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Wang K, Wang Y, Shi W, Shen K, Tao K, Ling R, Huang Y, Fu X, Hu D. Diagnosis and treatment of diabetic foot ulcer complicated with lower extremity vasculopathy: Consensus recommendation from the Chinese Medical Association (CMA), Chinese Medical Doctor Association (CMDA). Diabetes Metab Res Rev 2024; 40:e3776. [PMID: 38402455 DOI: 10.1002/dmrr.3776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 11/29/2023] [Accepted: 12/20/2023] [Indexed: 02/26/2024]
Abstract
Diabetic foot ulcer complicated with lower extremity vasculopathy is highly prevalent, slow healing and have a poor prognosis. The final progression leads to amputation, or may even be life-threatening, seriously affecting patients' quality of life. The treatment of lower extremity vasculopathy is the focus of clinical practice and is vital to improving the healing process of diabetic foot ulcers. Recently, a number of clinical trials on diabetic foot ulcers with lower extremity vasculopathy have been reported. A joint group of Chinese Medical Association (CMA) and Chinese Medical Doctor Association (CMDA) expert representatives reviewed and reached a consensus on the guidelines for the clinical diagnosis and treatment of this kind of disease. These guidelines are based on evidence from the literature and cover the pathogenesis of diabetic foot ulcers complicated with lower extremity vasculopathy and the application of new treatment approaches. These guidelines have been put forward to guide practitioners on the best approaches for screening, diagnosing and treating diabetic foot ulcers with lower extremity vasculopathy, with the aim of providing optimal, evidence-based management for medical personnel working with diabetic foot wound repair and treatment.
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Affiliation(s)
- Kejia Wang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Yunchuan Wang
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Wenlong Shi
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Kuo Shen
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Ke Tao
- Department of Wound Repair, Wound Repair and Regenerative Medicine Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Rui Ling
- Department of Thyroid, Breast and Vascular Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
| | - Yuesheng Huang
- Department of Wound Repair, Institute of Wound Repair and Regeneration Medicine, Southern University of Science and Technology Hospital, Southern University of Science and Technology School of Medicine, Shenzhen, China
| | - Xiaobing Fu
- Research Center for Tissue Repair and Regeneration Affiliated to the Medical Innovation Research Department and 4th Medical Center, PLA General Hospital and PLA Medical College, Beijing, China
| | - Dahai Hu
- Department of Burns and Cutaneous Surgery, Xijing Hospital, Air Force Medical University, Xi'an, Shaanxi, China
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Berger LE, Spoer DL, Huffman SS, Khayat E, Lava CX, Akbari CM, Atves JN, Steinberg JS, Attinger CE, Evans KK. A Comparative Analysis of Functional and Patient-Reported Outcomes Following Lisfranc and Chopart Amputations in High-Risk Limb Salvage Patients. J Foot Ankle Surg 2023; 62:933-938. [PMID: 37160203 DOI: 10.1053/j.jfas.2023.04.014] [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: 01/05/2023] [Revised: 04/21/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023]
Abstract
Midfoot amputations provide an opportunity for limb salvage through preservation of a weightbearing limb. However, the longevity of midfoot amputations is threatened by restrictions in surface area and risks of skin breakdown. To better inform decisions surrounding the level of amputation, we sought to compare outcomes of high-risk individuals who underwent Lisfranc or Chopart amputations. A single-center retrospective cohort study was performed from November 2013 to September 2022 of adult patients who underwent Lisfranc or Chopart amputations. Patients were stratified into cohorts based on the amputation type. Outcomes included postoperative rates of re-amputation, functional status, mortality and patient-reported outcome measures in the form of Lower Extremity Functional Scale scores. Sixty-six patients were identified; of which, 45 underwent Lisfranc amputation, and 21 underwent Chopart amputation. Median Charlson Comorbidity Index was 7, signifying a substantial comorbidity burden. By median follow-up of 14 (Interquartile range: 28) months, 31 patients (36%) progressed to higher-level amputation, and most patients were ambulatory (n = 38, 58%). Overall rates of re-amputation, ambulatory status, and mortality were comparable between groups. Re-amputation to another midfoot amputation was more common among the Lisfranc cohort (n = 16, 36% vs n = 1, 5%), whereas re-amputation to BKA was more prevalent among the Chopart cohort (Chopart: n = 7, 33% vs Lisfranc: n = 7, 16%; p = .011). Average Lower Extremity Functional Scale scores were similar between groups and corresponded to a maximal function of 48%. Lisfranc and Chopart amputations have the potential to be efficacious limb salvage options in high-risk patient populations in conjunction with intraoperative biomechanical optimization and optimal preoperative patient selection.
