID: 32980774 DOI: 10.1016/j.jss.2020.08.039] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/13/2020] [Accepted: 08/30/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes. MATERIALS AND METHODS Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences. RESULTS A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001). CONCLUSIONS Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.
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Affiliation(s)
- George Q Zhang
- The Johns Hopkins University School of Medicine, Baltimore, Maryland; Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Elliott Haut
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Division of Acute Care Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Ronald L Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Caitlin W Hicks
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland.
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25
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Rubio JA, Jiménez S, Lázaro-Martínez JL. Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer. J Clin Med 2020; 9:jcm9093009. [PMID: 32961974 PMCID: PMC7565534 DOI: 10.3390/jcm9093009] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 09/08/2020] [Accepted: 09/14/2020] [Indexed: 12/17/2022] Open
Abstract
Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.
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Affiliation(s)
- José Antonio Rubio
- Diabetic Foot Unit, Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, 28805 Madrid, Spain;
- Department of Biomedical Sciences, Universidad de Alcalá, Alcalá de Henares, 28805 Madrid, Spain
- Correspondence: ; Tel.: +34-918-878-100
| | - Sara Jiménez
- Diabetic Foot Unit, Department of Endocrinology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, 28805 Madrid, Spain;
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain;
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26
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Wilkinson HN, Hardman MJ. Senescence in Wound Repair: Emerging Strategies to Target Chronic Healing Wounds. Front Cell Dev Biol 2020; 8:773. [PMID: 32850866 PMCID: PMC7431694 DOI: 10.3389/fcell.2020.00773] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/22/2020] [Indexed: 01/10/2023] Open
Abstract
Cellular senescence is a fundamental stress response that restrains tumour formation. Yet, senescence cells are also present in non-cancerous states, accumulating exponentially with chronological age and contributing to age- and diabetes-related cellular dysfunction. The identification of hypersecretory and phagocytic behaviours in cells that were once believed to be non-functional has led to a recent explosion of senescence research. Here we discuss the profound, and often opposing, roles identified for short-lived vs. chronic tissue senescence. Transiently induced senescence is required for development, regeneration and acute wound repair, while chronic senescence is widely implicated in tissue pathology. We recently demonstrated that sustained senescence contributes to impaired diabetic healing via the CXCR2 receptor, which when blocked promotes repair. Further studies have highlighted the beneficial effects of targeting a range of senescence-linked processes to fight disease. Collectively, these findings hold promise for developing clinically viable strategies to tackle senescence in chronic wounds and other cutaneous pathologies.
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Affiliation(s)
- Holly N Wilkinson
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, United Kingdom
| | - Matthew J Hardman
- Centre for Atherothrombosis and Metabolic Disease, Hull York Medical School, University of Hull, Hull, United Kingdom
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27
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Ren H, Ding Y, Hu H, Gao T, Qin Z, Hu Y, Cao R, Liang L, Li C, Mei S. Relationships among economic stress, social support, age and quality of life in patients with chronic wounds: A moderated mediation model. J Adv Nurs 2020. [PMID: 32400891 DOI: 10.1111/jan.14413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/10/2020] [Accepted: 04/28/2020] [Indexed: 12/01/2022]
Abstract
AIMS The aims of this study were as follows: (a) to determine if social support mediates the relationship between economic stress and quality of life; and (b) to explore whether participants' ages would moderate the indirect relationship between economic stress and quality of life through social support. DESIGN A questionnaire-based, cross-sectional study. METHODS From January 2015-June 2016, a total of 300 patients with chronic wounds were recruited from three hospitals. Data regarding economic stress, social support and quality of life were collected through survey questionnaires. The moderated mediation analysis was examined using the Hayes' PROCESS macro modelling tool, based on the bias-corrected bootstrapping method. RESULTS Economic stress was negatively correlated with quality of life and social support. The indirect effect of economic stress on quality of life through social support was negative. Furthermore, age moderated the relationship between economic stress and quality of life, as well as the relationship between economic stress and social support. CONCLUSION Reducing economic stress and improving social support are important strategies for improving quality of life in patients with chronic wounds, especially for younger patients. IMPACT Patients with chronic wounds experience considerable economic stress and severely impaired quality of life; however, little is known about the inner mechanisms of this relationship. This study emphasized the importance of providing social support in coping with the damage that economic stress causes to health. Clinical nurses should strengthen the comprehensive assessment of the socioeconomic status of patients and adjust nursing plans timely, to reduce the economic burden of patients based on the rational use of wound care materials. Moreover, when nursing for patients with chronic wounds, especially the elders, caregivers should strengthen the evaluation of social support and develop interventions to improve social support.
