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Au A, Yii E, Andric A, Wong J, Saunder A, Yii M. Predictors of operative management in diabetic foot ulcers. J Foot Ankle Res 2024; 17:e12024. [PMID: 38797920 DOI: 10.1002/jfa2.12024] [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: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND & AIMS Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. METHODS All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2 years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. RESULTS Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p < 0.001), OR 2.19 (p < 0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p < 0.019) if osteomyelitis was present. CONCLUSIONS Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.
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Affiliation(s)
- Amos Au
- Department of Vascular Surgery, Monash Health, Clayton, Victoria, Australia
| | - Erwin Yii
- Department of Vascular Surgery, Eastern Health, Box Hill, Victoria, Australia
| | - Ana Andric
- Department of Podiatry, Monash Health, Clayton, Victoria, Australia
| | - Jennifer Wong
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
| | - Alan Saunder
- Department of Vascular Surgery, Monash Health, Clayton, Victoria, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Ming Yii
- Department of Vascular Surgery, Monash Health, Clayton, Victoria, Australia
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
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Nagaya R, R P, Deva R, Jagadeesh Y, Emmanuel P, Narayan G. Optimizing Antibiotic Treatment for Diabetic Foot Infections: A Study From a Tertiary Public Healthcare Center in Puducherry, South India. Cureus 2024; 16:e60139. [PMID: 38864045 PMCID: PMC11165439 DOI: 10.7759/cureus.60139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Diabetic foot infections (DFIs) represent a significant complication of diabetes mellitus, contributing to increased morbidity and mortality. Understanding antibiotic prescribing patterns and microbial susceptibility is crucial for effective management. OBJECTIVE This study aimed to assess antibiotic prescribing trends and microbial susceptibility patterns in DFIs in a tertiary care center in Puducherry. METHODS A prospective observational study was conducted over two months, involving patients with DFIs attending surgery OPD and admitted inpatient wards. Data on demographics, comorbidities, ulcer characteristics, antibiotic prescriptions, and microbial culture results were collected. Descriptive statistics and appropriate statistical tests were used for analysis. RESULTS Of 110 patients included, most were males (80, 72.7%) aged 51-60 years (43, 39.1%). Common risk factors included poor glycemic control (85, 77.3%), barefoot walking (29, 26.4%), and a family history of diabetes (46, 41.8%). Gram-negative organisms (78, 70.9%) predominated, with Escherichia coli (17, 15.5%), Pseudomonas aeruginosa (12, 10.9%), and Staphylococcus aureus (10, 9.1%) being common isolates. Polypharmacy was observed, with (63) 57.3% receiving multiple antibiotics, mainly via the parenteral route (16, 64.5%). Ceftriaxone (31, 28.2%) and cefotaxime (21, 19.1%) were frequently prescribed. Antibiotic resistance varied among isolates. CONCLUSION This study underscores the predominance of gram-negative organisms in DFIs and highlights the need for rational antibiotic prescribing. Cephalosporins were commonly used, emphasizing the importance of empirical therapy. Understanding local microbial patterns and susceptibility is crucial for guiding antibiotic selection and optimizing clinical outcomes. In addition, addressing modifiable risk factors is imperative for preventing DFIs and reducing associated complications. This study provides valuable insights for strengthening antimicrobial stewardship programs and improving patient care in diabetic foot management. Furthermore, the present study highlights the importance of essentially deprescribing the prescriptions both from the patient, their primary carer, and the treating physician/surgeon's perspective.
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Affiliation(s)
- Raghul Nagaya
- Internal Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Priyadharshini R
- Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Reka Deva
- Pharmacology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Yogeshwari Jagadeesh
- General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Pascal Emmanuel
- General Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND
| | - Gaurang Narayan
- Obstetrics and Gynecology, Indira Gandhi Government Medical College & Hospital, Nagpur, IND
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吴 静, Raju B, 查 盼, 龚 洪, 任 妍, 李 振, 陈 利, 刘 关, 陈 大, 王 椿, 冉 兴. [Characteristics of Inflammatory Markers in Diabetic Foot Patients and Their Relationship With Prognosis of Diabetic Foot Ulcers]. SICHUAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF SICHUAN UNIVERSITY. MEDICAL SCIENCE EDITION 2023; 54:1233-1238. [PMID: 38162051 PMCID: PMC10752772 DOI: 10.12182/20230960506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Indexed: 01/03/2024]
Abstract
Objective To explore the characteristics of baseline inflammatory markers in diabetic foot patients and their relationship with the prognosis of diabetic foot ulcers. Methods The clinical data of diabetic foot patients (n=495) admitted to West China Hospital, Sichuan University since 2016 were retrospectively collected through the hospital electronic medical record system to analyze the characteristics of inflammatory markers and their relationship with the prognosis of diabetic foot ulcers. Results White blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) levels were significantly higher in patients defined as grade 4 on the Wagner Scale than those in patients defined as grade 0-3 on the Wagner Scale. Neutrophil percentage (NE%) was higher in Wagner grade-4 patients than those in Wagner grade-0 and grade-1 patients and higher in Wagner grade-3 patients than those in Wagner grade-0 patients. NE%, CRP, PCT, and IL-6 levels were positively correlated with the severity of diabetic foot, with the respective odds ratio (OR) at 95% confidence interval (CI) being 1.038 (1.019-1.056), 1.019 (1.012-1.026), 8.225 (2.015-33.576), and 1.017 (1.008-1.025). Using Wagner grade-0 patients as the reference, patients with higher WBC were more likely to progress to Wagner grade 2, 3, and 4, with the respective OR (95% CI) values being 1.260 (1.096-1.447), 1.188 (1.041-1.356), and 1.301 (1.137-1.490); patients with higher ESR were more likely to progress to Wagner grade 3 and 4, with the respective OR (95% CI) values being 1.030 (1.006-1.054) and 1.045 (1.019-1.071). Baseline ESR (P=0.008), CRP (P=0.039), and IL-6 (P=0.033) levels were lower in patients who had received antibiotics prior to their admission than those in patients who had not received antibiotics before admission. The levels of WBC, NE%, ESR, PCT, and IL-6 were lower in the full recovery group than those in the group of patients who did not respond to treatment. The higher the levels of NE% and IL-6, the worse the prognosis of diabetic foot ulcers became, with the respective OR (95% CI) values being 1.030 (1.010-1.051) and 1.008 (1.002-1.013). Conclusion The severity of diabetic foot ulcers increased with the rise in baseline levels of inflammatory markers. Elevated baseline NE% and IL-6 levels suggest a poor prognosis. Our findings suggest that early assessment of diabetic foot infection and standardized antibiotic therapy should be implemented to improve the prognosis.
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Affiliation(s)
- 静 吴
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bista Raju
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 盼盼 查
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 洪平 龚
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- 四川大学华西医院 全科医学中心 (成都 610041)General Practice Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 妍 任
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 振怡 李
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 利鸿 陈
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 关键 刘
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 大伟 陈
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 椿 王
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - 兴无 冉
- 四川大学华西医院 内分泌代谢科 糖尿病足诊治中心 创面修复创新中心 (成都 610041)Innovation Center for Wound Repair, Diabetic Foot Care Center, Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
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Waldman OV, Dexter BJ, Sulovari A, Oh IC. Clinical presentation of group B Streptococcus-infected diabetic foot ulcers. J Wound Care 2023; 32:S19-S25. [PMID: 37405964 DOI: 10.12968/jowc.2023.32.sup7.s19] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
OBJECTIVE Group B Streptococcus (GBS) is a common pathogen in diabetic foot ulcers (DFUs), where it has been found to result in higher rates of soft tissue infection and amputation despite appropriate treatment. In this study, we aim to investigate clinical characteristics and prognosis of GBS DFU infections, especially those with tenosynovial involvement. We hypothesise that GBS-infected DFUs with tenosynovial involvement leads to an increased number of recurrent infections and unexpected returns to the operating room. METHOD Data were retrospectively collected from GBS-infected DFU patients surgically treated by an orthopaedic foot and ankle surgeon over a four-year period. Demographics, comorbidities, initial laboratory values and culture results from infected bone samples were recorded. Clinical outcome was assessed by recurrent infection and unplanned reoperation(s) within 3 months following the initial surgery. RESULTS In total, 72 patients were treated for GBS-infected DFUs. Intra-operative culture of infected bone identified GBS in 16 patients (22.2%). Significantly more black patients (p=0.017) were afflicted by GBS DFUs. Patients with GBS DFUs had higher initial haemoglobin A1C levels (p=0.019), and those with tenosynovial involvement were likely to require reoperation (p=0.036) and had a greater total number of surgeries (p=0.015) than those without. CONCLUSION GBS-infected DFUs are more common in black patients and those with elevated haemoglobin A1Cs. GBS infections with tenosynovial involvement are particularly destructive and require aggressive treatment by surgeons.
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Affiliation(s)
- Olivia V Waldman
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, US
| | - Brandon J Dexter
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
| | - Aron Sulovari
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
| | - Irvin C Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, US
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, US
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Yuzuguldu B, Zengin B, Simsir IY, Cetinkalp S. An Overview of Risk Factors for Diabetic Foot Amputation: An Observational, Single-centre, Retrospective Cohort Study. TOUCHREVIEWS IN ENDOCRINOLOGY 2023; 19:85-93. [PMID: 37313238 PMCID: PMC10258617 DOI: 10.17925/ee.2023.19.1.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/13/2023] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Not only are early detection and treatment of diabetic foot ulcers important, but also acknowledging potential risk factors for amputation gives clinicians a considerable advantage in preventing amputations. Amputations impact both healthcare services and the physical and mental health of patients. This study aimed to investigate the risk factors for amputation in patients with diabetic foot ulcers. METHODS The sample for this study was patients with diabetic foot ulcers who were treated by the diabetic foot council at our hospital between 2005 and 2020. A total of 32 risk factors for amputation were identified and investigated among 518 patients. RESULTS Our univariate analysis showed that 24 of 32 defined risk factors were statistically significant. In the multivariate analysis using the Cox regression model, seven risk factors remained statistically significant. The risk factors most significantly associated with amputation were Wagner grading, abnormal peripheral arteries, hypertension, high thrombocyte levels, low haematocrit levels, hypercholesterolaemia and male sex, respectively. The most common cause of death in patients with diabetes who have undergone amputation is cardiovascular disease, followed by sepsis. CONCLUSION To enable optimum treatment of patients with diabetic foot ulcers it is important for physicians to be aware of the amputation risk factors, and thus avoid amputations. Correcting risk factors, using suitable footwear and routinely inspecting feet are crucial factors for preventing amputations in patients with diabetic foot ulcers.
