Epidemiology of diabetes-related lower extremity amputations in Gran Canaria, Canary Islands (Spain)

Cost-effectiveness of multicomponent interventions in type 2 diabetes mellitus in a cluster randomised controlled trial: the INDICA study

OBJECTIVE

To analyse the cost-effectiveness of multicomponent interventions designed to improve outcomes in type 2 diabetes mellitus (T2DM) in primary care in the Canary Islands, Spain, within the INDICA randomised clinical trial, from the public health system perspective.

DESIGN

An economic evaluation was conducted for the within-trial period (2 years) comparing the four arms of the INDICA study.

SETTING

Primary care in the Canary Islands, Spain.

PARTICIPANTS

2334 patients with T2DM without complications were included.

INTERVENTIONS

Interventions for patients (PTI), for primary care professionals (PFI), for both (combined intervention arm for patients and professionals, CBI) and usual care (UC) as a control group.

OUTCOMES

The main outcome was the incremental cost per quality-adjusted life-years (QALY). Only the intervention and the healthcare costs were included.

ANALYSIS

Multilevel models were used to estimate results, and to measure the size and significance of incremental changes. Missed values were treated by means of multiple imputations procedure.

RESULTS

There were no differences between arms in terms of costs (p=0.093), while some differences were observed in terms of QALYs after 2 years of follow-up (p=0.028). PFI and CBI arms were dominated by the other two arms, PTI and UC. The differences between the PTI and the UC arms were very small in terms of QALYs, but significant in terms of healthcare costs (p=0.045). The total cost of the PTI arm (€2571, 95% CI €2317 to €2826) was lower than the cost in the UC arm (€2750, 95% CI €2506 to €2995), but this difference did not reach statistical significance. Base case estimates of the incremental cost per QALY indicate that the PTI strategy was the cost-effective option.

CONCLUSIONS

The INDICA intervention designed for patients with T2DM and families is likely to be cost-effective from the public healthcare perspective. A cost-effectiveness model should explore this in the long term.

TRIAL REGISTRATION NUMBER

NCT01657227.

Prevalence and risk factors of diabetic foot disease among the people with type 2 diabetes using real-world practice data from Catalonia during 2018

BACKGROUND

Our study aimed to assess the prevalence of diabetic foot disease (DFD) and its associated risk factors among subjects attending primary care centers in Catalonia (Spain).

METHODS

We undertook a cross-sectional analysis of data from the primary health care (SIDIAP) database. The presence of comorbidities and concomitant medication were analyzed for subjects with or without DFD. DFD prevalence was estimated from 1st January 2018 to 31st December 2018.

RESULTS

During the 12-month observational period, out of 394,266 people with type 2 diabetes, we identified 3,277 (0.83%) active episodes of DFD in the database. The majority of these episodes were foot ulcers (82%). The mean age of patients with DFD was 70.3 (± 12.5) years and 55% were male. In the multivariable descriptive models, male gender, diabetes duration, hypertension, macrovascular, microvascular complications, and insulin and antiplatelet agents were strongly associated with DFD. A previous history of DFD was the stronger risk factor for DFD occurrence in subjects with T2DM (OR: 13.19, 95%CI: 11.81; 14.72).

CONCLUSIONS

In this real-world primary care practice database, we found a lower prevalence of DFD compared to similar previous studies. Risk factors such as male sex, duration of diabetes, diabetes complications and previous history of DFD were associated with the presence of DFD.

Effectiveness of Internet-Based Multicomponent Interventions for Patients and Health Care Professionals to Improve Clinical Outcomes in Type 2 Diabetes Evaluated Through the INDICA Study: Multiarm Cluster Randomized Controlled Trial

Background

Type 2 diabetes mellitus (T2DM) is a chronic disease in which health outcomes are related to decision making by patients and health care professionals.

Objective

This study aims to assess the effectiveness of internet-based multicomponent interventions to support decision making of all actors involved in the care of patients with T2DM in primary care.