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Affiliation(s)
- Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC; Plastic and Reconstructive Surgery Division, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Daisy L Spoer
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Samuel S Huffman
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC; Georgetown University School of Medicine, Washington, DC
| | - Elias Khayat
- Georgetown University School of Medicine, Washington, DC
| | | | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - Jayson N Atves
- Department of Podiatric Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - John S Steinberg
- Department of Podiatric Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, DC.
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Hançerli CÖ, Doğan N. Comparison of below-knee and above-knee amputations with demographic, comorbidity, and haematological parameters in patients who died. J Foot Ankle Res 2023; 16:36. [PMID: 37308964 DOI: 10.1186/s13047-023-00635-x] [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] [Received: 01/25/2023] [Accepted: 06/05/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND This study aimed to establish mortality predictive parameters with a higher contribution to mortality by comparing the demographic data, comorbid factors, and haematological values of patients who underwent below-knee and above-knee amputation and had died during the follow-up period. MATERIALS AND METHODS Between March 2014 and January 2022, 122 patients in a single centre who developed foot gangrene due to chronic diabetes and underwent below-knee or above-knee amputation were evaluated retrospectively. Patients who died of natural causes during the post-operative period were included in the study. Those who were amputated below the knee were assigned to Group 1, and those who were amputated above the knee were assigned to Group 2. The patients' age, gender, side of amputation, comorbid diseases, American Society of Anaesthesiologists (ASA) score, Charlson comorbidity index (CCI), death time, and haematological values at the time of first admission were compared between the two groups and statistical analyses were performed. RESULTS Group 1 (n = 50) and Group 2 (n = 37) had similar distributions in terms of age, gender, side of operation, number of comorbidities, and CCI (p > 0.05). Group 2's mean ASA score and c-reactive protein (CRP) levels were statistically higher than those of Group 1 (p < 0.05). Death time, albumin value, and HbA1c levels were statistically lower in Group 2 than in Group 1 (p < 0.05). There were no significant differences between the groups in haemogram, white blood cells (WBC), lymphocytes, neutrophils, creatinine, and Na values at the time of first admission (p > 0.05). CONCLUSION A high ASA score, low albumin value, and high CRP value were significant predictors of high mortality. Creatinine levels and HbA1c values were quite ineffective in predicting mortality. LEVEL OF EVIDENCE Level 3, retrospective comparative study.
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Affiliation(s)
- Cafer Özgür Hançerli
- Department of Orthopaedics and Traumatology, University of Health Sciences, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Necati Doğan
- Department of Orthopaedics and Traumatology, Başaksehir Çam and Sakura City Training and Research Hospital, Basaksehir Olimpiyat Bulvarı Yolu, 34480, Basaksehir, Istanbul, Turkey.
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Kouevi-Koko TE, Amouzou KS, Sogan A, Apeti S, Dakey YEL, Abalo A. Lower extremity amputations (LEAs) in a tertiary hospital in Togo: a retrospective analysis of clinical, biological, radiological, and therapeutic aspects. J Orthop Surg Res 2023; 18:155. [PMID: 36864481 PMCID: PMC9979402 DOI: 10.1186/s13018-023-03628-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/19/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020. METHODS Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre (Sylvanus Olympio Teaching Hospital) from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software. RESULTS We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15-90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older (OR = 2.095, 95% CI = 1.050-4.183). The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications (P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F (3,237) = 5.505, P = 0.001. CONCLUSIONS Compared to previous decades, from 2010 to 2020, the average incidence of LEAs for all causes at Sylvanus Olympio Teaching Hospital (Lomé, Togo) decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and relative complications.