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Affiliation(s)
- Burak Yuzuguldu
- Division of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Bugra Zengin
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ilgin Yildirim Simsir
- Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, Izmir, Turkey
| | - Sevki Cetinkalp
- Division of Endocrinology and Metabolism Disorders, Faculty of Medicine, Ege University, Izmir, Turkey
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Lee DW, Kwak SH, Kim JH, Choi HJ. Prediction of diabetic foot amputation using newly revised DIRECT coding system: Comparison of accuracy with that of five existing classification systems. Int Wound J 2022; 20:359-371. [PMID: 35811359 PMCID: PMC9885474 DOI: 10.1111/iwj.13884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 02/03/2023] Open
Abstract
Diabetes mellitus (DM) causes various complications over time, one such complication is diabetic foot ulcers (DFU), which are challenging to treat and can lead to amputation. Additionally, a system for accurate prediction of amputation has yet to be developed. In total, 131 patients were included in the study after retrospectively collecting data from 2016 to 2020 about DFU. The collected data were used for comparison of the accuracy between five existing classification systems and the newly revised DIRECT coding system, and investigation of risk factors for lower extremity amputation (LEA). The existing five classification systems and DIRECT system can effectively predict LEA. The DIRECT3 system has three elements, C-reactive protein (CRP), ulcer history (UH), and hypertension (HTN) in addition to those of the DIRECT system. It had a high predictive value and accuracy similar to that of Wagner and University of Texas (UT) on depth among the five classification systems. Among the statistically significant risk factors, duration of DM and HTN, haemoglobin (Hb), CRP, and UH showed an association with LEA. The DIRECT coding system is effective for predicting LEA and explaining appropriate treatment methods for DFU, and is widely applicable because of its user accessibility and convenience.
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Affiliation(s)
- Da Woon Lee
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Si Hyun Kwak
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Jun Hyuk Kim
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
| | - Hwan Jun Choi
- Department of Plastic and Reconstructive Surgery, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea,Institute of Tissue Regeneration, College of MedicineSoonchunhyang UniversityCheonanRepublic of Korea
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Polikandrioti M. Quality of life in diabetic foot ulcer, grade 3: associated demographic factors. Folia Med (Plovdiv) 2022; 64:229-239. [DOI: 10.3897/folmed.64.e64876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/11/2021] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction: Patients with diabetic foot ulcer grade 3 experience some limitations that adversely affect their quality of life (QoL).
Aim: The aim of the study was to explore demographic characteristics associated with the quality of life of diabetic foot ulcer patients, grade 3.
Materials and methods: The present study recruited 120 diabetic foot ulcer patients. Data collected by completion of SF-36 Health Survey (SF-36).
Results: Of the 120 participants, 65.8% were men and 73% were more than 60 years of age. Patients showed moderate to high levels of quality of life in social functionality, energy/fatigue, emotional well-being, and physical pain (medians: 50, 60, 72, and 67.5, respectively) and poor levels in physical functioning, role physical, and role emotional (medians: 22, 0 and 0, respectively). In addition, patients had moderate levels of quality of life in general health (median: 48.5). It was observed that physical functioning was significantly associated with place of residence (p=0.005). Moreover, physical role was significantly associated with age (p=0.020) and occupation (p=0.018), while emotional role was significantly associated with age (p=0.012), marital status (p=0.016), and occupation (p=0.012). Energy/fatigue was significantly associated with age (p=0.026), marital status (p=0.018), and occupation (p=0.009). Emotional well-being was significantly associated with gender (p=0.009), level of education (p=0.001), and occupation (p=0.007). Social functionality was significantly associated with marital status (p=0.001) while pain was significantly associated with education level (p=0.010). General health was significantly associated with marital status (p=0.037), and place of residence (p=0.024).
Conclusions: The findings of the present study may adequately inform stakeholders in the field of diabetic foot ulcer grade 3 when planning effective care.
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CT-Angiography-Based Outcome Prediction on Diabetic Foot Ulcer Patients: A Statistical Learning Approach. Diagnostics (Basel) 2022; 12:diagnostics12051076. [PMID: 35626234 PMCID: PMC9140120 DOI: 10.3390/diagnostics12051076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/16/2022] [Accepted: 04/24/2022] [Indexed: 12/04/2022] Open
Abstract
The purpose of our study is to predict the occurrence and prognosis of diabetic foot ulcers (DFUs) by clinical and lower extremity computed tomography angiography (CTA) data of patients using the artificial neural networks (ANN) model. DFU is a common complication of diabetes that severely affects the quality of life of patients, leading to amputation and even death. There are a lack of valid predictive techniques for the prognosis of DFU. In clinical practice, the use of scales alone has a large subjective component, leading to significant bias and heterogeneity. Currently, there is a lack of evidence-based support for patients to develop clinical strategies before reaching end-stage outcomes. The present study provides a novel technical tool for predicting the prognosis of DFU. After screening the data, 203 patients with diabetic foot ulcers (DFUs) were analyzed and divided into two subgroups based on their Wagner Score (138 patients in the low Wagner Score group and 65 patients in the high Wagner Score group). Based on clinical and lower extremity CTA data, 10 predictive factors were selected for inclusion in the model. The total dataset was randomly divided into the training sample, testing sample and holdout sample in ratio of 3:1:1. After the training sample and testing sample developing the ANN model, the holdout sample was utilized to assess the accuracy of the model. ANN model analysis shows that the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) of the overall ANN model were 92.3%, 93.5%, 87.0%, 94.2% and 0.955, respectively. We observed that the proposed model performed superbly on the prediction of DFU with a 91.6% accuracy. Evaluated with the holdout sample, the model accuracy, sensitivity, specificity, PPV and NPV were 88.9%, 90.0%, 88.5%, 75.0% and 95.8%, respectively. By contrast, the logistic regression model was inferior to the ANN model. The ANN model can accurately and reliably predict the occurrence and prognosis of a DFU according to clinical and lower extremity CTA data. We provided clinicians with a novel technical tool to develop clinical strategies before end-stage outcomes.
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Meyr AJ, Skolnik J, Mateen S, Sansosti LE. A Comparison of Adverse Short-Term Outcomes Following Forefoot Amputation Performed on an Inpatient Versus Outpatient Basis. J Foot Ankle Surg 2022; 61:67-71. [PMID: 34266720 DOI: 10.1053/j.jfas.2020.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 02/03/2023]
Abstract
The objective of this investigation was to evaluate short-term adverse outcomes following forefoot amputation with a specific comparison between those procedures performed on an inpatient versus outpatient basis. The 2018 American College of Surgeons National Surgical Quality Improvement Program database was interrogated to select those subjects with a 28805 current procedural terminology code (amputation, foot; transmetatarsal) that underwent the procedure with "all layers of incision (deep and superficial) fully closed." This resulted in 326 subjects who underwent the procedure on an inpatient basis and 72 subjects who underwent the procedure on an outpatient basis. Results of the primary outcome measures found no significant differences between groups with respect to the development of a superficial surgical site infection (5.8% vs 5.6%; p = .950), deep incisional infection (3.4% vs 5.6%; p = .380), or wound disruption (3.4% vs 6.9%; p = .163). Additionally, no significant differences were observed between groups with respect to unplanned reoperations (15.6% vs 12.5%; p = .500) or unplanned hospital readmissions (21.8% vs 23.6%; p = .957). The results of this investigation demonstrate no difference in short-term adverse outcomes following the performance of forefoot amputation with primary closure when the procedure is performed on an inpatient or outpatient basis. We hope that this information is utilized in future investigations specifically examining this clinical scenario as it relates to hospital admission criteria related to lower extremity tissue loss, length of hospital stay considerations, the timing of partial foot amputation following revascularization, and the economics of limb preservation.
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Affiliation(s)
- Andrew J Meyr
- Clinical Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA.
| | - Jennifer Skolnik
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Sara Mateen
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA
| | - Laura E Sansosti
- Clinical Assistant Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA
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Bedriñana-Marañón B, Rubio-Rodríguez M, Yovera-Aldana M, Garcia-Villasante E, Pinedo-Torres I. Association Between the Diabetes mellitus Duration and the Severity of Diabetic Foot Disease in Hospitalized Patients in Latin America. INT J LOW EXTR WOUND 2021:15347346211063266. [PMID: 34889665 DOI: 10.1177/15347346211063266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The objective was to determine the association between a diabetes mellitus duration greater than 10 years and the severity of diabetic foot in hospitalized patients in Latin America.Analytical, observational, and retrospective study based in secondary databases. Patients older than 18 years with diagnosis of diabetes mellitus (DM) and hospitalized for any causes were included. The independent and dependent variables were having more than 10 years of diagnosis of DM and the severity of the diabetic foot disease (Wagner> = 2), respectively. A crude Poisson regression analysis was performed to obtain prevalence rates adjusted to confounders.Male gender was 54.8% and the median age was 62 years. In the group with more than10 years of disease (n = 903) 18% (n = 162) had severe injuries. We performed two Poisson regression analyzes, one of which included the entire sample; and in the other, only patients with some degree of ulcer were included at the time of evaluation (Wagner > = 1). In the first analysis the PR was 1.95 (p < 0.01) adjusted for the significant variables in the bivariate analysis and in the second analysis the PR was 1.18 (p < 0.01) adding to the adjustment the days of injury prior to hospitalization and the location of the ulcer.We conclude that in patients with more than 10 years of diabetes mellitus, diabetic foot injuries are more severe, regardless type of diabetes, gender, age, history of amputation and days of injury prior to hospitalization for inpatients in Latin America.