Methods

The INDICA study is an open, community-based, multicenter trial with random allocation to usual care or the intervention for patients, the intervention for health care professionals in primary care, or the combined intervention for both. In the intervention for patients, participants received an educational group program and were monitored and supported by logs, a web-based platform, and automated SMS. Those in the intervention for professionals also received an educational program, a decision support tool embedded in the electronic clinical record, and periodic feedback about patients’ results. A total of 2334 people with T2DM, regardless of glycated hemoglobin (HbA_1c) levels and without diabetes-related complications, were included. The primary end point was change in HbA_1c level. The main analysis was performed using multilevel mixed models.

Results

For the overall sample, the intervention for patients attained a significant mean reduction in HbA_1c levels of ‒0.27 (95% CI ‒0.45 to ‒0.10) at month 3 and ‒0.26 (95% CI ‒0.44 to ‒0.08) at month 6 compared with usual care, which remained marginally significant at month 12. A clinically relevant reduction in HbA_1c level was observed in 35.6% (191/537) of patients in the intervention for patients and 26.0% (152/586) of those in usual care at month 12 (P=.006). In the combined intervention, HbA_1c reduction was significant until month 18 (181/557, 32.6% vs 140/586, 23.9%; P=.009). Considering the subgroup of patients uncontrolled at baseline, all interventions produced significant reductions in HbA_1c levels across the entire study period: ‒0.49 (95% CI ‒0.70 to ‒0.27) for the intervention for patients, ‒0.35 (95% CI ‒0.59 to ‒0.14) for the intervention for professionals, and ‒0.35 (95% CI ‒0.57 to ‒0.13) for the combined intervention. Differences in HbA_1c for the area under the curve considering the entire period were significant for the intervention for patients and the combined intervention compared with usual care (P=.03 for both). Compared with usual care, the intervention for professionals and the combined intervention had significant longer-term reductions in systolic and diastolic blood pressure.

Conclusions

In uncontrolled patients, the intervention for patients at baseline provided clinically relevant and significant longer-term reductions of HbA_1c levels. The intervention for professionals and combined intervention also improved the cardiovascular risk profile of patients.

Trial Registration

ClinicalTrials.gov NCT01657227; https://clinicaltrials.gov/ct2/show/NCT01657227

Major amputations in type 2 diabetes between 2001 and 2015 in Spain: regional differences

Background

To analyze the trend of lower extremity major amputations (MA) among patients with type 2 diabetes mellitus (T2DM) in the Regions of Spain from year 2001 until 2015.

Methods

Descriptive study of 40,392 MA. Data were obtained from the national hospital discharge database in patients with T2DM. The incidence rate was calculated in each Region, in addition to the incidence ratios (IR) between annual incidence and incidence of the year 2001. The length of hospital stay and mortality risks were analyzed using regression models adjusted for sex, age and smoking.

Results

The major amputations incidence rate per 100,000 person-years was 0.48 in Spain; Canary Islands showed the highest incidence (0.81). The trend was a slight decrease or stability of the incidence in all Regions except in the Canary Islands (IR₂₀₁₅ = 2.0 [CI95% = 1.5, 2.6]) and in Madrid (IR₂₀₁₅ = 0.1 [CI95% = 0.1, 0.2]). Mortality after major amputations was 10% in Spain; Cantabria suffered the highest risk of death [1.7 (CI95% = 1.4; 2.1), p < 0.001] and La Rioja the lowest risk (0.5 [CI95% = 0.2; 0.9]; p = 0.026). The longest hospital stay was registered in the Canary Islands [(CI95% = 11.4;13.3], p < 0.001)], and the shortest in the Valencian Community [(CI95% = − 7.3; − 5.8), p < 0.001)].

Conclusion

MA in T2DM followed a growing trend in the Canary Islands, which diverged from the downward trend in Spain. The variability of mortality and hospital stay, suggest to review the clinical management in some Regions. Sudden incidence decrease in Madrid suggests checking the record procedures of hospital discharges.