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Affiliation(s)
- T. E. Kouevi-Koko
- grid.12364.320000 0004 0647 9497Burn and Wound Healing Unit, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo ,Sylvanus Olympio Teaching Hospital, Lomé, Togo
| | - K. S. Amouzou
- grid.12364.320000 0004 0647 9497Burn and Wound Healing Unit, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo
| | - A. Sogan
- grid.12364.320000 0004 0647 9497Department of General Surgery, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo ,grid.12364.320000 0004 0647 9497Laboratory of Human Anatomy, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo
| | - S. Apeti
- grid.12364.320000 0004 0647 9497Department of Geriatrics, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo
| | - Y. E. L. Dakey
- grid.12364.320000 0004 0647 9497Burn and Wound Healing Unit, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo ,grid.12364.320000 0004 0647 9497General Surgery, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo
| | - A. Abalo
- grid.12364.320000 0004 0647 9497Traumatology-Orthopaedics Department, Faculté des Sciences de la Santé, University of Lomé, Lomé, Togo
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A review of user needs to drive the development of lower limb prostheses. J Neuroeng Rehabil 2022; 19:119. [PMCID: PMC9636812 DOI: 10.1186/s12984-022-01097-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 10/25/2022] [Indexed: 11/08/2022] Open
Abstract
Abstract
Background
The development of bionic legs has seen substantial improvements in the past years but people with lower-limb amputation still suffer from impairments in mobility (e.g., altered balance and gait control) due to significant limitations of the contemporary prostheses. Approaching the problem from a human-centered perspective by focusing on user-specific needs can allow identifying critical improvements that can increase the quality of life. While there are several reviews of user needs regarding upper limb prostheses, a comprehensive summary of such needs for those affected by lower limb loss does not exist.
Methods
We have conducted a systematic review of the literature to extract important needs of the users of lower-limb prostheses. The review included 56 articles in which a need (desire, wish) was reported explicitly by the recruited people with lower limb amputation (N = 8149).
Results
An exhaustive list of user needs was collected and subdivided into functional, psychological, cognitive, ergonomics, and other domain. Where appropriate, we have also briefly discussed the developments in prosthetic devices that are related to or could have an impact on those needs. In summary, the users would like to lead an independent life and reintegrate into society by coming back to work and participating in social and leisure activities. Efficient, versatile, and stable gait, but also support to other activities (e.g., sit to stand), contribute to safety and confidence, while appearance and comfort are important for the body image. However, the relation between specific needs, objective measures of performance, and overall satisfaction and quality of life is still an open question.
Conclusions
Identifying user needs is a critical step for the development of new generation lower limb prostheses that aim to improve the quality of life of their users. However, this is not a simple task, as the needs interact with each other and depend on multiple factors (e.g., mobility level, age, gender), while evolving in time with the use of the device. Hence, novel assessment methods are required that can evaluate the impact of the system from a holistic perspective, capturing objective outcomes but also overall user experience and satisfaction in the relevant environment (daily life).