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Affiliation(s)
- Hui Ren
- School of Public Health, Jilin University, Changchun, China.,The First Hospital of Jilin University, Changchun, China
| | - Yanming Ding
- Peking University First Hospital, Beijing, China
| | - Haiyan Hu
- The First Hospital of Jilin University, Changchun, China
| | - Tingting Gao
- School of Public Health, Jilin University, Changchun, China
| | - Zeying Qin
- School of Public Health, Jilin University, Changchun, China
| | - Yueyang Hu
- School of Public Health, Jilin University, Changchun, China
| | - Ruilin Cao
- School of Public Health, Jilin University, Changchun, China
| | - Leilei Liang
- School of Public Health, Jilin University, Changchun, China
| | - Chuanen Li
- School of Public Health, Jilin University, Changchun, China
| | - Songli Mei
- School of Public Health, Jilin University, Changchun, China
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28
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Hurst JE, Barn R, Gibson L, Innes H, Bus SA, Kennon B, Wylie D, Woodburn J. Geospatial mapping and data linkage uncovers variability in outcomes of foot disease according to multiple deprivation: a population cohort study of people with diabetes. Diabetologia 2020; 63:659-667. [PMID: 31848633 PMCID: PMC6997267 DOI: 10.1007/s00125-019-05056-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 10/23/2019] [Indexed: 01/22/2023]
Abstract
AIMS/HYPOTHESIS Our aim was to investigate the geospatial distribution of diabetic foot ulceration (DFU), lower extremity amputation (LEA) and mortality rates in people with diabetes in small geographical areas with varying levels of multiple deprivation. METHODS We undertook a population cohort study to extract the health records of 112,231 people with diabetes from the Scottish Care Information - Diabetes Collaboration (SCI-Diabetes) database. We linked this to health records to identify death, LEA and DFU events. These events were geospatially mapped using multiple deprivation maps for the geographical area of National Health Service (NHS) Greater Glasgow and Clyde. Tests of spatial autocorrelation and association were conducted to evaluate geographical variation and patterning, and the association between prevalence-adjusted outcome rates and multiple deprivation by quintile. RESULTS Within our health board region, people with diabetes had crude prevalence-adjusted rates for DFU of 4.6% and for LEA of 1.3%, and an incidence rate of mortality preceded by either a DFU or LEA of 10.5 per 10,000 per year. Spatial autocorrelation identified statistically significant hot spot (high prevalence) and cold spot (low prevalence) clusters for all outcomes. Small-area maps effectively displayed near neighbour clustering across the health board geography. Disproportionately high numbers of hot spots within the most deprived quintile for DFU (p < 0.001), LEA (p < 0.001) and mortality (p < 0.001) rates were found. Conversely, a disproportionately higher number of cold spots was found within the least deprived quintile for LEA (p < 0.001). CONCLUSIONS/INTERPRETATION In people with diabetes, DFU, LEA and mortality rates are associated with multiple deprivation and form geographical neighbourhood clusters.
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Affiliation(s)
- Joanne E Hurst
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, Scotland, G4 0BA, UK.
| | - Ruth Barn
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, Scotland, G4 0BA, UK
| | - Lesley Gibson
- Institute for Infrastructure & Environment, University of Edinburgh, Edinburgh, Scotland, UK
| | - Hamish Innes
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, Scotland, G4 0BA, UK
| | - Sicco A Bus
- Amsterdam University Medical Center, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Brian Kennon
- Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - David Wylie
- Renfrewshire Health and Social Care Partnership, Paisley, Scotland, UK
| | - James Woodburn
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, Scotland, G4 0BA, UK
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29
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Saluja S, Anderson SG, Hambleton I, Shoo H, Livingston M, Jude EB, Lunt M, Dunn G, Heald AH. Foot ulceration and its association with mortality in diabetes mellitus: a meta-analysis. Diabet Med 2020; 37:211-218. [PMID: 31613404 DOI: 10.1111/dme.14151] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diabetic foot ulcers portend an almost twofold increase in all-cause mortality compared with diabetes on its own. AIM To investigate the association between diabetic foot ulcers and risk of death. METHODS We performed a meta-analysis of all observational studies investigating the association between diabetic foot ulcers and all-cause mortality. Risk ratios and risk differences were pooled in a random-effects model. The I2 statistic was used to quantify heterogeneity between studies. RESULTS Altogether, we identified 11 studies that reported 84 131 deaths from any cause in 446 916 participants with diabetes during a total of 643 499 person-years of follow-up. The crude event rate for all-cause mortality in individuals with diabetes who did not develop foot ulceration was 22% lower at 181.5 deaths (per 1000 person-years) than in those who developed foot ulcers (230.8 per 1000 person-years). Diabetic foot ulceration was associated with an increased risk of all-cause mortality (pooled relative risk 2.45, 95% CI 1.85-2.85). We did not observe any tangible differences in risk of all-cause mortality from diagnosis in studies reporting a mean duration of follow-up of ≤3 years (relative risk 2.43, 95% CI 2.27-2.61) or >3 years (relative risk 2.26, 95% CI 2.13-2.40) years. Funnel plot inspection revealed no significant publication bias among studies included in this meta-analysis. CONCLUSIONS Our study shows an excess rate of all-cause mortality in people with diabetic foot ulceration when compared to those without foot ulceration. It is imperative that early interventions to prevent foot ulceration and modify cardiovascular disease risk factors are put in place to reduce excess mortality.