Evaluation of the risk of diabetic peripheral neuropathy: Design and validation of the NeuDiaCan nursing screening procedure

OBJECTIVE

To design and validate a nursing screening procedure for diabetic peripheral neuropathy in primary care.

METHODS

The study was carried out in three phases. 1)Construction of an item bank to form the procedure with an exit score describing the patient's clinical situation. 2)Test and reduction of the initial tentative procedure on a sample of 50 patients using community nurse consultations, eliminating the components with low inter-intra nurse reliability. 3)Validation of the version of the procedure obtained in the previous step on a sample of 106 patients. Calculation of validity and reliability by eliminating components with low criterion validity with respect to the results of the diagnostic electromyography used as a reference standard. Cut-off points were estimated for the use of the procedure as a screening tool, predictive values, performance, internal consistency and inter-nurse reliability.

RESULTS

The initial tentative procedure consisted of 12 components that were reduced to 10. In the process of validation of this second version the procedure was simplified again, eventually comprising 6 components, with a cut-off point of 2.5 in its output scale, the point at which it reaches adequate values of sensitivity and negative predictors to be used as a screening instrument. For this cut-off point the inter-intra nurse reliability, criterion validity and predictive validity reached acceptable values.

CONCLUSIONS

NeuDiaCan as a nursing screening procedure for diabetic peripheral neuropathy in primary care is valid, reliable and easy to use.

Diabetic foot self-care and concordance of 3diabetic foot risk stratification systems in a basic health area of Gran Canaria

OBJECTIVE

To assess the level of self-care in the population with diabetes and determine the risk of diabetic foot lesions through the use of 3stratification systems as well as to establish the degree of concordance between these systems.

METHOD

Observational, cross-sectional and descriptive study carried out in the Basic Health Area of Santa Brígida (Gran Canaria-Canary Islands-Spain) in people diagnosed with diabetes (DM Type 1/DM Type 2) (n=182). Interview, physical examination, review of clinical history and completion of the Diabetic Foot Self-Care questionnaire of the University of Malaga were carried out. The risk stratification was then calculated using 3systems (System of the National Institute for Health Care Excellence, Classification of the International Working Group on the Diabetic Foot and High-Risk Diabetic Foot-60-Second Tool©-2012). The Kappa index was calculated to study the concordance between systems, the relative risk of negative screening of one method against another was estimated and the exact Fisher test to establish whether there were differences.

RESULTS

30.2% of diabetics had a low level of self-care, 45.1% a medium level and 24.7% a high level. The risk levels calculated were: National Institute for Health Care Excellence Classification (Negative Risk 71.4%-Positive Risk 28.6%), International Working Group on the Diabetic Foot Classification (Negative Risk 67.0%-Positive Risk 33.0%) and High-Risk Diabetic Foot-60-Second Tool© (Negative Risk 62.6%-Positive Risk 37.4%).

CONCLUSIONS

All 3systems have good concordance with each other. The High-Risk Diabetic Foot-60-Second Tool© only distinguishes 2levels of risk but detects a higher percentage of people at risk. The Diabetic Foot Self-Care questionnaire of the University of Malaga may be useful in the context of Primary Care to assess the level of self-care of people with diabetes.

Genomic Analyses of Human European Diversity at the Southwestern Edge: Isolation, African Influence and Disease Associations in the Canary Islands