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Affiliation(s)
| | | | - Marlon Yovera-Aldana
- Grupo de Investigación Neurociencia, Efectividad y Salud Pública, Universidad Científica del Sur, Lima, Perú
- 33209Red de Eficacia Clinica y Sanitaria, REDECS, Lima, Perú
| | - Eilhart Garcia-Villasante
- 33209Red de Eficacia Clinica y Sanitaria, REDECS, Lima, Perú
- 269034Hospital Nacional Daniel Alcides Carrion, Callao, Perú
| | - Isabel Pinedo-Torres
- Grupo de Investigación Neurociencia, Efectividad y Salud Pública, Universidad Científica del Sur, Lima, Perú
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11
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Sulovari A, Ninomiya MJ, Beck CA, Ricciardi BF, Ketonis C, Mesfin A, Kaplan NB, Soin SP, McDowell SM, Mahmood B, Daiss JL, Schwarz EM, Oh I. Clinical utilization of species-specific immunoassays for identification of Staphylococcus aureus and Streptococcus agalactiae in orthopedic infections. J Orthop Res 2021; 39:2141-2150. [PMID: 33274775 PMCID: PMC8175449 DOI: 10.1002/jor.24935] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/09/2020] [Accepted: 12/01/2020] [Indexed: 02/04/2023]
Abstract
Staphylococcus aureus and Streptococcus agalactiae (Group B streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture-based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use before presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen-specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture-related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.
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Affiliation(s)
- Aron Sulovari
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Mark J. Ninomiya
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher A. Beck
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin F. Ricciardi
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Constantinos Ketonis
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Addisu Mesfin
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Nathan B. Kaplan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Sandeep P. Soin
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Susan M. McDowell
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Bilal Mahmood
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John L. Daiss
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
- Department of Microbiology & Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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12
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High-intensity Hospital Utilization Among Adults with Diabetic Foot Ulcers: A Population-Based Study. Can J Diabetes 2021; 46:330-336.e7. [DOI: 10.1016/j.jcjd.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 09/04/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022]
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13
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Hariftyani AS, Novida H, Edward M. Profile of Diabetic Foot Ulcer Patients at Tertiary Care Hospital in Surabaya, Indonesia. JURNAL BERKALA EPIDEMIOLOGI 2021. [DOI: 10.20473/jbe.v9i32021.293-302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background: Diabetic Foot Ulcer (DFU) has been associated with a high mortality rate of Diabetes Mellitus (DM) patients. Both behavioral and biological factors cause predisposition to DFU. Purpose: This research describes the profile of hospitalized DFU patients at a tertiary care hospital in Surabaya. Methods: A retrospective descriptive study that analyzed medical records of hospitalized T2DM patients with DFU in Dr. Soetomo General Hospital. Sampled respondents were patients ≥ 21 years old who were hospitalized between 2016–2018. Demographic data, clinical characteristics, medical histories, length of hospital stay, laboratory results, precipitating factors, microorganism culture results, treatment, and outcome were analyzed. Descriptive analysis is presented in the form of narratives, tables, and diagrams. Results: 9.08% of hospitalized Type 2 DM (T2DM) cases were related to foot ulcers. The average patient age was 57.00 ± 9.83 years with no gender predominance. DM was poorly controlled (Mean HbA1C 9.78±2.83%; RBG 251.83 ± 158.15 mg/dL). The majority of patients had sepsis (68.26%) and renal function impairment (62.72%). Ulcers with Wagner grades of 4–5 were frequent (41.31%). The highest percentage of sepsis (80.49%) and the average leukocyte level (22.60±11.95 x109/L) were found in gangrenous feet. Anemia was more predominant and severe in ulcers with higher Wagner grades. Trauma and Escherichia coli were the most common precipitating factors and microorganisms isolated, respectively. Amputation was performed for 82.36% of patients who were admitted to hospital with gangrene. The Lower Extremity Amputation (LEA) and mortality rates were 14.11% and 40.93%, respectively. Conclusion: DFUs were found to have a relatively high prevalence among T2DM patients, and must never be neglected due to the high associated mortality rate.
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14
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Fan L, Wu XJ. Sex difference for the risk of amputation in diabetic patients: A systematic review and meta-analysis. PLoS One 2021; 16:e0243797. [PMID: 33705430 PMCID: PMC7951841 DOI: 10.1371/journal.pone.0243797] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/26/2020] [Indexed: 02/07/2023] Open
Abstract
The risk of amputation is a sequelae of diabetic foot ulceration, which are significantly increased in diabetic patients and caused huge morbidly and mortality. However, whether the risk amputation in diabetic patients are differing in male and female remains inconclusive. We therefore conducted a systematic review and meta-analysis to assess the sex difference for the risk of amputation in diabetic patients. We systematically searched PubMed, EmBase, and the Cochrane library to identify eligible study from their inception up to November 2020. The diagnostic value of male patients on subsequent amputation risk were assessed by using sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC). Twenty-two studies recruited a total of 33,686,171 diabetic patients were selected for quantitative analysis. The risk of amputation in male diabetic patients was greater than female diabetic patients (DOR: 1.38; 95%CI: 1.13–1.70; P<0.001). The sensitivity and specificity for male diabetic patients on the risk of amputation were 0.72 (95%CI: 0.72–0.73), and 0.51 (95%CI: 0.51–0.51), respectively. Moreover, the PLR and NLR of male diabetic patients for predicting amputation were 1.13 (95%CI: 1.05–1.22), and 0.82 (0.72–0.94), respectively. Furthermore, the AUC for male diabetic patients on amputation risk was 0.56 (95%CI: 0.48–0.63). This study found male diabetic patients was associated with an increased risk of amputation than female diabetic patients, and the predictive value of sex difference on amputation risk in diabetic patients was mild.
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Affiliation(s)
- Lei Fan
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Orthopedic Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Xue-Jian Wu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- * E-mail:
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15
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Hao SP, Masters EA, Ninomiya MJ, Beck CA, Schwarz EM, Daiss JL, Oh I. Species-Specific Immunoassay Aids Identification of Pathogen and Tracks Infectivity in Foot Infection. Foot Ankle Int 2021; 42:363-372. [PMID: 33161780 PMCID: PMC7946706 DOI: 10.1177/1071100720965136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Conventional bacterial cultures frequently fail to identify the dominant pathogen in polymicrobial foot infections, in which Staphylococcus aureus is the most common infecting pathogen. Previous work has shown that species-specific immunoassays may be able to identify the main pathogen in musculoskeletal infections. We sought to investigate the clinical applicability of a S. aureus immunoassay to accurately identify the infecting pathogen and monitor its infectivity longitudinally in foot infection. We hypothesized that this species-specific immunoassay could aid in the diagnosis of S. aureus and track the therapeutic response in foot infections. METHODS From July 2015 to July 2019, 83 infected foot ulcer patients undergoing surgical intervention (debridement or amputation) were recruited and blood was drawn at 0, 4, 8, and 12 weeks. Whole blood was analyzed for S. aureus-specific serum antibodies (mix of historic and new antibodies) and plasmablasts were isolated and cultured to quantify titers of newly synthesized antibodies (NSAs). Anti-S. aureus antibody titers were compared with culture results to assess their concordance in identifying S. aureus as the pathogen. The NSA titer changes at follow-ups were compared with wound healing status to evaluate concordance between evolving host immune response and clinically resolving or relapsing infection. RESULTS Analysis of serum for anti-S. aureus antibodies showed significantly increased titers of 3 different anti-S. aureus antibodies, IsdH (P = .037), ClfB (P = .025), and SCIN (P = .005), in S. aureus culture-positive patients compared with culture-negative patients. Comparative analysis of combining antigens for S. aureus infection diagnosis increased the concordance further. During follow-up, changes of NSA titers against a single or combination of S. aureus antigens significantly correlated with clinically resolving or recurring infection represented by wound healing status. CONCLUSION In the management of foot infection, the use of S. aureus-specific immunoassay may aid in diagnosis of the dominant pathogen and monitoring of the host immune response against a specific pathogen in response to treatment. Importantly, this immunoassay could detect recurrent foot infection, which may guide a surgeon's decision to intervene. LEVEL OF EVIDENCE Level II, prospective comparative study.