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Affiliation(s)
- S Saluja
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - S G Anderson
- Division of Cardiovascular Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Cavehill, Barbados
| | - I Hambleton
- George Alleyne Chronic Disease Research Centre, University of the West Indies, Cavehill, Barbados
| | - H Shoo
- Diabetes and Endocrine Department, Countess of Chester NHS Foundation Trust, Chester, UK
| | - M Livingston
- Department of Blood Sciences, Walsall Manor Hospital, Walsall, UK
| | - E B Jude
- Department of Diabetes and Endocrinology, Tameside Hospital NHS Foundation Trust, Ashton-under-Lyne, UK
| | - M Lunt
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, School of Biological Sciences, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - G Dunn
- Department of Podiatry, East Cheshire NHS Trust, Macclesfield, UK
| | - A H Heald
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Salford Royal NHS Foundation Trust, Diabetes and Endocrinology, Salford, UK
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30
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Heald A, Lunt M, Rutter MK, Anderson SG, Cortes G, Edmonds M, Jude E, Boulton A, Dunn G. Developing a foot ulcer risk model: what is needed to do this in a real-world primary care setting? Diabet Med 2019; 36:1412-1416. [PMID: 30320946 DOI: 10.1111/dme.13837] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2018] [Indexed: 12/24/2022]
Abstract
AIM To determine how routinely collected data can inform a risk model to predict de novo foot ulcer presentation in the primary care setting. METHODS Data were available on 15 727 individuals without foot ulcers and 1125 individuals with new foot ulcers over a 12-year follow-up in UK primary care. We examined known risk factors and added putative risk factors in our logistic model. RESULTS People with foot ulcers were 4.2 years older (95% CI 3.1-5.2) than those without, and had higher HbA1c % (mean 7.9 ± 1.9 vs 7.5 ± 1.7) / HbA1c mmol/mol (63 ± 21 vs 59 ± 19) (p<0.0001) concentration [+0.45 (95% CI 0.33-0.56), creatinine level [+6.9 μmol/L (95% CI 4.1-9.8)] and Townsend score [+0.055 (95% CI 0.033-0.077)]. Absence of monofilament sensation was more common in people with foot ulcers (28% vs 21%; P<0.0001), as was absence of foot pulses (6.4% vs 4.8%; P=0.017). There was no difference between people with or without foot ulcers in smoking status, gender, history of stroke or foot deformity, although foot deformity was extremely rare (0.4% in people with foot ulcers, 0.6% in people without foot ulcers). Combining risk factors in a single logistic regression model gave modest predictive power, with an area under the receiver-operating characteristic curve of 0.65 (95% CI 0.62-0.67). The prevalence of ulceration in the bottom decile of risk was 1.8% and in the top decile it was 13.4% (compared with an overall prevalence of 6.5%); thus, the presence of all six risk factors gave a relative risk of 7.4 for development of a foot ulcer over 12 years. CONCLUSION We have made some progress towards defining a variable set that can be used to create a foot ulcer prediction model. More accurate determination of foot deformity/pedal circulation in primary care may improve the predictive value of such a future risk model, as will identification of additional risk variables.