Despite the genetic resemblance of Canary Islanders to other southern European populations, their geographical isolation and the historical admixture of aborigines (from North Africa) with sub-Saharan Africans and Europeans have shaped a distinctive genetic makeup that likely affects disease susceptibility and health disparities. Based on single nucleotide polymorphism array data and whole genome sequencing (30×), we inferred that the last African admixture took place ∼14 generations ago and estimated that up to 34% of the Canary Islander genome is of recent African descent. The length of regions in homozygosis and the ancestry-related mosaic organization of the Canary Islander genome support the view that isolation has been strongest on the two smallest islands. Furthermore, several genomic regions showed significant and large deviations in African or European ancestry and were significantly enriched in genes involved in prevalent diseases in this community, such as diabetes, asthma, and allergy. The most prominent of these regions were located near LCT and the HLA, two well-known targets of selection, at which 40‒50% of the Canarian genome is of recent African descent according to our estimates. Putative selective signals were also identified in these regions near the SLC6A11-SLC6A1, KCNMB2, and PCDH20-PCDH9 genes. Taken together, our findings provide solid evidence of a significant recent African admixture, population isolation, and adaptation in this part of Europe, with the favoring of African alleles in some chromosome regions. These findings may have medical implications for populations of recent African ancestry.

[Family, socioeconomic status and health services: Clues to health care in diabetic patients with lower limb amputations in Andalusia. A qualitative study]

Objetivo

Explorar la vivencia de los cuidados diabéticos en pacientes sometidos a amputación de miembros inferiores por pie diabético.

Diseño

Estudio cualitativo con perspectiva fenomenológica.

Emplazamiento

Área hospitalaria de Cádiz.

Participantes

Dieciséis participantes (11 hombres y 5 mujeres) con diabetes tipo 2 y amputación no traumática de miembros inferiores.

Métodos

Entrevistas semiestructuradas individuales y análisis de contenido de la información usando el método propuesto por Graneheim y Lundman.

Resultados

Se identificaron 4 categorías: 1. La familia es la piedra angular de los cuidados; 2. Los aspectos socioeconómicos y laborales determinan la calidad de los autocuidados; 3. La interacción paciente-personal de salud dinamiza los cuidados; y 4. Las limitaciones en la provisión de servicios sanitarios.

Conclusión

La familia, la situación económica y laboral y los factores del sistema sanitario constituyen los elementos más relevantes en los cuidados de pacientes con diabetes y amputación de miembros inferiores. Los determinantes sociales, económicos y laborales deben ser tomados en especial consideración y de manera más personalizada desde los servicios sanitarios para aumentar el impacto de los cuidados proporcionados en la prevención de las complicaciones de la diabetes mellitus.

Influence of wound scores and microbiology on the outcome of the diabetic foot syndrome

AIMS

To establish if the microbiology and the TEXAS, PEDIS and Wagner wound classifications of the diabetic foot syndrome (DFS) predict amputation.

METHODS

Prospective cohort study of 250 patients with DFS from 2009 to 2013. Tissue samples for culture were obtained and wound classification scores were recorded at admission.

RESULTS

Infection was monomicrobial in 131 patients (52%). Staphylococcus aureus was the most frequent pathogen (76 patients, 30%); being methicillin-resistant S. aureus in 26% (20/76) Escherichia coli and Enterobacter faecalis were 2nd and 3rd most frequent pathogens. Two hundred nine patients (85%) needed amputation being major in 25 patients (10%). The three wound scales associated minor amputation but did not predict this outcome. Predictors of minor amputation in the multivariate analysis were the presence of osteomyelitis, the location of the wound in the forefoot and of major amputation elevated C reactive proteine (CRP) levels. A low ankle-brachial index (ABI) predicted major amputation in the follow-up. Overall, 74% of gram-positives were sensitive to quinolones and 98% to vancomycin and 90% of gram-negatives to cefotaxime and 95% to carbapenems.

CONCLUSIONS

The presence of osteomyelitis and the location of the wound in the forefoot predict minor amputation and elevated CRP levels predict major amputation. In the follow-up a low ABI predicts major amputation.

On the problem of type 2 diabetes-related mortality in the Canary Islands, Spain. The DARIOS Study

AIMS

To compare diabetes-related mortality rates and factors associated with this disease in the Canary Islands compared with other 10 Spanish regions.

METHODS

In a cross-sectional study of 28,887 participants aged 35-74 years in Spain, data were obtained for diabetes, hypertension, dyslipidemia, obesity, insulin resistance (IR), and metabolic syndrome. Healthcare was measured as awareness, treatment and control of diabetes, dyslipidemia, and hypertension. Standardized mortality rate ratios (SRR) were calculated for the years 1981 to 2011 in the same regions.