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Yammine K, Akiki S, Assi C, Hayek Md F. Amputation as a First Treatment is Highly Associated With Late Presentation: An Underestimated Modifiable Major Risk Factor for Diabetic Foot Ulcer. Foot Ankle Spec 2021:19386400211067625. [PMID: 34967230 DOI: 10.1177/19386400211067625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE Several risk factors for lower extremity amputation in diabetic patients have been identified; however, late presentation has been poorly investigated. Very few studies looked at the impact of such risk factor. As none has investigated the link between admission to amputation and late presentation in this population, we investigated such association. METHODS The study is a retrospective comparative cohort of continuous series of patients admitted for amputation related to diabetic foot ulcer (DFU) as a first treatment. A late presentation was defined as a period of 3 weeks or more from the onset of the ulcer. RESULTS Forty-six patients admitted for amputation and all wounds were infected and located on the plantar forefoot in 32 cases (69.5%), on the toes in 10 cases (21.7%), and in the heel area in 4 cases (8.8%). The mean duration to admission was 5.2 ±1.8 weeks (range 4-10 weeks). Late presentation was recorded in 42 (91.3%) patients. CONCLUSION This study demonstrates that amputation due to DFU is highly associated with late presentation. Educational campaigns targeting patient and first-line health care providers and highlighting the urgency of diabetic ulcers are needed to impact this major modifiable risk factor.Levels of Evidence: Therapeutic, Level III: Retrospective Comparative.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
| | - Sandra Akiki
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
| | - Chahine Assi
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
| | - Fady Hayek Md
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (KY, CA)
- Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, Beirut, Lebanon (KY)
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research (KY, CA)
- Department of Clinical Nutrition, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (SA)
- Division of Vascular Surgery, Department of Surgery, LAU Medical Center-Rizk Hospital, School of Medicine, Lebanese American University, Beirut, Lebanon (FH)
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Ratliff HT, Shibuya N, Jupiter DC. Minor vs. major leg amputation in adults with diabetes: Six-month readmissions, reamputations, and complications. J Diabetes Complications 2021; 35:107886. [PMID: 33653663 DOI: 10.1016/j.jdiacomp.2021.107886] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 10/22/2022]
Abstract
AIMS The objective of this study was comparing medium-term outcomes between comparable minor and major amputations in adults with diabetes. METHODS We used data from the 2016-2017 National Readmissions Database to construct a representative cohort of 15,581 adults with diabetes with lower extremity amputations. Patients were categorized by level of index amputation (major/minor), and propensity score matched to compare outcomes in candidates for either level of amputation. Readmission and reamputations were assessed at 1, 3, and 6 months following index amputation. RESULTS In the 6 months following index amputation, large proportions of patients were readmitted (n = 7597, 48.8%) or had reamputations (n = 1990, 12.8%). Patients with minor amputations had greater odds of readmission (OR = 1.25; 95% CI 1.18-1.31), reamputation (OR = 3.71; 95% CI 3.34-4.12), and more proximal reamputation (OR = 2.61; 95% 2.33-2.93) (all P < 0.001). Further, minor amputation patients had higher and lower odds of readmission for postoperative infection (OR = 4.45; 95% CI 3.27-6.05), or sepsis (OR = 0.79; 95% CI 0.68-0.93), respectively. CONCLUSION Patients desire to save as much limb as possible and should be counseled on higher risk for reamputation, readmission, and infection with minor amputations.
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Affiliation(s)
- Hunter T Ratliff
- School of Medicine, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555, United States
| | - Naohiro Shibuya
- Texas A&M University, College of Medicine, Temple, TX, United States; Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX, United States.
| | - Daniel C Jupiter
- Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-1148, United States; Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0165, United States.
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Schmidt BM, Munson ME, Rothenberg GM, Holmes CM, Pop-Busui R. Strategies to reduce severe diabetic foot infections and complications during epidemics (STRIDE). J Diabetes Complications 2020; 34:107691. [PMID: 32883566 PMCID: PMC7384978 DOI: 10.1016/j.jdiacomp.2020.107691] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 01/22/2023]
Abstract
AIMS Patients with diabetes, including those with foot complications, are at highest risk for severe outcomes during the COVID-19 pandemic. Diabetic foot ulcers (DFU) present additional challenges given their superimposed risk for severe infections and amputations. The main objectives were to develop a triage algorithm to effectively risk-stratify all DFUs for potential complications, complying with social distancing regulations, preserving personal protective equipment, and to assess feasibility of virtual care for DFU. METHODS Longitudinal study during the COVID-19 pandemic performed at a large tertiary institution evaluating the effectiveness of a targeted triage protocol developed using a combined approach of virtual care, electronic medical record data mining, and tracing for rapid risk stratification to derive optimal care delivery methods. 2868 patients with diabetes at risk for foot complications within last 12 months were included and rates of encounters, hospitalizations, and minor amputations were compared to one year prior. RESULTS The STRIDE protocol was implemented in 1-week and eventually included 2600 patients (90.7%) demonstrating effective triage. During normal operations, 40% (938 of 2345) of all visits were due to DFUs and none were performed virtually. After implementation, 98% face-to-face visits were due to DFU, and virtual visits increased by 21,900%. This risk stratified approach led to similar low rates of DFU-related-hospitalization and minor amputation rates 20% versus 24% (p > 0.05) during and prior the pandemic, respectively. CONCLUSIONS Implementation of STRIDE protocol was effective to risk-stratify and triage all patients with diabetic foot complications preventing increase in hospitalization and amputations while promoting both social and physical distancing.