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Affiliation(s)
- A Heald
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester
- Department of Diabetes and Endocrinology, Salford Royal Hospital, Salford
| | - M Lunt
- School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester
| | - M K Rutter
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - S G Anderson
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester
| | - G Cortes
- Medical Department, High Speciality Regional Hospital of Ixtapaluca, Mexico City, Mexico
| | - M Edmonds
- Department of Diabetes, Kings College Hospital, London
| | - E Jude
- Tameside Hospital NHS Foundation Trust, Ashton-under-Lyme
| | - A Boulton
- Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - G Dunn
- East Cheshire Trust, Cheshire, UK
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Encounters for foot and ankle pain in UK primary care: a population-based cohort study of CPRD data. Br J Gen Pract 2019; 69:e422-e429. [PMID: 31109927 PMCID: PMC6532799 DOI: 10.3399/bjgp19x703817] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/24/2018] [Indexed: 12/21/2022] Open
Abstract
Background Older patients who have foot pain report variation in access to services to manage their foot health. To plan services it is essential to understand the scale and burden of foot pain that exists for GPs. Aim To provide UK-wide population-level data of the frequency of foot and/or ankle pain encounters recorded in general practice. Design and setting Population-based cohort design study using data drawn from the UK Clinical Practice Research Datalink (CPRD) from January 2010 to December 2013. Method All CPRD data were collected prospectively by participating GPs. The primary outcome was prevalence of GP encounters for foot and/or ankle pain, stratified by age, sex, and different subgroups of causes. Results A foot and/or ankle pain encounter was recorded for 346 067 patients, and there was a total of 567 095 recorded encounters (mean per person 1.6, standard deviation [SD] 1.3). The prevalence of recorded encounters of foot and/or ankle pain was 2980 per 100 000 (3%). The number of patients with a recorded encounter of foot and/or ankle pain was 1820 per 100 000 (1.8%). Foot and/or ankle pain encounters were reported across all age groups (54.4% females), with those aged 71–80 years placing the greatest burden on GPs. The most common specified referrals were to orthopaedics (n = 36 881) and physiotherapy (n = 33 987), followed by podiatry (n = 25 980). Conclusion The burden of foot and/or ankle pain encounters recorded by GPs is not insubstantial, and spans all ages, with a high proportion of referrals to orthopaedics. The authors recommend further exploration of ‘first-contact practitioners’ for foot and/or ankle pain in general practice to alleviate the burden on GPs.
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Younis BB, Shahid A, Arshad R, Khurshid S, Ahmad M, Yousaf H. Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan. BMC Endocr Disord 2018; 18:53. [PMID: 30081878 PMCID: PMC6090692 DOI: 10.1186/s12902-018-0282-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/27/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Diabetic foot ulceration is a serious limb-threatening complication of diabetes. It is the common cause of hospital admissions and amputations. The objective of the study was to determine the prevalence of diabetic foot ulcers (DFU) and its association with age, gender, duration of diabetes, peripheral neuropathy (PN), peripheral arterial disease (PAD) and HbA1c. METHODS A total of 1940 people (≥ 30 years of age) with type 2 diabetes coming to the Sakina Institute of Diabetes and Endocrine Research (specialist diabetes clinic) at Shalamar Hospital, Lahore, Pakistan, were recruited over a period of 1 year from January 2016 to January 2017. The foot ulcers were identified according to the University of Texas classification. PN was assessed by biothesiometer and PAD by ankle-brachial index (< 0.9). Body weight, height, body mass index (BMI), HbA1c and duration of diabetes were recorded. RESULTS The prevalence of DFU was 7.02%, of which 4.5% of the ulcers were on the planter and 2.6% on the dorsal surface of the foot; 8.5% of the persons had bilateral foot ulcers and 0.4% subjects had Charcot deformity. There was significant association of foot ulcers with age, duration of diabetes, HbA1c, PN and PAD, whereas no association was observed with gender and BMI. PN and PAD were observed in 26.3 and 6.68% of people with diabetes respectively. Neuropathic ulcers and neuro-ischemic ulcers were identified in 74 and 19% of the study population. Logistic regression analysis revealed significant odds ratio for peripheral neuropathy 23.9 (95% confidence interval (5.41-105.6). CONCLUSIONS Peripheral neuropathy is the commonest cause of foot ulcers. An optimum control of blood glucose to prevent neuropathy and regular feet examination of every person with diabetes may go a long way in preventing foot ulceration.
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Affiliation(s)
- Bilal Bin Younis
- Sakina Institute of Diabetes and Endocrine Research, Shalamar Hospital, Lahore, Pakistan
| | - Adeela Shahid
- Physiology Department, Shalamar Medical and Dental College, Lahore, Pakistan
| | - Rozina Arshad
- Sakina Institute of Diabetes and Endocrine Research, Shalamar Hospital, Lahore, Pakistan
| | - Saima Khurshid
- Sakina Institute of Diabetes and Endocrine Research, Shalamar Hospital, Lahore, Pakistan
| | - Muhammad Ahmad
- Sakina Institute of Diabetes and Endocrine Research, Shalamar Hospital, Lahore, Pakistan
| | - Haroon Yousaf
- Sakina Institute of Diabetes and Endocrine Research, Shalamar Hospital, Lahore, Pakistan
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