RESULTS

Diabetes, obesity, and hypertension were more prevalent in people under the age of 64 in the Canary Islands than in Spain. For all ages, metabolic syndrome and insulin resistance (IR) were also more prevalent in those from the Canary Islands. Healthcare parameters were similar in those from the Canary Islands and the rest of Spain. Diabetes-related mortality in the Canary Islands was the highest in Spain since 1981; the maximum SRR was reached in 2011 in men (6.3 versus the region of Madrid; p<0.001) and women (9.5 versus Madrid; p<0.001). Excess mortality was prevalent from the age of 45 years and above.

CONCLUSIONS

Diabetes-related mortality is higher in the Canary Islands population than in any other Spanish region. The high mortality and prevalence of IR warrants investigation of the genetic background associated with a higher incidence and poor prognosis for diabetes in this population. The rise in SRR calls for a rapid public health policy response.

Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot

We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of -6.6% (95% CI = -10.2 to -2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes.

Peripheral arterial disease, type 2 diabetes and postprandial lipidaemia: Is there a link?

Peripheral arterial disease, manifested as intermittent claudication or critical ischaemia, or identified by an ankle/brachial index < 0.9, is present in at least one in every four patients with type 2 diabetes mellitus. Several reasons exist for peripheral arterial disease in diabetes. In addition to hyperglycaemia, smoking and hypertension, the dyslipidaemia that accompanies type 2 diabetes and is characterised by increased triglyceride levels and reduced high-density lipoprotein cholesterol concentrations also seems to contribute to this association. Recent years have witnessed an increased interest in postprandial lipidaemia, as a result of various prospective studies showing that non-fasting triglycerides predict the onset of arteriosclerotic cardiovascular disease better than fasting measurements do. Additionally, the use of certain specific postprandial particle markers, such as apolipoprotein B-48, makes it easier and more simple to approach the postprandial phenomenon. Despite this, only a few studies have evaluated the role of postprandial triglycerides in the development of peripheral arterial disease and type 2 diabetes. The purpose of this review is to examine the epidemiology and risk factors of peripheral arterial disease in type 2 diabetes, focusing on the role of postprandial triglycerides and particles.

Trends in the incidence of lower extremity amputations in people with and without diabetes over a five-year period in the Republic of Ireland

Aims

To describe trends in the incidence of non-traumatic amputations among people with and without diabetes and estimate the relative risk of an individual with diabetes undergoing a lower extremity amputation compared to an individual without diabetes in the Republic of Ireland.

Methods

All adults who underwent a nontraumatic amputation during 2005 to 2009 were identified using HIPE (Hospital In-patient Enquiry) data. Participants were classified as having diabetes or not having diabetes. Incidence rates were calculated using the number of discharges for diabetes and non-diabetes related lower extremity amputations as the numerator and estimates of the resident population with and without diabetes as the denominator. Age-adjusted incidence rates were used for trend analysis.

Results

Total diabetes-related amputation rates increased non-significantly during the study period; 144.2 in 2005 to 175.7 in 2009 per 100,000 people with diabetes (p = 0.11). Total non-diabetes related amputation rates dropped non-significantly from 12.0 in 2005 to 9.2 in 2009 per 100,000 people without diabetes (p = 0.16). An individual with diabetes was 22.3 (95% CI 19.1–26.1) times more likely to undergo a nontraumatic amputation than an individual without diabetes in 2005 and this did not change significantly by 2009.

Discussion

This study provides the first national estimate of lower extremity amputation rates in the Republic of Ireland. Diabetes-related amputation rates have remained steady despite an increase in people with diabetes. These estimates provide a base-line and will allow follow-up over time.

Incidence of lower limb amputations in individuals with and without diabetes mellitus in Andalusia (Spain) from 1998 to 2006

AIMS

We studied the changes in the incidence of lower limb amputation (LLA) in Andalusia from 1998 to 2006 in the population with and without diabetes.