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Affiliation(s)
- Brian M Schmidt
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, United States of America.
| | - Michael E Munson
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, United States of America
| | - Gary M Rothenberg
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, United States of America
| | - Crystal M Holmes
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, United States of America
| | - Rodica Pop-Busui
- Michigan Medicine, Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, Domino's Farms (Lobby C, Suite 1300) 24 Frank Lloyd Wright Drive, Ann Arbor, MI 48106, United States of America
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Yammine K, Hayek F, Assi C. A meta-analysis of mortality after minor amputation among patients with diabetes and/or peripheral vascular disease. J Vasc Surg 2020; 72:2197-2207. [PMID: 32835790 DOI: 10.1016/j.jvs.2020.07.086] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 07/06/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed. METHODS A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality. RESULTS A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and "diabetic" results. CONCLUSIONS Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Division of Vascular Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon.
| | - Fady Hayek
- Division of Vascular Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
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Li H, Yang C, Lu K, Zhang L, Yang J, Wang F, Liu D, Cui D, Sun M, Pang J, Dai L, Han D, Liao F. A long-distance fluid transport pathway within fibrous connective tissues in patients with ankle edema. Clin Hemorheol Microcirc 2016; 63:411-421. [PMID: 27163690 DOI: 10.3233/ch-162057] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | - Liyang Zhang
- Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | | | | | | | - Di Cui
- Beijing Hospital, Beijing, China
| | | | | | - Luru Dai
- National Centre for Nanoscience and Technology, Beijing, China
| | - Dong Han
- National Centre for Nanoscience and Technology, Beijing, China
| | - Fulong Liao
- National Centre for Nanoscience and Technology, Beijing, China
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Thorud JC, Plemmons B, Buckley CJ, Shibuya N, Jupiter DC. Mortality After Nontraumatic Major Amputation Among Patients With Diabetes and Peripheral Vascular Disease: A Systematic Review. J Foot Ankle Surg 2016; 55:591-9. [PMID: 26898398 DOI: 10.1053/j.jfas.2016.01.012] [Citation(s) in RCA: 164] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Indexed: 02/03/2023]
Abstract
High mortality rates have been reported after major amputations of a lower limb secondary to diabetes and peripheral vascular disease. However, the mortality rates have varied across studies. A systematic review of the 5-year mortality after nontraumatic major amputations of the lower extremity was conducted. A data search was performed of Medline using OVID, CINHAL, and Cochrane, 365 abstracts were screened, and 79 full text articles were assessed for eligibility. After review, 31 studies met the inclusion and exclusion criteria. Overall, the 5-year mortality rate was very high among patients with any amputation (major and minor combined), ranging from 53% to 100%, and in patients with major amputations, ranging from 52% to 80%. Mortality after below-the-knee amputation ranged from 40% to 82% and after above-the-knee amputation from 40% to 90%. The risk factors for increased mortality included age, renal disease, proximal amputation, and peripheral vascular disease. Although our previous systematic review of the 5-year mortality after ulceration had much lower rates of death, additional studies are warranted to determine whether amputation hastens death or is a marker for underlying disease severity.