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Affiliation(s)
- Stephanie P. Hao
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
| | - Elysia A. Masters
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA,Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
| | - Mark J. Ninomiya
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher A. Beck
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, NY, USA
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA,Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - John L. Daiss
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Irvin Oh
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA,Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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16
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Jouhar L, Jaafar RF, Nasreddine R, Itani O, Haddad F, Rizk N, Hoballah JJ. Microbiological profile and antimicrobial resistance among diabetic foot infections in Lebanon. Int Wound J 2020; 17:1764-1773. [PMID: 32779355 PMCID: PMC7949405 DOI: 10.1111/iwj.13465] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/30/2020] [Indexed: 01/18/2023] Open
Abstract
Diabetic Foot Infection (DFI) is a challenging complication of diabetes mellitus with a high burden in the Middle East where there is a marked increase in diabetes prevalence and complications. Early detection of DFI and the infectious organisms could result in the early initiation of appropriate antibiotic therapy and improved outcomes. DFI microbiological profiles differ between countries. In our region, Western guidelines are used when initiating treatment for DFI in the absence of local guidance. The purpose of our study was to determine the microbiologic profile and antimicrobial susceptibility of the DFI admissions at a large tertiary referral centre in Beirut and review other reported series in Lebanon and our region. This is a retrospective observational study of patients with DFI admitted to the American University of Beirut Medical Centre from January 2008 to June 2017. The bacteriologic isolation and antimicrobial susceptibility tests were performed according to standard microbiological methods. Between 2008 and 2017, 319 diabetic patients with DFU were admitted to AUBMC, and deep-tissue cultures were taken for 179 patients. From 179 deep tissue cultures, 314 bacterial isolates were obtained. Fifty-four percent of patients had the polymicrobial infection. Aerobic gram-negative rods (GNR) were more prevalent than gram-positive cocci (GPC) (55%, 39%, respectively). The most common isolate was Escherichia coli (15%) followed by Enterococcus (14%) and Pseudomonas aeruginosa (11%). Staphylococcus aureus isolates accounted for 9% with 50% of them being methicillin-resistant (MRSA). Among Enterobacteriaceae, 37% of isolates were fluoroquinolone-resistant, 25% were ESBL producers, and 2% were carbapenem-resistant. Antibiotic resistance was significantly associated with prior usage of antibiotics. Anaerobes were isolated in 1% and Candida species in 5% of isolates. The sensitivity, specificity, PPV, and NPV of swab culture recovery of pathogens compared with deep tissue culture were (76%, 72%, 76%, 72%) and (94%, 81%, 91%, 86%) for gram-positive and gram-negative organisms, respectively. The microbiological profile of DFI in Lebanon is comparable to other countries in the MENA region with big differences compared with the West. Therefore, it is imperative to develop local guidelines for antimicrobial treatment. The high prevalence of GNR in DFI and the high fluoroquinolone resistance should be taken into consideration when choosing empiric antibiotics. Empiric treatment for MRSA or Pseudomonas does not appear necessary except for patients with specific risk factors.
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Affiliation(s)
- Lamia Jouhar
- Department of Surgery, Division of Vascular SurgeryAmerican University of BeirutBeirutLebanon
| | - Rola F. Jaafar
- Department of Surgery, Division of Vascular SurgeryAmerican University of BeirutBeirutLebanon
| | - Rakan Nasreddine
- Department of Surgery, Division of Vascular SurgeryAmerican University of BeirutBeirutLebanon
| | - Omar Itani
- Department of Internal Medicine, Division of Infectious DiseasesAmerican University of Beirut Medical CenterBeirutLebanon
| | - Fady Haddad
- Department of Surgery, Division of Vascular SurgeryAmerican University of BeirutBeirutLebanon
| | - Nisrine Rizk
- Department of Surgery, Division of Vascular SurgeryAmerican University of BeirutBeirutLebanon
| | - Jamal J. Hoballah
- Department of Surgery, Division of Vascular SurgeryAmerican University of BeirutBeirutLebanon
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17
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Jørgensen TS, Hellsten Y, Gottlieb H, Brorson S. Assessment of diabetic foot ulcers based on pictorial material: an interobserver study. J Wound Care 2020; 29:658-663. [PMID: 33175625 DOI: 10.12968/jowc.2020.29.11.658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The frequent change in clinicians, and the emerging use of photographic documentation in wound management, could require a more diverse treatment of patients due to poor interobserver agreement. The aim of this study was to assess the interobserver agreement of a commonly used classification system for diabetic foot ulcers (DFUs), the Meggitt-Wagner classification, and to compare the agreement on classification with the agreement in treatment recommendations. METHOD An interobserver study was conducted based on a questionnaire linked to 30 photographs of DFUs. Different groups of observers were tested to investigate whether there was a difference between professions or level of education: experienced orthopaedic wound care doctors (n=7); nurses specialised in wound care (n=8) and untrained nurses assigned to a diabetic wound care training course (n=23). Krippendorff's alpha was used to calculate interobserver agreement, and an agreement of >0.67 was defined as substantial. RESULTS The Krippendorff's alpha value for interobserver agreement on the Meggitt-Wagner classification was 0.52 for the doctors group, 0.67 for the specialised nurses and 0.61 for the untrained nurses. The corresponding values regarding agreement on recommendation of surgical revision of the wound were 0.35, 0.22 and 0.15, respectively. The choice of dressing type or antibiotic treatment had even lower interobserver agreement. CONCLUSIONS The interobserver agreement on the Meggitt-Wagner classification was substantial in the specialised nurse group, but the evaluation and treatment of DFUs should not be exclusively based on pictorial materials.
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Affiliation(s)
- Tue Smith Jørgensen
- Department of Orthopedic Surgery, Herlev University Hospital.,Department of Nutrition Exercise and Sports, Faculty of Science, University of Copenhagen
| | - Ylva Hellsten
- Department of Nutrition Exercise and Sports, Faculty of Science, University of Copenhagen
| | - Hans Gottlieb
- Department of Orthopedic Surgery, Herlev University Hospital
| | - Stig Brorson
- Department of Orthopedic Surgery, Zealand University Hospital; Department of Clinical Medicine, University of Copenhagen
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18
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Lane KL, Abusamaan MS, Voss BF, Thurber EG, Al-Hajri N, Gopakumar S, Le JT, Gill S, Blanck J, Prichett L, Hicks CW, Sherman RL, Abularrage CJ, Mathioudakis NN. Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies. J Diabetes Complications 2020; 34:107638. [PMID: 32527671 PMCID: PMC7721205 DOI: 10.1016/j.jdiacomp.2020.107638] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/05/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS Medline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. Ameta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842). RESULTS Of 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses(n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes. CONCLUSIONS Our findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.
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Affiliation(s)
- Kyrstin L Lane
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Betiel Fesseha Voss
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Emilia G Thurber
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Noora Al-Hajri
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Shraddha Gopakumar
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jimmy T Le
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Sharoon Gill
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jaime Blanck
- Informationist Services, Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Laura Prichett
- Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Ronald L Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nestoras N Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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19
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Brodell JD, Ayers BC, Baumhauer JF, DiGiovanni BF, Flemister AS, Ketz JP, Oh I. Chopart Amputation: Questioning the Clinical Efficacy of a Long-standing Surgical Option for Diabetic Foot Infection. J Am Acad Orthop Surg 2020; 28:684-691. [PMID: 32769724 DOI: 10.5435/jaaos-d-19-00757] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Diabetic foot ulcers with associated infection and osteomyelitis often lead to partial or complete limb loss. Determination of the appropriate level for amputation based on the patient's baseline physical function, extent of infection, vascular patency, and comorbidities can be challenging. Although Chopart amputation preserves greater limb length than more proximal alternatives such as Syme or below-the-knee amputations (BKA), challenges with wound healing and prosthesis fitting have been reported. We aimed to investigate the functional and clinical outcomes of Chopart amputation combined with tendon transfers. METHODS We identified patients who underwent Chopart amputations for diabetic foot infections by an academic orthopaedic group between August 2013 and September 2018. Subjects completed three Patient-Reported Outcomes Measurement Information Systems (PROMIS) instruments. Incidence of postoperative complications and change in patient-reported outcomes before and after surgery were recorded. RESULTS Eighteen patients with an average age of 60.8 (range, 44 to 79) years were identified. The mean follow-up was 22.8 months (range, 6.7 to 51.0). Seventeen of the 18 total patients developed postoperative wound complications. These lead to revision amputations in 10 Chopart amputees, consisting of two Syme and eight BKAs. Half of the Chopart patients never received a prosthesis because of delayed wound healing and revision amputation. PROMIS physical function (PF) (31.1 pre-op and 28.6 post-op), pain interference (63.1 pre-op and 59.4 post-op), and depression (53.0 pre-op and 54.8 post-op) did not show significant change (P-values = 0.38, 0.29, 0.72, respectively). Pre- and post-op the PROMIS physical function scores were well below the US average. DISCUSSION In our patient cohort, 94% of patients developed postoperative wound complication. Only 44% of patients ever successfully ambulated with a prosthesis after Chopart amputation, and the others (56%) required revision amputations such as a BKA. Even after wound healing, Chopart amputees may struggle with obtaining a prosthesis suitable for ambulation. Surgeons should exercise judicious patient selection before performing Chopart amputation. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
- James D Brodell
- From the Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY
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20
