Trends in Major Lower Limb Amputation Related to Peripheral Arterial Disease in Hungary: A Nationwide Study (2004-2012)

Prediction of amputation risk of patients with diabetic foot using classification algorithms: A clinical study from a tertiary center

Diabetic foot ulcers can have vital consequences, such as amputation for patients. The primary purpose of this study is to predict the amputation risk of diabetic foot patients using machine-learning classification algorithms. In this research, 407 patients treated with the diagnosis of diabetic foot between January 2009-September 2019 in Istanbul University Faculty of Medicine in the Department of Undersea and Hyperbaric Medicine were retrospectively evaluated. Principal Component Analysis (PCA) was used to identify the key features associated with the amputation risk in diabetic foot patients within the dataset. Thus, various prediction/classification models were created to predict the "overall" risk of diabetic foot patients. Predictive machine-learning models were created using various algorithms. Additionally to optimize the hyperparameters of the Random Forest Algorithm (RF), experimental use of Bayesian Optimization (BO) has been employed. The sub-dimension data set comprising categorical and numerical values was subjected to a feature selection procedure. Among all the algorithms tested under the defined experimental conditions, the BO-optimized "RF" based on the hybrid approach (PCA-RF-BO) and "Logistic Regression" algorithms demonstrated superior performance with 85% and 90% test accuracies, respectively. In conclusion, our findings would serve as an essential benchmark, offering valuable guidance in reducing such hazards.

Examination of Lower Limb Microcirculation in Diabetic Patients with and without Intermittent Claudication

Intermittent claudication is a frequent complaint in lower extremity artery disease, but approximately two thirds of patients are asymptomatic, most of which are diabetic patients. Non-invasive angiological and microrheological tests on diabetic subjects with and without intermittent claudication were performed in the present study. In total, 98 diabetic patients were included and divided into two groups: 20 patients (63.5 ± 8.8 years, 55% men, 45% women) had intermittent claudication, 78 patients (65.5 ± 9.3 years, 61.5% men, 38.5% women) were asymptomatic. Hand-held Doppler ultrasound examination, transcutaneous tissue partial oxygen pressure (tcpO2) measurement, Rydel-Seiffer tuning fork tests, and 6-min walk tests were performed, and erythrocyte aggregation was investigated. Ankle-brachial index (p < 0.02) and tcpO2, measured during provocation tests (p < 0.003) and the 6-min walk test (p < 0.0001), significantly deteriorated in the symptomatic group. A higher erythrocyte aggregation index and faster aggregate formation was observed in claudication patients (p < 0.02). Despite the statistically better results of the asymptomatic group, 13% of these patients had severe limb ischemia based on the results of tcpO2 measurement. Claudication can be associated with worse hemodynamic and hemorheological conditions in diabetic patients; however, severe ischemia can also develop in asymptomatic subjects. Non-invasive vascular tests can detect ischemia, which highlights the importance of early instrumental screening of the lower limbs.

Incidence of Lower Extremity Amputation in Romania: A Nationwide 5-Year Cohort Study, 2015-2019

Background and Objectives: The primary objective of this study was to investigate the incidence of lower extremity amputations (LEAs) in a representative population from Romania, in both diabetic and non-diabetic adults, including trauma-related amputations. The secondary objective was to evaluate the trends in LEAs and the overall ratio of major-to-minor amputations. Material and Methods: The study was retrospective and included data from the Romanian National Hospital Discharge Records, conducted between 1 January 2015 and 31 December 2019. Results: The overall number of cases with LEAs was 88,102, out of which 38,590 were aterosclerosis-related LEAs, 40,499 were diabetes-related LEAs, and 9013 were trauma-related LEAs, with an ascending trend observed annually for each of these categories. Of the total non-traumatic amputations, 51.2% were in patients with diabetes. Most LEAs were in men. The total incidence increased from 80.61/100,000 in 2015 to 98.15/100,000 in 2019. Conclusions: Our study reported a 21% increase in total LEAs, 22.01% in non-traumatic LEAs, and 19.65% in trauma-related amputation. The minor-to-major amputation ratio increased over the study period in patients with diabetes. According to these findings, it is estimated that currently, in Romania, there is one diabetes-related amputation every hour and one non-traumatic amputation every 30 min.

Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature

Lower limb amputation (LLA) is a major surgical procedure with a significant impact on quality of life and mortality rates as well. Previous studies have shown that mortality rates following LLA can range from 9-17% within 30 days in the UK. This study systematically evaluates and reviews the published literature on life expectancy, mortality, and survival rates following lower extremity amputation (LEA). We have conducted a comprehensive search on Medline, CINAHL, and Cochrane Central databases resulting in 87 full-text articles. After a thorough review, only 45 (52.9%) articles met the minimum inclusion criteria for the study. Our analysis indicated 30-day mortality rates following LEA ranged from 7.1% to 51.4%, with an average mortality rate of 16.45% (SD 14.35) per study. Furthermore, 30-day mortality rates following below-knee amputation (BKA) and above-knee amputation (AKA) were found to be between 6.2% to 51.4%, X= 17.16% ± 19.46 SD and 12.7 to 21.7%, X= 16.15% ± 4.17 SD, respectively. Our review provides a comprehensive insight into the life expectancy, mortality, and survival rates following LEA. These findings highlight the importance of considering various factors, including patient age, presence of comorbidities such as diabetes, heart failure, and renal failure, and lifestyle factors such as smoking, in determining prognosis following LLA. Further research is necessary to determine strategies for improving outcomes and reducing mortality in this patient population.

Disease-Specific Quality of Life among Patients with Peripheral Artery Disease in Hungary

Peripheral artery disease (PAD) is a progressive atherosclerotic disease significantly impacting functional status and health-related quality of life (HRQoL). This study aimed to investigate HRQoL among PAD patients in Hungary using the validated Hungarian version of the PADQoL questionnaire. Patients with symptomatic PAD were consecutively recruited from the Department of Angiology, Clinical Center, University of Pécs, Hungary. Demographics, risk factors, and comorbidities were registered. Disease severity was measured by Fontaine and WIFI stages. Descriptive statistical analysis, Chi-square test, and non-parametric tests were performed (p < 0.05). Overall, 129 patients (mean age 67.6 ± 11.9 years, men 51.9%) participated in our study. The Hungarian PADQoL demonstrated good internal consistency (α range: 0.745-0.910). Factors on intimate and social relationships gave the best (89.15 ± 20.91; 63.17 ± 26.05) and sexual function (28.64 ± 27.42), and limitations in physical functioning (24.68 ± 11.40) the worst scores. PAD had a significant negative impact on the social relationships of patients aged 21-54 years (51.6 ± 25.4). Fontaine stage IV patients experienced significantly lower HRQoL due to fear and uncertainty (46.3 ± 20.9) and limited physical functioning (33.2 ± 24.8). The Hungarian PADQoL identified central aspects of HRQoL. Advanced PAD was found to impact several areas of HRQoL, primarily physical functioning and psycho-social well-being, drawing attention to the importance of early diagnosis and management.

Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: a review of national rates in the 21st century

AIMS/HYPOTHESIS

Diabetic foot disease (DFD) is a leading cause of hospital admissions and amputations. Global trends in diabetes-related amputations have been previously reviewed, but trends in hospital admissions for multiple other DFD conditions have not. This review analysed the published incidence of hospital admissions for DFD conditions (ulceration, infection, peripheral artery disease [PAD], neuropathy) and diabetes-related amputations (minor and major) in nationally representative populations.

METHODS

PubMed and Embase were searched for peer-reviewed publications between 1 January 2001 and 5 May 2022 using the terms 'diabetes', 'DFD', 'amputation', 'incidence' and 'nation'. Search results were screened and publications reporting the incidence of hospital admissions for a DFD condition or a diabetes-related amputation among a population representative of a country were included. Key data were extracted from included publications and initial rates, end rates and relative trends over time summarised using medians (ranges).

RESULTS

Of 2527 publications identified, 71 met the eligibility criteria, reporting admission rates for 27 countries (93% high-income countries). Of the included publications, 14 reported on DFD and 66 reported on amputation (nine reported both). The median (range) incidence of admissions per 1000 person-years with diabetes was 16.3 (8.4-36.6) for DFD conditions (5.1 [1.3-7.6] for ulceration; 5.6 [3.8-9.0] for infection; 2.5 [0.9-3.1] for PAD) and 3.1 (1.4-10.3) for amputations (1.2 [0.2-4.2] for major; 1.6 [0.3-4.3] for minor). The proportions of the reported populations with decreasing, stable and increasing admission trends were 80%, 20% and 0% for DFD conditions (50%, 0% and 50% for ulceration; 50%, 17% and 33% for infection; 67%, 0% and 33% for PAD) and 80%, 7% and 13% for amputations (80%, 17% and 3% for major; 52%, 15% and 33% for minor), respectively.