METHODS

We undertook a retrospective study of all LLA performed in Andalusia in people aged 30 years old, with or without diabetes, between 1 January 1998 and 31 December 2006. We obtained the crude and standardized incidence rates by year, and sex for three periods: 1998-2000, 2001-2003 and 2004-2006 and calculated the RR of requiring LLA in patients with diabetes. To test for time trend, Poisson regression models were fitted.

RESULTS

A total of 16,210 LLA were carried out in Andalusia, 72.6% in patients with diabetes mellitus and 66.4% in men. In the population with diabetes the standardized incidence of all LLA was found to be 344.0 per 100,000 (95% CI, 315.4-372.4) in 2004-2006. There was an estimated incidence increase for all LLA by 14% and for minor LLA by 13.6% in 2004-2006. In people with diabetes the RR increased by 31.6% as compared to the first period.

CONCLUSIONS

Despite the implementation of a care plan for patients with diabetes, the incidence of LLA has not fallen in Andalusia in recent years.

Lower extremity amputations--a review of global variability in incidence

AIM

To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes mellitus.

METHODS

An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for incidence of lower extremity amputation. The literature review conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards.

RESULTS

Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 10(5) in the population with diabetes compared with 5.8-31 per 10(5) in the total population. Major amputation ranges from 5.6 to 600 per 10(5) in the population with diabetes and from 3.6 to 68.4 per 10(5) in the total population. Significant reductions in incidence of lower extremity amputation have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics.

CONCLUSION

Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation reporting methods demonstrate significant variation with no single standard upon which to benchmark care. Effective standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the growing multidisciplinary team effect on lower extremity amputation rates globally.

The role of a specialized approach for patients with diabetes, critical ischaemia and foot ulcers not previously considered for proactive management

AIMS

To analyse the outcome of the proactive management of patients with diabetes, critical limb ischaemia and foot ulcers using percutaneous transluminal angioplasty as the only vascular procedure and adjuvant conservative surgery when indicated.

METHODS

A retrospective study of patients with diabetes included in our database who sought a second opinion in our unit and met the following criteria: foot ulcer and critical limb ischaemia in patients for whom any proactive vascular treatment had not previously been considered by other teams.

RESULTS

Twenty patients underwent endovascular procedures. Success was achieved in 19 cases (95%). No post-operative mortality (within 30 days after the procedure) was found. Additional surgery was required in eight cases (40%): one calcaneal ostectomy and seven minor amputations. The need for surgery was associated with infection (P < 0.01). Limb salvage was sustained during a mean period of follow-up of 642 days (SD 488) in 19 cases (95%). Healing was achieved in 14 cases (70%), four are still healing (20%), one underwent major amputation (5%) and the last one died before being healed (5%). Three patients died during follow-up (15%).

CONCLUSIONS

Management of patients with diabetes, foot ulcers and critical limb ischaemia by means of a proactive approach including endovascular procedures in specialized settings provides a high rate of limb salvage. This may result in lowering the number of lower limb amputations in our community.

Trends in lower-extremity amputations in people with and without diabetes in Spain, 2001-2008

OBJECTIVE

To examine trends in nontraumatic lower-extremity amputations (LEAs) over an 8-year period in patients with and without diabetes in Spain.

RESEARCH DESIGN AND METHODS

We identified all patients who underwent an LEA using national hospital discharge data. Discharges were grouped by diabetes status: type 1 diabetes, type 2 diabetes, and no diabetes. The incidence of discharges attributed to amputations were calculated overall and stratified by diabetes status and year. We calculated length of stay and in-hospital fatality stratified by diabetes status and type of LEA.

