Five-year outcomes of patients attending a diabetic foot clinic in a tertiary referral centre

Diabetic foot ulcer is associated with cardiovascular-related mortality and morbidity - a systematic review and meta-analysis of 8062 patients

OBJECTIVES

To conduct a systematic review and meta-analysis of prevalence of cardiovascular-related morbidity and mortality in patients with diabetic foot ulcers (DFU), as well as compare risks of cardiovascular-related morbidity and mortality between diabetic patients with and without DFU.

METHODS

A systematic search was conducted on Medline, Embase, and Cochrane databases for randomized controlled trials and observational studies which explored the association between DFU and cardiovascular-related morbidity & mortality, or compared differences in hazard ratios of cardiovascular diseases between diabetics with and without DFU. Frequentist, pairwise meta-analysis was performed on studies with two comparator arms, whereas single-arm studies reporting pooled incidences of cardiovascular-related mortality and morbidity were calculated based on exact binomial distributions. A random-effect meta-analysis model was used with heterogenicity of studies assessed using I2, τ2, and χ2 statistics.

RESULTS

10 studies were identified and included in the systematic review & meta-analysis of 8602 patients. DFU was consistently found to have significant association with cardiovascular-related morbidity and mortality, with pooled prevalences of all cause cardiovascular-related morbidity (37.1%), IHD (44.7%), CHF (25.1%), CAD (11.7%), and CVA (10.9%), and all cause cardiovascular-related mortality (14.6%), fatal IHD (6.2%), fatal CHF (3.67%), fatal CAD (7.92%), and fatal CVA (1.99%). Diabetic patients with DFU were found to have significantly increased risk of IHD (RR 1.25), CVA (RR 2.03), and all-cause cardiovascular-related mortality (RR 2.59) compared to those without DFU.

CONCLUSIONS

The presence of DFU is associated with major adverse cardiac events. The alarming rates of cardiovascular-related morbidity and mortality in DFU patients highlight its potential role as a marker of cardiovascular complications and should prompt early clinical investigation and management.

Development of a coordinated acute diabetic foot pathway for management of acute diabetic foot infection and ulceration

BACKGROUND

Diabetic foot ulceration (DFU) has become an increasingly common emergency presentation. These patients are presenting at a younger age and with increasingly complex co-morbidities. They require frequent hospitalisation for management of DFU which has significant consequences for management of health resources but also for quality of life in the diabetic patient population.

AIM

The aim of this study was to evaluate the impact of the development of a coordinated, streamlined acute diabetic foot pathway for management of in-patients presenting as emergencies with DFU on length of stay, re-admission to hospital and minor and major amputations.

METHODS

A dedicated acute diabetic foot pathway was introduced to St. Vincent's University Hospital (SVUH) in April 2016. Management of patients admitted urgently to the emergency department or out-patient clinics of St. Vincent's University Hospital during the 3-year period before April 2016 was compared to that of patients admitted in the 3 years after April 2016 following introduction of the acute diabetic foot pathway. Demographic data hospital length of stay, need for re-admission, major and minor amputations performed and cost of hospital stay were compared before and after introduction of the pathway.

RESULTS

There were 931 admissions with acute diabetic foot ulceration or infection between January 2012 and December 2019; 419 were admitted between January 2012 and March 2016 and 512 between April 2016 and December 2019. There was no difference in demographic data between the two time periods. Length of stay decreased from 13 +/- 4.24 to 3 +/- 1.41 days between the two time periods (p < 0.001). Re-admission rates within 30 days decreased from 21.7 to 10.1% (p < 0.05). The number of major lower limb amputations decreased over the two time periods from 8.8 to 7.2% with a concomitant increase in minor amputations from 16.7 to 25.3%. Risk of major lower limb amputation was significantly higher in those patients living more than 20 km from the hospital. Costs associated with in-patient stay for management of DFU decreased from €9,247,700 to €8,988,100 despite an 18% increase in the number of patients treated and a 9.9% increase in hospital admissions.

CONCLUSION

Introduction of a dedicated, streamlined pathway involving multi-disciplinary input resulted in a significant improvement in patient management as assessed by length of hospital stay and need for re-admission. While the number of major lower limb amputations has decreased there has been a significant increase in the number of minor amputations.