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Al-Thani H, El-Matbouly M, Al-Sulaiti M, Al-Thani N, Asim M, El-Menyar A. Does Perioperative Hemoglobin A1c Level Affect the Incidence, Pattern and Mortality of Lower Extremity Amputation? Curr Vasc Pharmacol 2020; 17:354-364. [PMID: 29359671 DOI: 10.2174/1570161116666180123112529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 05/14/2018] [Accepted: 06/14/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND We hypothesized that perioperative HbA1c influenced the pattern and outcomes of Lower Extremity Amputation (LEA). METHODS A retrospective analysis was conducted for all patients who underwent LEA between 2000 and 2013. Patients were categorized into 5 groups according to their perioperative HbA1c values [Group 1 (<6.5%), Group 2 (6.5-7.4%), Group 3 (7.5-8.4%), Group 4 (8.5-9.4%) and Group 5 (≥9.5%)]. We identified 848 patients with LEA; perioperative HbA1c levels were available in 547 cases (Group 1: 18.8%, Group 2: 17.7%, Group 3: 15.0%, Group 4: 13.5% and Group 5: 34.9%). Major amputation was performed in 35%, 32%, 22%, 10.8% and 13.6%, respectively. RESULTS The overall mortality was 36.5%; of that one quarter occurred during the index hospitalization. Mortality was higher in Group 1 (57.4%) compared with Groups 2-5 (46.9%, 38.3%, 36.1% and 31.2%, respectively, p=0.001). Cox regression analysis showed that poor glycemic control (Group 4 and 5) had lower risk of mortality post-LEA [hazard ratio 0.57 (95% CI 0.35-0.93) and hazard ratio 0.46 (95% CI 0.31-0.69)]; this mortality risk persisted even after adjustment for age and sex but was statistically insignificant. The rate of LEA was greater among poor glycemic control patients; however, the mortality was higher among patients with tight control. CONCLUSION The effects of HbA1c on the immediate and long-term LEA outcomes and its therapeutic implications need further investigation.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Vascular and Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | | | | | - Noora Al-Thani
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Vascular and Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Vascular and Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
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21
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Eren MA, Güneş AE, Kırhan İ, Sabuncu T. The role of the platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in the prediction of length and cost of hospital stay in patients with infected diabetic foot ulcers: A retrospective comparative study. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:127-131. [PMID: 32254026 DOI: 10.5152/j.aott.2020.02.518] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The aim of this study was to determine the role of new inflammatory markers, including the platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR), in the prediction of length and cost of hospital stay in patients with infected diabetic foot ulcers (DFUs). METHODS A total of 78 patients with DFUs who were admitted to our endocrinology clinic between January 2016 and July 2017 were included. Patients were then divided into three groups according to the Wagner DFU classification system: group 1: 18 patients with grade 2 DFU (11 men, 7 women; mean age = 57.5±7 years); group 2: 44 patients with grade 3 DFU (18 men, 26 women; mean age = 59.7±8.7 years); and group 3: 16 patients with grade 4 DFU (10 men, 6 women; mean age = 59.9±11.6 years). Laboratory findings were retrospectively obtained from hospital records; the PLR and NLR were calculated in all groups. Length and cost of hospital stay were recorded. Hospital costs were estimated in Turkish Lira (TL) based on the evaluation of glucose regulation, wound care, and antibiotic treatment. RESULTS The mean NLR was significantly lower in group 1 (2.8±0.9) than in group 2 (6.0±5.2; p=0.017) and group 3 (6.9±5.3; p=0.011). The mean PLR was significantly lower in group 1 (140.8±42.6) than in group 3 (222.1±95.5; p=0.006). The mean length of stay was 7.9±2.7 days in group 1, 15.0±8.9 days in group 2, and 12.5±8.9 days in group 3. The mean cost was 1,310.8±500 TL in group 1, 2,966.9±2105 TL in group 2, and 3,488.1±3603.1 TL in group 3. Length and cost of stay were both significantly lower in group 1 than in groups 2 and 3 (p=0.011 and p=0.002, respectively). Comparative results showed that the length and cost of hospital stay increased with increasing severity of DFUs. Furthermore, correlation analyses demonstrated no correlation of length of stay with PLR and NLR but an obvious correlation between cost of stay and PLR (r=0.412; p<0.001). Additionally, there was no correlation between cost of stay and NLR (r=0.158, p>0.05). CONCLUSION The PLR is inflammatory marker that can be measured by an inexpensive and easily accessible test and can aid in the prediction of length and cost of hospital stay in patients with DFUs. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Affiliation(s)
- Mehmet Ali Eren
- Department of Endocrinology, Harran University, School of Medicine, Şanlıurfa, Turkey
| | - Ali Erdal Güneş
- Department of Undersea and Hyperbaric Medicine, Harran University, School of Medicine, Şanlıurfa, Turkey
| | - İdris Kırhan
- Department of Internal Medicine, Harran University, School of Medicine, Şanlıurfa, Turkey
| | - Tevfik Sabuncu
- Department of Endocrinology, Harran University, School of Medicine, Şanlıurfa, Turkey
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22
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Ghobadi A, Ahmadi Sarbarzeh P, Jalilian M, Abdi A, Manouchehri S. Evaluation of Factors Affecting the Severity of Diabetic Foot Ulcer in Patients with Diabetes Referred to a Diabetes Centre in Kermanshah. Diabetes Metab Syndr Obes 2020; 13:693-703. [PMID: 32214832 PMCID: PMC7078779 DOI: 10.2147/dmso.s242431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Accepted: 03/02/2020] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Diabetes mellitus is a metabolic disease characterized by high blood sugar (BS) levels and the change in the metabolism of lipids, carbohydrates, and insulin resistance, and is one of the main causes of disability and mortality worldwide. Among the different types of complications, which have many negative effects on personal and social life, diabetic foot ulcer (DFU) is very important. This study aims to investigate the factors affecting the severity of DFU among patients with diabetes. METHODS The study participants included 190 diabetic patients with a diagnosis of DFU. Data were collected using a two-part questionnaire for self-care awareness and functions in diabetic patients and Wagner's scale. The questionnaire was answered in cooperation with patients and the Wagner's score was estimated by a wound supervisor in the diabetes center. RESULTS There was 109 women (57.4%). Twenty-six patients had other diabetic complications as well as DFU. The average score of awareness in patients was 6.99±2.76 and the function was 62.22±9.92. The results found a direct relation between the age and the duration of illness with the score of the patient's awareness (P=0.008, P=0.000). There was also a direct relation between the level of education with score of awareness and the score of function in self-care (P=0.000, P=0.000), but the statistical results did not find any relation between awareness and the function in self-care of patients with the severity of DFU (P>0.05). DISCUSSION There was no relation between the self-care awareness and function with severity of DFU (P>0.05) that can be due to the more relation between DFU severity with hygiene and physical factors after the disease and the effect of awareness and function would be only in the incidence of the DFU. CONCLUSION Awareness and function of patients in self-care is less than average. Increasing awareness of patients and empowering them through appropriate training can be effective in preventing diabetic foot ulcers.
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Affiliation(s)
- Akram Ghobadi
- Nursing Department, Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Pegah Ahmadi Sarbarzeh
- Nursing Department, Nursing and Midwifery School, Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
- Correspondence: Pegah Ahmadi Sarbarzeh Nursing Department, Nursing and Midwifery School, Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, IranTel +98 930 1946547 Email
| | - Milad Jalilian
- Nursing Department, Nursing and Midwifery School, Student Research Committee, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Alireza Abdi
- Nursing Department, Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Sara Manouchehri
- Biostatistics Department, Kermanshah University of Medical Sciences, Kermanshah, Iran
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23
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Aljarrah Q, Allouh MZ, Bakkar S, Aleshawi A, Obeidat H, Hijazi E, Al-Zoubi N, Alalem H, Mazahreh T. Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community. BMC Surg 2019; 19:170. [PMID: 31722699 PMCID: PMC6852935 DOI: 10.1186/s12893-019-0637-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Background We aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan. Methods Clinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon’s specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated. Results The study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA. Conclusions In developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.
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Affiliation(s)
- Qusai Aljarrah
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
| | - Mohammed Z Allouh
- Department of Anatomy, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.,Department of Anatomy, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, 17666, UAE
| | - Sohail Bakkar
- Department of Surgery, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa, 13133, Jordan
| | - Abdelwahab Aleshawi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Hasan Obeidat
- School of Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Emad Hijazi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Nabil Al-Zoubi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Heba Alalem
- Department of Surgery, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa, 13133, Jordan
| | - Tagleb Mazahreh
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
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24
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Ahn J, Raspovic KM, Liu GT, Lavery LA, La Fontaine J, Nakonezny PA, Wukich DK. Renal Function as a Predictor of Early Transmetatarsal Amputation Failure. Foot Ankle Spec 2019; 12:439-451. [PMID: 30537872 DOI: 10.1177/1938640018816371] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic kidney disease (CKD) is a major concern in patients with foot disease because it is associated with high rates of neuropathy, peripheral vascular disease, and poor wound healing. The purpose of this study was to evaluate renal dysfunction as a risk factor for reamputation after initial transmetatarsal amputation (TMA). Patients who underwent a TMA were retrospectively identified in the American College of Surgeons National Surgical Quality Improvement Program database. Of 2018 patients, reamputation after TMA occurred in 4.4%. End-stage renal disease (ESRD) was associated with 100% increased odds of TMA failure (adjusted odds ratio [OR] = 2.00; 95% CI = 1.10, 3.52), 128% increased odds of major amputation (adjusted OR = 2.28; 95% CI = 1.27, 3.96), and 182% increased odds of 30-day mortality (adjusted OR = 2.82; 95% CI = 1.69, 4.64). In addition, white blood cell count >10 000/mm3 and deep infection at the time of surgery were independently associated with TMA failure. In conclusion, severe renal dysfunction is associated with TMA failure in the short-term, perioperative period. There was no incremental increase in risk of TMA failure with worsening level of renal function before ESRD. A multidisciplinary approach should be implemented in patients with CKD to prevent foot-related pathologies that may necessitate lower-extremity amputation. Levels of Evidence: Level III: Retrospective cohort study.