CONCLUSIONS/INTERPRETATION

These findings suggest that hospital admission rates for all DFD conditions are considerably higher than those for amputations alone and, thus, the more common practice of reporting admission rates only for amputations may substantially underestimate the burden of DFD. While major amputation rates appear to be largely decreasing, this is not the case for hospital admissions for DFD conditions or minor amputation in many populations. However, true global conclusions are limited because of a lack of consistent definitions used to identify admission rates for DFD conditions and amputations, alongside a lack of data from low- and middle-income countries. We recommend that these areas are addressed in future studies.

REGISTRATION

This review was registered in the Open Science Framework database ( https://doi.org/10.17605/OSF.IO/4TZFJ ).

Epidemiology of Peripheral Artery Disease: Narrative Review

Past decades have witnessed a major epidemiologic transition with a considerable increase in the disease burden associated with atherosclerotic cardiovascular diseases (CVDs), with low-income and middle-income countries (LMICs) experiencing substantial increase in CVDs. As the global population is aging and peripheral artery disease (PAD) is strongly age-related, it is estimated to become increasingly prevalent in the future. PAD shares risk factors with coronary and cerebrovascular risk factors, particularly diabetes mellitus and smoking, and is associated with significant CVD morbidity and mortality. Despite advances in therapeutic modalities, 236 million people were estimated to be suffering from PAD worldwide in 2015, and numbers have been rising since. The prevalence of asymptomatic PAD has remained high; PAD prevalence seems higher among women and is related to ethnicity. Although several epidemiological studies have been published on PAD during the past decades, data from LMICs are scarce. Besides providing up-to-date epidemiological data retrieved from the literature and the Global Burden of Disease (GBD) study database, this narrative review also intends to draw attention to the substantial disease burden of PAD manifesting in more Years of Life Lost (YLL), age-adjusted mortality and amputation rates, with a special focus on some European countries and especially Hungary, i.e., the country with the highest amputation rate in Europe.

The incidence and trend of geriatric amputations in Taiwan from 1996 to 2013

BACKGROUND

There has been a reported reduction in the incidence of amputation, but it is unclear whether the number of amputations has decreased in the elderly, a cohort that typically has the largest proportion of amputees.

OBJECTIVES

To investigate the incidence proportion and time trends of amputation in patients aged ≥ 65 years in Taiwan.

STUDY DESIGN

A retrospective cohort study from a large national database.

METHODS

The records of patients who underwent an amputation were collected from a nationally representative sample of 1,000,000 enrollees of Taiwan's National Health Insurance program during 1996-2013. The patients were divided into four age groups: ≤64, 65-74, 75-84, and ≥85 years. Joinpoint regression was performed with adjustment for age and sex to identify changes in incidence proportion by year.

RESULTS

During the 18 years, the incidence of upper and lower limb amputation decreased significantly in the total population, with the average annual percentage change (AAPC) of -6.1 and -1.8, respectively. However, in the elderly population over 65 years, the incidence did not decrease significantly for upper minor amputation, lower minor amputation, and major amputation with the AAPC of -1.1, -0.1, and -0.4, respectively. Although not significant, the incidence of major and minor lower limb amputation in the population over 85 years old showed an increasing trend, with the AAPC of 1.2 and 3.2, respectively.

CONCLUSION

During the study period, although the incidence of amputation of the overall population decreased in Taiwan, this trend was not simultaneously observed in the elderly and hence, it should not be ignored.

A Divide between the Western European and the Central and Eastern European Countries in the Peripheral Vascular Field: A Narrative Review of the Literature

Thirty years after the transition period, starting from 1989, Central and Eastern European countries (CEECs), representing one-fifth of the entire European population, share many historical, societal, political, economic, and cultural characteristics. Although accumulating data on coronary heart diseases and cerebrovascular diseases support these observations, in the case of peripheral arterial disease, data are scarce. The present review attempts to summarise the shreds of data that may highlight a divide in this field between CEECs and Western European countries. Disparities in risk factors and peripheral vascular care across Europe seem to be tangible and can be seen as a signal of existing differences. Improvements in research and development and the collection and cross-border share of scientific data are essential to initiate and facilitate convergence in this field.