Semi-Solid Product of Medicinal Leech Enhances Wound Healing in Rats

Background: Wound causes a series of cascading reactions such as cellular damage, inflammatory reactions, and infection. Objectives: The present study aimed to prepare pharmaceutical skin product from lyophilized Hirudo orientalis leech source with active enzyme and proteins, having wound healing and anti-coagulation activities. Methods: The present study focused on the bioactive protein of Hirudo orientalis with anti-trypsin and anti-coagulation activity. First, biological active substance was prepared from lyophilized leech conducted on resultant 5% leech cream. Skin absorption of 5% leech cream was evaluated by Franz cell test, and in vivo wound healing capability of the leech cream was compared with phenytoin cream. In addition, the microbial control of final product was summed-up. Further, the quality control analysis and protein purification in final product were conducted using elution procedure on Hirudin protein-related region. Finally, the anticoagulant activity of the resultant protein was observed. Results: Using the result of the experiments investigating the successful effect containment function of the trypsin, we established the decreased rate of UV absorption in the area of 410 nm in question based on increases in the amount of cream. With 0, 100, 200 and 300 mg of 5% leech cream, absorbance (A) rate was: A (1.9, 1.47, 0.753 and 0.00) (P < 0.05; √2 = 21.6). In anticoagulation activity increased rate of partial thromboplastin time (PTT) (sec) (mean ± SEM), (26 ± 0.00, 34.22 ± 0.61 and 42 ± 0.71) with the 0, 100, and 200 mg final product was established. No bacterial colony growth was observed in the microbial culture analysis. In vivo results demonstrated that leech cream and phenytoin could promote wound regeneration by accelerating the re-epithelialization process and initial angiogenesis among all treatment groups. Conclusions: In the wound healing, we usually seek to reduce pain and inflammation, beside epitelialization and angiogenesis. Leech saliva contains biological substances that we have proven in this study. Our expectations for wound healing will be met with this pharmaceutical product citing the result of this study. The leech product proved to be the best selection for cosmetic with the added capabilities of renovation of the hair glands and regular skin form and typical depth of outer layer of skin. Thus, the leech cream can be considered as a better substitute for the conventional wound healing products.

Re-amputation and survival following toe amputation: outcome data from a tertiary referral centre

PURPOSE

Toe amputation is a commonly performed procedure for irreversible foot sepsis. However, outcome and predictors of outcome are poorly understood. Our aim was to determine survival and rate of progression to further amputation following index toe amputation.

METHODS

Consecutive patients between 2010 and 2015 were included. Progression to further minor amputation, major amputation or death was recorded. Multivariable Cox regression analyses were undertaken to determine independent predictors of outcome and survival.

RESULTS

One hundred forty-six patients were included, with mean age of 65 years. Fifty-five (37.7%) patients underwent hallux amputation, while 91 (62.3%) underwent amputation of non-hallux digit(s). Following index toe amputation, 63 (43.2%) patients progressed to further minor or major ipsilateral amputation, median time to which was 36 months. Twenty-one patients (14.4%) progressed to major ipsilateral amputation. Patients undergoing index non-hallux amputation were significantly more likely to require further minor amputation (P = 0.050); however, the rate of major amputation between hallux (14.5%) and non-hallux (14.3%) groups was similar. Overall, 5-year ipsilateral amputation-free (iAFS) was 39.6 ± 4.1%, ipsilateral major amputation-free (iMAFS) was 55.9 ± 4.1% and overall survival (OS) was 64.3 ± 4.0% and did not differ between index amputation sites.

CONCLUSION

Almost half of patients undergoing toe amputation required further digital amputation. However, limb preservation rates are high, and a majority of patients are alive at 5-year follow-up. There was no significant difference in outcome between patients undergoing hallux and non-hallux primary procedures. Overall, increasing age remains the only independent predictor of iMAFS and OS.

Trends and outcomes of non-traumatic major lower extremity amputations in an Irish tertiary referral hospital

OBJECTIVES

Data on vascular patients following amputation in Ireland is lacking, limiting capability to plan services. This paper seeks to benchmark survival and rehabilitation outcomes among vascular patients in Ireland following lower extremity amputation (LEA), and compare subgroups of those undergoing transfemoral (TFA) or transtibial amputation (TTA).

METHODS

A review was conducted of all patients who underwent non-traumatic TFA or TTA from 2000 to 2009 in a tertiary vascular surgery centre. Demographics, surgical data, perioperative outcomes, medium-term functional outcomes, and survival were assessed.

RESULTS

One hundred and seventy-two patients (2:1 male: female) underwent 192 non-traumatic LEAs. Median age for TFA was 75 years and TTA 67 (p = 0.002). A percentage of 36.5% had undergone prior attempts at surgical revascularization, 25% had undergone prior distal amputation or debridement. Thirty-three (17%) required stump revision. Twenty-three (13.2%) died in hospital. Median survival for those who died in hospital was 17 days (0-367), versus 17 months (2-106) for those who survived to discharge.

CONCLUSION

LEA for vascular pathology has significant morbidity and mortality, with long in-patient stays and short median survival; there is need to focus on improving quality of life in postoperative pathways.