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Affiliation(s)
- Jakob C Thorud
- Podiatrist, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Podiatrist, Department of Surgery, Baylor Scott & White Health, Temple, TX.
| | - Britton Plemmons
- Podiatrist, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Third Year Resident, Baylor Scott & White Health, Temple, TX; and Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Clifford J Buckley
- Chief, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; Director, Division of Surgery, Baylor Scott & White Health, Temple, TX; and Professor, Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX
| | - Naohiro Shibuya
- Associate Professor, Department of Surgery, Texas A&M Health Science Center, College of Medicine, Temple, TX; Chief, Section of Podiatry, Department of Surgery, Central Texas Veterans Affairs Health Care System, Temple, TX; and Podiatrist, Baylor Scott & White Health, Temple, TX
| | - Daniel C Jupiter
- Assistant Professor, Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX
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Mendez N, Nayak NV, Kolomeyer AM, Szirth BC, Khouri AS. Feasibility of Spectral Domain Optical Coherence Tomography Acquisition Using a Handheld Versus Conventional Tabletop Unit. J Diabetes Sci Technol 2015; 10:277-81. [PMID: 26719135 PMCID: PMC4773977 DOI: 10.1177/1932296815624712] [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] [Indexed: 11/15/2022]
Abstract
PURPOSE Patients afflicted with ocular complications of diabetes represent a diverse demographic who often cannot undergo spectral-domain optical coherence tomography (SD-OCT) imaging of the retina due to postural restraints. Our pilot study compared imaging acquisition methods using SD-OCT in the handheld (HH) mode versus the conventional tabletop (TT) method. METHODS Our study included 22 undilated eyes of 22 subjects (mean ± SD age, 35.8 ± 16.8 years) imaged using HH and TT iVue SD-OCT (Optovue, Fremont, CA). Statistical analysis was performed using Microsoft Excel 12.2.7 (Microsoft Corporation, Redmond, WA) software with an accepted significance of P < .05. RESULTS Strong intraclass correlation coefficient was observed for (1) overall (.97), superior (.93), and inferior (.94) ganglion cell complex thickness, and (2) central (.98), inferior (.90), superior (.92), nasal (.94), and temporal (.93) macular retinal thickness. Mean scan quality index was adequate but lower in HH versus TT SD-OCT (62.8 vs 68.1, respectively; P < .0001). Multiple attempts for adequate imaging were required more frequently in HH versus TT SD-OCT (34% vs 5%, respectively; P < .001). CONCLUSION HH SD-OCT may be a feasible alternative to TT SD-OCT in select situations, especially in patients suffering from diabetic complications with limited mobility.
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Affiliation(s)
- Nicole Mendez
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Natasha V Nayak
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, NY, USA
| | - Anton M Kolomeyer
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ben C Szirth
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Albert S Khouri
- Department of Ophthalmology and Visual Science, Rutgers New Jersey Medical School, Newark, NJ, USA
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Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J 2015; 13:892-903. [PMID: 25601358 DOI: 10.1111/iwj.12404] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2014] [Accepted: 12/03/2014] [Indexed: 12/26/2022] Open
Abstract
A great deal of emphasis, clinical and financial, is placed on limb salvage efforts in diabetic patients suffering from lower extremity ulceration. This is because of the impression that amputation in such patients may be a proximal cause of death. While amputation is certainly a negative clinical outcome, it is not entirely clear that it causes death. In this systematic review, we examine the available literature to attempt to understand the role that the ulceration itself may play in mortality. In brief, we searched for human studies in OVID, CINAHL and the COCHRANE CENTRAL DATABASE from 1980 to 2013, looking for articles related to ulcer or wound of the foot, in patients with diabetes or peripheral vascular disease, and death. We looked for articles with 5 years of follow-up, or Kaplan-Meier estimates of 5-year mortality, and excluded reviews and letters. Articles were assessed for quality and potential bias using the Newcastle-Ottawa scale. We find that while the patient populations studied varied widely in terms of demographics and comorbidities, limiting generalisability, 5-year mortality rates after ulceration were around 40%. Risk factors for death commonly identified were increased age, male gender, peripheral vascular disease and renal disease.