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Affiliation(s)
- Junho Ahn
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katherine M Raspovic
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
| | - George T Liu
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lawrence A Lavery
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Javier La Fontaine
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Paul A Nakonezny
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
| | - Dane K Wukich
- Department of Orthopaedic Surgery (JA, KMR, GTL, DKW), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Plastic Surgery (LAL, JLF), University of Texas Southwestern Medical Center, Dallas, Texas.,Department of Clinical Science, Division of Biostatistics (PAN), University of Texas Southwestern Medical Center, Dallas, Texas
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25
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Sen P, Demirdal T, Emir B. Meta-analysis of risk factors for amputation in diabetic foot infections. Diabetes Metab Res Rev 2019; 35:e3165. [PMID: 30953392 DOI: 10.1002/dmrr.3165] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/20/2019] [Accepted: 03/31/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Knowledge of risk factors is crucial to develop management and treatment protocols for the prevention of lower extremity amputation for patients with diabetic foot infections (DFIs). METHODS We searched the research literature for studies reporting risk factors for lower extremity amputation in patients with DFI. The main outcome variables included both minor and major amputations. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and the protocol was registered in PROSPERO (CRD42018118543). RESULTS A total of 2471 potential articles from the database search met the inclusion criteria. After reviewing the titles, abstracts, and full texts, remaining 25 articles were included in the final analysis. We identified 6132 patients with DFI in the 25 included articles. Of these, 1873 patients who underwent amputation were investigated. Male gender (odds ratio [OR]: 1.31), smoking (OR: 1.38), history of amputation (OR: 1.47), history of osteomyelitis (OR: 1.94), peripheral arterial disease (OR: 2.35), retinopathy (OR: 1.32), International Working Group on the Diabetic Foot (IWGDF) grades 3 and 4 (OR: 1.7 and 2.5), Wagner grades 4 and 5 (OR: 4.3 and 6.4), gangrene/necrosis (OR: 9.9), osteomyelitis (OR: 4.5), neuroischaemic DFI (OR: 3.06), severe infection (OR: 3.12), length of hospitalization (standardized mean difference [SMD]: 0.7), leukocytosis (OR: 1.76), mean erythrocyte sedimentation rate (ESR) (SMD: 0.5), mean C-reactive protein (CRP) (SMD: 0.8), tissue culture positivity (OR: 1.61), and isolation of Gram-negative bacteria from tissue culture (OR: 1.5) were found as predictors of amputation in DFI. CONCLUSIONS The present study highlighted some differences in diabetic foot ulcers and DFIs in terms of risk factors for lower extremity amputation. These data provide detailed information about risk factors for amputations among patients with DFI, thus contributing to the creation of new classification systems for assessment of high-risk patients.
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Affiliation(s)
- Pinar Sen
- Department of Infectious Diseases and Clinical Microbiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Tuna Demirdal
- Department of Infectious Diseases and Clinical Microbiology, Izmir Katip Celebi University Ataturk Training and Research Hospital, Izmir, Turkey
| | - Busra Emir
- Department of Biostatistics, Izmir Katip Celebi University School of Medicine, Izmir, Turkey
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26
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MacDonald A, Brodell JD, Daiss JL, Schwarz EM, Oh I. Evidence of differential microbiomes in healing versus non-healing diabetic foot ulcers prior to and following foot salvage therapy. J Orthop Res 2019; 37:1596-1603. [PMID: 30908702 PMCID: PMC6659747 DOI: 10.1002/jor.24279] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 02/25/2019] [Indexed: 02/04/2023]
Abstract
Diabetic foot ulcers (DFU) contribute to 80% of lower extremity amputations. Although physicians currently rely on clinical signs along with non-specific biomarkers of infection, such as erythrocyte sedimentation rate and C-reactive protein, to diagnose and monitor DFU, there is no specific and sensitive measure available to monitor or prognosticate the success of foot salvage therapy (FST). To address this we performed a prospective, observational microbiome analysis to test the hypotheses that: (i) the initial microbiomes of healed versus non-healed DFU are distinct; (ii) the microbial load, diversity and presence of pathogenic organism of the DFU change in response to antibiotics treatment; and (iii) the changes in the DFU microbiome during treatment are prognostic of clinical outcome. To test this, microbiome analyses were performed on 23 DFU patients undergoing FST, in which wound samples were collected at zero, four, and eight weeks following wound debridement and antibiotics treatment. Bacterial abundance was determined using quantitative polymerase chain reaction (qPCR). Eleven patients healed their DFU, while FDT failed to heal DFU in the other 12 patients. Microbiome results demonstrated that healing DFUs had a larger abundance Actinomycetales and Staphylococcaceae (p < 0.05), while DFUs that did not heal had a higher abundance of Bacteroidales and Streptococcaceae (p < 0.05). FST marked increases Actinomycetales in DFU, and this increase is significantly greater in patients that healed (p < 0.05). Future studies to confirm the differential microbiomes, and that increasing Actinomycetales is prognostic of successful FST are warranted. Statement of Clinical Significance: Tracking changes in the prevalence of pathogens in diabetic foot ulcers may be a clinical tool for monitoring treatment response to foot salvage therapy and prognosticating the need for further surgical intervention. The initial wound sample microbiome may provide important prognostic information on the eventual clinical outcome of foot salvage therapy. It may serve as an important clinical tool for patient counseling and making surgical decision of pursuing foot salvage versus amputation. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1596-1603, 2019.
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Affiliation(s)
- Ashlee MacDonald
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center
| | - James D. Brodell
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center
| | - John L. Daiss
- Center for Musculoskeletal Research, University of Rochester Medical Center
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center
| | - Irvin Oh
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center
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27
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Ugwu E, Adeleye O, Gezawa I, Okpe I, Enamino M, Ezeani I. Predictors of lower extremity amputation in patients with diabetic foot ulcer: findings from MEDFUN, a multi-center observational study. J Foot Ankle Res 2019; 12:34. [PMID: 31223342 PMCID: PMC6570910 DOI: 10.1186/s13047-019-0345-y] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 06/04/2019] [Indexed: 12/19/2022] Open
Abstract
Background Lower extremity amputation (LEA) is a potential sequelae of diabetic foot ulceration (DFU) and is associated with huge morbidly and mortality. Low and middle income countries are currently at the greatest risk of diabetes-related complications and deaths. We sought to identify demographic, clinical and laboratory variables that significantly predict LEA in patients hospitalized for DFU. Methods The Multi-center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study conducted between March 2016 and April 2017 in six tertiary healthcare institutions. We prospectively followed 336 diabetic patients hospitalized for DFU and managed by a multidisciplinary team until discharge or death. Demographic and diabetes-related information and ulcer characteristics were documented. Patients were evaluated for neuropathy, peripheral arterial disease (PAD) and medical co-morbidities while relevant laboratory and imaging tests were performed. The study end-points were ulcer healing, LEA, duration of hospitalization and mortality. Here we present data on amputation. Results One hundred and nineteen subjects (35.4%) underwent LEA during the follow-up period. Univariate predictors of LEA were ulcer duration more than 1 month prior to hospitalization (P < 0.001), PAD (P < 0.001), Wagner grade ≥ 4 (P < 0.001), wound infection (P 0.041), Proteinuria (P 0.021), leucocytosis (P 0.001) and osteomyelitis (P < 0.001). On multivariate regression, only three variables emerged as significant independent predictors of LEA and these include: ulcer duration more than 1 month (O.R. 10.3, 95% C.I. 4.055–26.132), PAD (O.R. 2.8, 95% C.I. 1.520–5.110) and presence of osteomyelitis (O.R. 5.6, 95% C.I. 2.930–10.776). Age, gender, diabetes type and duration, neuropathy, glycemic control and anemia did not predict LEA in the studied population. Conclusion We identified duration of ulcer greater than 1 month, PAD, Wagner grade 4 or higher, proteinuria, leucocytosis, wound infection and osteomyelitis as the significant predictors of LEA in patients hospitalized for DFU. Prompt attention to these risk factors may reduce amputation rate among these patients.
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Affiliation(s)
- Ejiofor Ugwu
- 1Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Enugu State University of Science and Technology, Enugu, Nigeria
| | - Olufunmilayo Adeleye
- 2Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Lagos State University, Lagos, Nigeria
| | - Ibrahim Gezawa
- 3Department of Medicine, Division of endocrinology, Diabetes and Metabolism, Bayero University, Kano, Nigeria
| | - Innocent Okpe
- 4Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Ahmadu Bello University, Zaria, Nigeria
| | - Marcelina Enamino
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Federal Medical Center, Keffi, Nigeria
| | - Ignatius Ezeani
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Federal Medical Center, Umuahia, Nigeria
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28
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Chin YF, Huang TT, Hsu BRS, Weng LC, Wang CC. Factors associated with foot ulcer self-management behaviours among hospitalised patients with diabetes. J Clin Nurs 2019; 28:2253-2264. [PMID: 30791155 DOI: 10.1111/jocn.14822] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 01/22/2019] [Accepted: 02/09/2019] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES To determine prehospitalised diabetes-related foot ulcer (DFU) self-management behaviours and explore the factors associated with these behaviours. BACKGROUND Although there are many studies that explore DFU prevention and treatment, to our knowledge, there are no quantitative studies of DFU self-management behaviours. DESIGN Cross-sectional design. METHODS From June 2015-June 2016, 199 hospitalised patients with DFU were given a survey questionnaire at a medical centre in northern Taiwan. DFU self-management behaviours, diabetes foot self-care behaviours, beliefs in regard to barriers to DFU self-management behaviours, and knowledge regarding warning signs of DFU deterioration were assessed by well-designed measurement tools. The Strengthening the Reporting of Observational Studies in Epidemiology checklist was used to ensure quality reporting during this observational study (see Supporting Information Appendix S1). RESULTS The results revealed that 62.8% of participants never monitored their blood glucose level when they had foot ulcers, and 63.8% never sought treatment for their wounds when their wounds were not painful. After controlling for demographic and medical variables, stepwise multiple regression analysis revealed that the following eight significant variables were associated with DFU self-management behaviours: two DFU self-management barrier beliefs, foot self-care behaviour, no treatment for diabetes, poor financial status, employment, knowledge regarding the warning signs of DFU deterioration, and number of DFU hospitalisations. CONCLUSIONS Diabetes-related foot ulcer self-management behaviours were insufficient. Some modifiable factors and high-risk groups for insufficient DFU self-management behaviour were identified. RELEVANCE TO CLINICAL PRACTICE Diabetes-related foot ulcer self-management behaviours should be promoted. Interventions that modify the risk factors that were identified in this study can be designed to promote the performance of DFU self-management behaviours.