RESULTS

From 2001 to 2008, 46,536 minor LEAs and 43,528 major LEAs were performed. In patients with type 1 diabetes, the incidence of minor and major amputations decreased significantly from 2001 to 2008 (0.88-0.43 per 100,000 inhabitants and 0.59-0.22 per 100,000 inhabitants, respectively). In patients with type 2 diabetes, the incidence of minor and major LEAs increased significantly (9.23-10.9 per 100,000 inhabitants and 7.12-7.47 per 100,000 inhabitants). Hospital stay was similar among type 1 diabetic and type 2 diabetic subjects, according to the type of LEA. Only in-hospital mortality for minor LEAs among type 1 diabetic subjects decreased significantly (4.0% in 2001 vs. 1.6% in 2008).

CONCLUSIONS

Our national data show a decrease in the incidence of major and minor LEAs in patients with type 1 diabetes and an increase among patients with type 2 diabetes. Further improvement is necessary in the preventive care and early treatment of patients with diabetes. The management of foot lesions, especially among type 2 diabetic patients, is particularly urgent.

Prospective randomized controlled study of a Chinese herbal medicine compound Tangzu Yuyang Ointment for chronic diabetic foot ulcers: a preliminary report

AIM OF THE STUDY

The purpose of this study was to evaluate the efficacy and safety of a topical Chinese herbal medicine (CHM) compound Tangzu Yuyang Ointment (TYO) for treatment of chronic diabetic foot ulcers.

MATERIALS AND METHODS

This multi-center, prospective, randomized, controlled and add-on clinical trial was conducted at seven centers in the China mainland. Fifty-seven patients with chronic diabetic foot ulcers of Wagner's ulcer grade 1-3 were enrolled in this study. Patients who were randomly assigned to the control group (n=28) received standard wound therapy (SWT), whereas those randomized to the treatment group (n=28) received SWT plus topical TYO. Only 48 patients who finished 24 weeks of observations were entered for data analysis.

RESULTS

The TYO and SWT groups were comparable for baseline characteristics. Ulcer improvement was 79.2% in the TYO group and 41.7% in the SWT group (P=0.017) at 12 weeks, and 91.7% vs. 62.5% (P=0.036) at 24 weeks. The number of ulcers that were completely healed at 4, 12 and 24 weeks was similar in both groups, as were the numbers of adverse events. Healing time was 96±56 days (n=19) in the TYO group and 75±53 days (n=14) in the SWT group (P=0.271).

CONCLUSION

TYO plus SWT is more effective than SWT in the management of chronic diabetic foot ulcers and has few side-effects.

In-Hospital Complications and Mortality Following Major Lower Extremity Amputations in a Series of Predominantly Diabetic Patients

The purpose of this study was to analyze the outcomes of major lower extremity amputations (MLEAs) in a series, including diabetic patients, with the aim to study whether diabetes mellitus is a risk factor of in-hospital mortality and perioperative complications. A retrospective analysis of 283 MLEAs (221 of these patients were diabetic and 62 were nondiabetic) performed between January 1, 1998, and December 31, 2008, at the General Surgery Department and Diabetic Foot Unit of La Paloma Hospital in Las Palmas de Gran Canaria (Canary Islands) was done. The significant risk factors of mortality were >" xbd="324" xhg="301" ybd="1481" yhg="1446"/>75 years of age (odds ratio [OR] = 4.1, 95% confidence interval [CI] = 1.4-11.7), postoperative cardiac complications (OR = 12.3, 95% CI = 3.7-40.2) and postoperative respiratory complications (OR = 3.8, 95% CI = 1.0-13.3). No statistically significant risk factors were found related to the presence of systemic and wound-related complications. In diabetic patients, the significant risk factors of mortality were postoperative cardiological complications (OR = 13.6, 95% CI = 3.1-59.6), postoperative respiratory complications (OR = 5.9, 95% CI = 1.0-35.5), and first episode of amputation (OR = 5.9, 95% CI = 1.4-24.3). There were no statistically significant differences in the outcome of major amputations between diabetic and nondiabetic patients. Hospital stay was significantly longer in diabetic patients ( P < .01) though when the patients with diabetic foot infections were excluded, this difference was not found.