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Affiliation(s)
- Daniel C Jupiter
- Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, TX, USA
| | - Jakob C Thorud
- Section of Podiatry, Department of Surgery, Central Texas VA Health Care System, Temple, TX, USA. .,Department of Surgery, Baylor Scott & White Health, Temple, TX, USA.
| | - Clifford J Buckley
- Department of Surgery, Baylor Scott & White Health, Temple, TX, USA.,Department of Surgery, Central Texas VA Health Care System, Temple, TX, USA.,Department of Surgery, Texas A&M University Health Science Center, College of Medicine, Temple, TX, USA
| | - Naohiro Shibuya
- Section of Podiatry, Department of Surgery, Central Texas VA Health Care System, Temple, TX, USA.,Department of Surgery, Baylor Scott & White Health, Temple, TX, USA.,Department of Surgery, Texas A&M University Health Science Center, College of Medicine, Temple, TX, USA
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Pirogow's Amputation: A Modification of the Operation Method. Adv Orthop 2013; 2013:460792. [PMID: 23606976 PMCID: PMC3625588 DOI: 10.1155/2013/460792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 02/12/2013] [Indexed: 11/17/2022] Open
Abstract
Introduction. Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers the ability to stay mobile without the use of a prosthesis, it is rarely performed. This paper proposes a modification regarding the operation method of the Pirogow amputation. The results of the modified operation method on ten patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score). Material and Methods. We modified the original method by rotating the calcaneus. To fix the calcaneus to the tibia, Kirschner wire and a 3/0 spongiosa tension screw as well as a Fixateur externe were used. Results. 70% of those questioned who were amputated following the modified Pirogow method indicated an excellent or very good result in total points whereas in the control group (original Pirogow's amputation) only 40% reported excellent or very good result. In addition, the level of pain experienced one year after the completed operation showed different results in favour of the group being operated with the modified way. Furthermore, patients in both groups showed differences in radiological results, postoperative leg length difference, and postoperative mobility. Conclusion. The modified Pirogow amputation presents a valuable alternative to the original amputation method for patients with the corresponding indications. The benefits are found in the significantly reduced pain, difference in reduced radiological complications, the increase in mobility without a prosthesis, and the reduction of postoperative leg length difference.
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Altindas M, Kilic A, Cinar C. A reliable surgical approach for the two-staged amputation in unsalvageable limb and life threatening acute progressive diabetic foot infections: tibiotalar disarticulation with vertical crural incisions and secondary transtibial amputation. Foot Ankle Surg 2011; 17:13-8. [PMID: 21276559 DOI: 10.1016/j.fas.2009.11.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 11/17/2009] [Accepted: 11/20/2009] [Indexed: 02/04/2023]
Abstract
BACKGROUND If all efforts to treat acute progressive diabetic foot infection remain insufficient, the decision of major amputation should be undertaken. For this purpose, guillotine amputation is usually performed first. However, guillotine amputation below the knee level may cause the corresponding infection to spread to preserved anatomical spaces. METHOD First stage of our procedure consists of tibiotalar disarticulation and vertical incisions performed throughout the lower leg to remove the septic foot and drain the compartments. During the interval period, appropriate antibiotherapy and wound care are applied. After the interval period, definitive transtibial amputation is performed in the second stage. RESULTS Fifty-nine percent of the 62 transtibial amputations were healed completely. Failure developed in 3 cases which required opening of the amputation stump. In one patient, revision amputation at a higher transtibial level was done. Infection and necrosis reached to the knee joint in the other two patients and transfemoral amputation became the only treatment option for these 2 cases. CONCLUSION Tibiotalar disarticulation with vertical lower leg incisions as a first stage of two-stage transtibial amputation is a safe and reliable method. It reduces the risk of unnecessary tissue sacrifice and failure rate of the secondary transtibial amputation.