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Affiliation(s)
- Yen-Fan Chin
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Tzu-Ting Huang
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Healthy Aging Research Center, College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Brend Ray-Sea Hsu
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Li-Chueh Weng
- School of Nursing, College of Medicine, Chang Gung University, Taoyuan City, Taiwan.,Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Chih-Ching Wang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
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Tracking Anti- Staphylococcus aureus Antibodies Produced In Vivo and Ex Vivo during Foot Salvage Therapy for Diabetic Foot Infections Reveals Prognostic Insights and Evidence of Diversified Humoral Immunity. Infect Immun 2018; 86:IAI.00629-18. [PMID: 30275008 DOI: 10.1128/iai.00629-18] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Accepted: 09/20/2018] [Indexed: 12/18/2022] Open
Abstract
Management of foot salvage therapy (FST) for diabetic foot infections (DFI) is challenging due to the absence of reliable diagnostics to identify the etiologic agent and prognostics to justify aggressive treatments. As Staphylococcus aureus is the most common pathogen associated with DFI, we aimed to develop a multiplex immunoassay of IgG in serum and medium enriched for newly synthesized anti-S. aureus antibodies (MENSA) generated from cultured peripheral blood mononuclear cells of DFI patients undergoing FST. Wound samples were collected from 26 DFI patients to identify the infecting bacterial species via 16S rRNA sequencing. Blood was obtained over 12 weeks of FST to assess anti-S. aureus IgG levels in sera and MENSA. The results showed that 17 out of 26 infections were polymicrobial and 12 were positive for S. aureus While antibody titers in serum and MENSA displayed similar diagnostic potentials to detect S. aureus infection, MENSA showed a 2-fold-greater signal-to-background ratio. Multivariate analyses revealed increases in predictive power of diagnosing S. aureus infections (area under the receiver operating characteristic curve [AUC] > 0.85) only when combining titers against different classes of antigens, suggesting cross-functional antigenic diversity. Anti-S. aureus IgG levels in MENSA decreased with successful FST and rose with reinfection. In contrast, IgG levels in serum remained unchanged throughout the 12-week FST. Collectively, these results demonstrate the applicability of serum and MENSA for diagnosis of S. aureus DFI with increased power by combining functionally distinct titers. We also found that tracking MENSA has prognostic potential to guide clinical decisions during FST.
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30
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Fesseha BK, Abularrage CJ, Hines KF, Sherman R, Frost P, Langan S, Canner J, Likes KC, Hosseini SM, Jack G, Hicks CW, Yalamanchi S, Mathioudakis N. Association of Hemoglobin A 1c and Wound Healing in Diabetic Foot Ulcers. Diabetes Care 2018; 41:1478-1485. [PMID: 29661917 PMCID: PMC6014539 DOI: 10.2337/dc17-1683] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 03/26/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This study evaluated the association between hemoglobin A1c (A1C) and wound outcomes in patients with diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS We conducted a retrospective analysis of an ongoing prospective, clinic-based study of patients with DFUs treated at an academic institution during a 4.7-year period. Data from 270 participants and 584 wounds were included in the analysis. Cox proportional hazards regression was used to assess the incidence of wound healing at any follow-up time in relation to categories of baseline A1C and the incidence of long-term (≥90 days) wound healing in relation to tertiles of nadir A1C change and mean A1C change from baseline, adjusted for potential confounders. RESULTS Baseline A1C was not associated with wound healing in univariate or fully adjusted models. Compared with a nadir A1C change from baseline of -0.29 to 0.0 (tertile 2), a nadir A1C change of 0.09 to 2.4 (tertile 3) was positively associated with long-term wound healing in the subset of participants with baseline A1C <7.5% (hazard ratio [HR] 2.07; 95% CI 1.08-4.00), but no association with wound healing was seen with the mean A1C change from baseline in this group. Neither nadir A1C change nor mean A1C change were associated with long-term wound healing in participants with baseline A1C ≥7.5%. CONCLUSIONS There does not appear to be a clinically meaningful association between baseline or prospective A1C and wound healing in patients with DFUs. The paradoxical finding of accelerated wound healing and increase in A1C in participants with better baseline glycemic control requires confirmation in further studies.
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Affiliation(s)
- Betiel K Fesseha
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathryn F Hines
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Ronald Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Priscilla Frost
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Susan Langan
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Joseph Canner
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kendall C Likes
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Sayed M Hosseini
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Gwendolyne Jack
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Swaytha Yalamanchi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University, Baltimore, MD
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31
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Abstract
Diabetes is associated with various complications and reduced quality of life. Of the many complications, some are life-threatening. Among these, foot complications remain an important concern. The major foot complications include foot ulceration, cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis, with different pathophysiological concepts behind each of them. Gangrene occurs due to reduced blood supply in the body tissues that leads to necrosis. This condition may arise because of an injury, infection, or other health conditions, majorly diabetes. Gangrene is classified as dry, wet, and gas gangrene. In case of wet and gas gangrene, surgical amputation is usually performed to prevent the spread of infection to other tissues. In dry gangrene, due to the presence of clear demarcation, autoamputation is preferred in certain parts of the globe. The present review aims to analyze the mode of dry gangrene management in diabetic patients based on previous evidence and plans to highlight various management strategies available for dry gangrene and the advantages/disadvantages of different treatments with special consideration to autoamputation.
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Affiliation(s)
- Abdullah Al Wahbi
- Division of Vascular Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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33
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Kim JL, Shin JY, Roh SG, Chang SC, Lee NH. Predictive Laboratory Findings of Lower Extremity Amputation in Diabetic Patients: Meta-analysis. INT J LOW EXTR WOUND 2017; 16:260-268. [PMID: 29141468 DOI: 10.1177/1534734617737660] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Lower extremity amputation is a source of morbidity and mortality among diabetic patients. This meta-analysis aimed to identify significant laboratory data in patients with diabetic foot ulcer with high rates of lower extremity amputation. We performed a systematic literature review and meta-analysis using MEDLINE, EMBASE, and Cochrane databases. We extracted and evaluated 11 variables from the included studies based on amputation rates. This study used the Newcastle-Ottawa Scale to assess the quality of the studies. The search strategy identified 101 publications from which we selected 16 articles for review. We identified HbA1c, fasting blood glucose, white blood cells, C-reactive protein, and erythrocyte sedimentation rate as predictive variables of higher major amputation rate. Although further investigation of long-term and prospective studies is needed, we identified 5 variables as predisposing factors for higher major amputation in diabetic patients through meta-analysis.
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Affiliation(s)
- Jong-Lim Kim
- 1 Medical School of Chonbuk National University, Jeonju, Republic of Korea.,2 Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Jin Yong Shin
- 1 Medical School of Chonbuk National University, Jeonju, Republic of Korea.,2 Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Si-Gyun Roh
- 1 Medical School of Chonbuk National University, Jeonju, Republic of Korea.,2 Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea.,3 Mayo Clinic, Rochester, MN, USA
| | - Suk Choo Chang
- 1 Medical School of Chonbuk National University, Jeonju, Republic of Korea.,2 Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Nae-Ho Lee
- 1 Medical School of Chonbuk National University, Jeonju, Republic of Korea.,2 Research Institute of Clinical Medicine of Chonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
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34
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Cervantes-García E, Salazar-Schettino PM. Clinical and surgical characteristics of infected diabetic foot ulcers in a tertiary hospital of Mexico. Diabet Foot Ankle 2017; 8:1367210. [PMID: 28904744 PMCID: PMC5590539 DOI: 10.1080/2000625x.2017.1367210] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/04/2017] [Indexed: 05/15/2023]
Abstract
Background: The objective of this study was to determine the clinical and surgical characteristics of diabetic foot ulcers in a tertiary level hospital in Mexico. Methods: We performed a longitudinal, descriptive study from July, 2012 to August, 2015 on a sample composed of 100 patients with type 2 diabetes mellitus and infected diabetic foot ulcers. We analyzed socio-demographic variables, comorbidities, characteristics of ulcers, and the applied treatment. Results: We found that the most affected areas were the forefoot (48%) and the plantar region (55%) of the foot. Also, most of the patients arrived with advanced stages of diabetic foot ulcers, since 93% of the lesions were of grades III-V according to the Wagner classification. Moreover, lesions usually present with advanced states of infection, since 60% of the lesions were of grades 3-4 in the PEDIS scale. In addition, the great majority of the patients are prone to complications because we found that 43% of the patients suffered from hypertension, 47% of the patients had chronic kidney disease, and 45% reported smoking. In fact, 45% of the patients eventually suffered an amputation. We also found that the situation is more difficult because the great majority of the patients (96%) have a low level of education and very low income and they do not have any health insurance. Nevertheless, we also found that an efficient treatment can help in avoiding amputations, since 53% of grade IV and 25% of grade V lesions according to the Wagner system did not suffer an amputation. Conclusions: Therefore, an effective antibiotic treatment and an education of the patient on the adequate care of their lesions are essential in increasing the welfare of patients, especially when they have a low level of education.
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35
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Shin JY, Roh SG, Lee NH, Yang KM. Influence of Epidemiologic and Patient Behavior–Related Predictors on Amputation Rates in Diabetic Patients. INT J LOW EXTR WOUND 2017; 16:14-22. [DOI: 10.1177/1534734617699318] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Amputation of patients with diabetic foot is a major issue worldwide, particularly from a medical and economic standpoint. This meta-analysis aimed to identify significant risk factors of high amputation rate among epidemiologic and patient behavior–related predictors in diabetic patients. A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. Seven variables were extracted from the included studies and evaluated based on amputation rate. The Newcastle-Ottawa scale was used to assess the quality of the studies. The search strategy identified 101 publications. After screening, 33 articles were selected for review. Male sex and smoking were identified as significant risk factors of high amputation rate of diabetic foot. Although further investigation of long-term and randomized controlled studies is needed, we identified 2 variables as significant risk factors for high amputation rate in diabetic patients in this meta-analysis.