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Affiliation(s)
- Muzaffer Altindas
- Istanbul University Cerrahpasa Medical School, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul, Turkey
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Solway DR, Clark WA, Levinson DJ. A parallel open-label trial to evaluate microbial cellulose wound dressing in the treatment of diabetic foot ulcers. Int Wound J 2011; 8:69-73. [PMID: 21159127 PMCID: PMC7950783 DOI: 10.1111/j.1742-481x.2010.00750.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The purpose of this study was to compare the rate of wound healing in diabetic foot ulcers (DFU) using either a microbial cellulose (MC) wound dressing or Xeroform™ Petrolatum gauze. In a parallel, open-label trial in which the primary outcome was the rate of wound healing and the time to wound closure, 15 ulcers in type II diabetic patients received an MC dressing. Wounds in 19 control patients with type II diabetes were treated with a Xeroform gauze dressing. All wounds were non infected, Wagner stage II or III and received standard care including debridement, non weight bearing limb support and weekly wound evaluation. The mean time to heal in the MC (±SE) treated group was 32 days ± 2.5 and for controls it was 48 days ± 4.7 (P < 0.01). The rate of weekly wound closure (mean ± SE) was 1.7 times faster in the MC-treated group (cellulose treated, -5.04% per week ± 0.38 versus control, -2.93% per week ± 0.19), (P < 0.001). Among covariants tested by univariate regression, only the original wound area correlated with the time to wound closure (P < 0.001). In conclusion, with the provision of current standards of care, the application of an MC dressing to a diabetic ulcer may enhance the rate of wound healing and shorten the time course of epithelisation.
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Coffey L, Gallagher P, Horgan O, Desmond D, MacLachlan M. Psychosocial adjustment to diabetes-related lower limb amputation. Diabet Med 2009; 26:1063-7. [PMID: 19900240 DOI: 10.1111/j.1464-5491.2009.02802.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To examine psychosocial adjustment in persons with lower limb amputations related to diabetes. METHODS Thirty-eight participants with diabetes-related lower limb amputations, recruited from two limb-fitting centres, completed three psychological self-report assessments: the Trinity Amputation and Prosthesis Experience Scales (TAPES); the Hospital Anxiety and Depression Scale (HADS); and the Amputation Body Image Scale-Revised (ABIS-R). RESULTS Over 18% of participants scored above the normal range (> 8) for depression on the HADS and 18.5% scored above the normal range for anxiety. Both depression (rho = 0.75, P < 0.01) and anxiety (rho = 0.62, P < 0.01) scores were significantly associated with body image disturbance, as measured using the ABIS-R. Significant relationships were also observed between body image disturbance and three TAPES subscales measuring psychosocial adjustment [general adjustment (rho = -0.48, P < 0.01), social adjustment (rho = -0.51, P < 0.01), adjustment to limitations (rho = -0.45, P < 0.05)]. CONCLUSIONS Individuals with diabetes-related amputations may be at elevated risk for psychological distress as a result of their co-morbid medical condition. Regular screening for anxiety and depression and the provision of appropriate follow-up care may therefore be advisable in this population.
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Affiliation(s)
- L Coffey
- Faculty of Science and Health, School of Nursing, Dublin City University, Dublin, Ireland
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Affiliation(s)
- Sergio Fazio
- Division of Cardiovascular Medicine, Atherosclerosis Research Unit, Vanderbilt University Medical Center, Nashville, TN 37232-6300, USA.
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Abstract
Pain is as very common problem in wound management and is one that is often neglected. This has an impact on both healing rates and patient quality of life. Pain is an indication that something is wrong and acts as one of the body's most important protective mechanisms and as such, should never be ignored. A comprehensive assessment of pain is vital and a plan of care formed that considers the type of pain that is being experienced and what interventions should be used. ActiFormCool is an ionic hydrogel dressing that has the ability to reduce pain in painful wounds, and this natural type of intervention should be the first consideration in reducing pain.
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