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Affiliation(s)
- Jin Yong Shin
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Si-Gyun Roh
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Nae-Ho Lee
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Kyung-Moo Yang
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
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36
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Abstract
The rising prevalence of diabetes estimated at 3.6 million people in the UK represents a major public health and socioeconomic burden to our National Health Service. Diabetes and its associated complications are of a growing concern. Diabetes-related foot complications have been identified as the single most common cause of morbidity among diabetic patients. The complicating factor of underlying peripheral vascular disease renders the majority of diabetic foot ulcers asymptomatic until latter evidence of non-healing ulcers become evident. Therefore, preventative strategies including annual diabetic foot screening and diabetic foot care interventions facilitated through a multidisciplinary team have been implemented to enable early identification of diabetic patients at high risk of diabetic foot complications. The National Diabetes Foot Care Audit reported significant variability and deficiencies of care throughout England and Wales, with emphasis on change in the structure of healthcare provision and commissioning, improvement of patient education and availability of healthcare access, and emphasis on preventative strategies to reduce morbidities and mortality of this debilitating disease. This review article aims to summarise major risk factors contributing to the development of diabetic foot ulcers. It also considers the key evidence-based strategies towards preventing diabetic foot ulcer. We discuss tools used in risk stratification and classifications of foot ulcer.
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Affiliation(s)
| | | | - Cecil Thomas
- 1 Diabetes Centre, Aintree University Hospital, Liverpool L9 7AL, UK
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37
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Oksuz E, Malhan S, Sonmez B, Numanoglu Tekin R. Cost of illness among patients with diabetic foot ulcer in Turkey. World J Diabetes 2016; 7:462-469. [PMID: 27795820 PMCID: PMC5065666 DOI: 10.4239/wjd.v7.i18.462] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 07/25/2016] [Accepted: 08/29/2016] [Indexed: 02/05/2023] Open
Abstract
AIM To evaluate the annual cost of patients with Wagner grade 3-4-5 diabetic foot ulcer (DFU) from the public payer’s perspective in Turkey.
METHODS This study was conducted focused on a time frame of one year from the public payer’s perspective. Cost-of-illness (COI) methodology, which was developed by the World Health Organization, was used in the generation of cost data. By following a clinical path with the COI method, the main total expenses were reached by multiplying the number of uses of each expense item, the percentage of cases that used them and unit costs. Clinical guidelines and real data specific to Turkey were used in the calculation of the direct costs. Monte Carlo Simulation was used in the study as a sensitivity analysis.
RESULTS The following were calculated in DFU treatment from the public payer’s perspective: The annual average per patient outpatient costs $579.5 (4.1%), imaging test costs $283.2 (2.0%), laboratory test costs $284.8 (2.0%), annual average per patient cost of intervention, rehabilitation and trainings $2291.7 (16.0%), annual average per patient cost of drugs used $2545.8 (17.8%) and annual average per patient cost of medical materials used in DFU treatment $735.0 (5.1%). The average annual per patient cost for hospital admission is $7357.4 (51.5%). The average per patient complication cost for DFU is $210.3 (1.5%). The average annual per patient cost of DFU treatment in Turkey is $14287.70. As a result of the sensitivity analysis, the standard deviation of the analysis was $5706.60 (n = 5000, mean = $14146.8, 95%CI: $13988.6-$14304.9).
CONCLUSION The health expenses per person are $-PPP 1045 in 2014 in Turkey and the average annual per patient cost for DFU is 14-fold of said amount. The total health expense in 2014 in Turkey is $-PPP 80.3 billion and the total DFU cost has a 3% share in the total annual health expenses for Turkey. Hospital costs are the highest component in DFU disease costs. In order to prevent DFU, training of the patients at risk and raising consciousness in patients with diabetes mellitus (DM) will provide benefits in terms of economy. Appropriate and efficient treatment of DM is a health intervention that can prevent complications.
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38
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The analysis of the cost and amputation rates of hospitalized diabetic foot infection patients. Int J Diabetes Dev Ctries 2016. [DOI: 10.1007/s13410-016-0524-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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39
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Egan AM, Dinneen SF. In-hospital metabolic regulation in patients with a diabetic foot ulcer: is it worthwhile? Diabetes Metab Res Rev 2016; 32 Suppl 1:297-302. [PMID: 26453180 DOI: 10.1002/dmrr.2741] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Revised: 07/15/2015] [Accepted: 09/20/2015] [Indexed: 01/08/2023]
Abstract
It is well established that hyperglycaemia is associated with many negative cardiovascular and immunological effects. Because of the high prevalence of underlying vascular disease along with associated infection, patients with diabetic foot ulcers are especially vulnerable to these adverse consequences. While studies consistently demonstrate worse outcomes in the setting of hyperglycaemia during hospitalization, multiple trials examining the effects of intensive glycaemic control reveal mixed results. In particular, effects on mortality are varied, and although there may be some benefit in the setting of infection, hypoglycaemia is a concern when glucose levels are treated down to the normoglycaemic range. Therefore, although metabolic regulation is worthwhile theoretically, the optimal intensity of control is unclear. There is a need for future research to clarify the benefits and risks associated with strict metabolic control in patients with diabetic foot ulceration. In the interim recommendations from international guidelines should be followed; these advise pre-meal glucose targets of <7.8 mmol/L and random targets of <10.0 mmol/L in general medical and surgical settings.
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Affiliation(s)
- Aoife M Egan
- Galway University Hospitals and National University of Ireland Galway, Galway, Ireland
| | - Sean F Dinneen
- Galway University Hospitals and National University of Ireland Galway, Galway, Ireland
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40
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Li XH, Guan LY, Lin HY, Wang SH, Cao YQ, Jiang XY, Wang YB. Fibrinogen: A Marker in Predicting Diabetic Foot Ulcer Severity. J Diabetes Res 2016; 2016:2358321. [PMID: 28044140 PMCID: PMC5156809 DOI: 10.1155/2016/2358321] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 11/10/2016] [Indexed: 11/17/2022] Open
Abstract
Aims. To examine whether fibrinogen levels are a valuable biomarker for assessing disease severity and monitoring disease progression in patients with diabetic foot ulcer (DFU). Methods. A retrospective study was designed to examine the utility of fibrinogen in estimating disease severity in patients with DFU admitted to our hospital between January 2015 and January 2016. In total, 152 patients with DFU were enrolled in the study group, and 52 age and gender matched people with diabetes but no DFU were included as the control group. DFU severity was assessed using Wagner criteria. Results. Patients with DFU were divided into 2 subgroups based on the Wagner criteria. Mean fibrinogen values were significantly higher in patients with DFU grade ≧ 3 compared to those with DFU grades 1-2 (5.23 ± 1.37 g/L versus 3.61 ± 1.04 g/L). Using ROC statistic, a cut-off value of 5.13 g/L indicated the possible amputation with a sensitivity of 81.8% and a specificity of 78.9% (positive predictive value [PPV] 78.6%, negative predictive value [89.0%]). Fibrinogen values were found to be correlated with CRP levels, neutrophil, and WBC count. Conclusions. Fibrinogen levels might be a valuable tool for assessing the disease severity and monitoring the disease progression in patients with DFU.
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Affiliation(s)
- X. H. Li
- Health Management Center, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - L. Y. Guan
- Health Management Center, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - H. Y. Lin
- Health Management Center, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - S. H. Wang
- Health Management Center, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - Y. Q. Cao
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - X. Y. Jiang
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
| | - Y. B. Wang
- Department of Burn and Plastic Surgery, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021, China
- *Y. B. Wang:
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41
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Zhou ZY, Liu YK, Chen HL, Yang HL, Liu F. HbA1c and Lower Extremity Amputation Risk in Patients With Diabetes. INT J LOW EXTR WOUND 2015; 14:168-77. [PMID: 26130760 DOI: 10.1177/1534734615593190] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In this meta-analysis, we aimed to assess glycosylated hemoglobin (HbA1c) level and lower extremity amputation (LEA) risk in patients with diabetes. Systematic computerized searches of the PubMed and Web of Knowledge were performed. We compared HbA1c level between groups with LEA and without LEA by meta-analysis; we also examined the dose–response relationship between HbA1c level and LEA risk. Sixteen studies were included in the meta-analysis. Eleven studies with 43 566 patients compared HbA1c between groups with and without LEA. The mean HbA1c (%) ranged from 8.3 to 12.5 in the group with LEA and from 7.4 to 11.3 in the group without LEA. The pooled weighted mean difference was 1.110 (95% confidence interval = 0.510-1.709; Z = 3.63, P = .008). The funnel plot was symmetrical, and Begg’s test ( z = 0.00, P = 1.000) and Egger’s test ( t = −0.02, P = .984) suggested no significant publication bias. Six studies with 109 933 patients included in the dose–response meta-analysis. The LEA incidence ranged from 0.3% to 14.6% between different HbA1c levels. Dose–response meta-analysis showed statistically significant association between HbA1c and LEA risk (χ2 = 65.51, P = .000). In linear model, the odds ratio for LEA incidence was 1.229 (95% confidence interval = 1.169-1.292) for every 1% HbA1c increase. In the spline model, the odds ratio of LEA risk increased with HbA1c levels, especially when HbA1c ranged from 5% to 9%. Our meta-analysis indicates that high level of HbA1c is an important risk factor for LEA in patients with diabetes. This evidence supports the strategy for lowering glucose levels to reduce amputation in patients with diabetes.
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Affiliation(s)
- Zhen-Yu Zhou
- First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
- Affiliated Hospital of Nantong University, Nantong, Jiangsu, PR China
| | - Ya-Ke Liu
- Affiliated Hospital of Nantong University, Nantong, Jiangsu, PR China
| | | | - Hui-Lin Yang
- First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, PR China
| | - Fan Liu
- Affiliated Hospital of Nantong University, Nantong, Jiangsu, PR China
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