Different approaches to quantify years of life lost from COVID-19

The burden of an epidemic is often characterized by death counts, but this can be misleading as it fails to acknowledge the age of the deceased patients. Years of life lost is therefore widely used as a more relevant metric, however, such calculations in the context of COVID-19 are all biased upwards: patients dying from COVID-19 are typically multimorbid, having far worse life expectation than the general population. These questions are quantitatively investigated using a unique Hungarian dataset that contains individual patient level data on comorbidities for all COVID-19 deaths in the country. To account for the comorbidities of the patients, a parametric survival model using 11 important long-term conditions was used to estimate a more realistic years of life lost. As of 12 May, 2021, Hungary reported a total of 27,837 deaths from COVID-19 in patients above 50 years of age. The usual calculation indicates 10.5 years of life lost for each death, which decreases to 9.2 years per death after adjusting for 11 comorbidities. The expected number of years lost implied by the life table, reflecting the mortality of a developed country just before the pandemic is 11.1 years. The years of life lost due to COVID-19 in Hungary is therefore 12% or 1.3 years per death lower when accounting for the comorbidities and is below its expected value, but how this should be interpreted is still a matter of debate. Further research is warranted on how to optimally integrate this information into epidemiologic risk assessments during a pandemic.

Population-based secular trends in lower-extremity amputation for diabetes and peripheral artery disease

BACKGROUND

The evolving clinical burden of limb loss secondary to diabetes and peripheral artery disease remains poorly characterized. We sought to examine secular trends in the rate of lower-extremity amputations related to diabetes, peripheral artery disease or both.

METHODS

We included all individuals aged 40 years and older who underwent lower-extremity amputations related to diabetes or peripheral artery disease in Ontario, Canada (2005-2016). We identified patients and amputations through deterministic linkage of administrative health databases. Quarterly rates (per 100 000 individuals aged ≥ 40 yr) of any (major or minor) amputation and of major amputations alone were calculated. We used time-series analyses with exponential smoothing models to characterize secular trends and forecast 2 years forward in time.

RESULTS

A total of 20 062 patients underwent any lower-extremity amputation, of which 12 786 (63.7%) underwent a major (above ankle) amputation. Diabetes was present in 81.8%, peripheral artery disease in 93.8%, and both diabetes and peripheral artery disease in 75.6%. The rate of any amputation initially declined from 9.88 to 8.62 per 100 000 between Q2 of 2005 and Q4 of 2010, but increased again by Q1 of 2016 to 10.0 per 100 000 (p = 0.003). We observed a significant increase in the rate of any amputation among patients with diabetes, peripheral artery disease, and both diabetes and peripheral artery disease. Major amputations did not significantly change among patients with diabetes, peripheral artery disease or both.

INTERPRETATION

Lower-extremity amputations related to diabetes, peripheral artery disease or both have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss.

Simple assessment of quality of life and lower limb functional capacity during cilostazol treatment – results of the SHort-tERm cIlostazol eFFicacy and quality of life (SHERIFF) study

Summary: Background: Symptomatic peripheral arterial disease (intermittent claudication) is a major cause of disability and mobility loss in older men and women and thus has a significant negative impact on the patients’ quality of life. Both surgical and endovascular revascularization procedures and noninvasive medical therapies, such as supervised training and drug treatment, can improve walking capacity. Cilostazol is the only drug having a class I (level of evidence A) recommendation for the treatment of intermittent claudication (IC). The aim of this study was to evaluate the effect of three-month cilostazol treatment on the health-related quality of life and on the lower limb functional capacity in patients with IC in the clinical practice. Patients and methods: The study was a multicenter, non-interventional trial, performed in Hungary in 2018. 812 PAD patients (Fontaine II stage, mean age: 67.17 years, male/female: 58.25/41.75 %) were enrolled, who received cilostazol (50 or 100 mg b.i.d.) for 3 months. 802 patients completed the study. Quality of life was evaluated with the EQ-5D-3L questionnaire functional capacity with the WELCH (Walking Estimated-Limitation Calculated by History) questionnaire. Pain-free and maximal walking distance, ankle-brachial index (ABI) were measured at baseline and after 3-month treatment. Results: Upon conclusion of the study, the EQ-5D-3L index improved (baseline: –0.46 ± 0.22, 3rd month: –0.26 ± 0.18; p < 0.0001) and there was a significant increase in the WELCH score as well (19 ± 14, 31 ± 18; respectively, p < 0.0001). Both pain-free and maximal walking distance improved significantly by 54.52 % (median: 53.85 %) and 42.5 % (median: 34.68 %); respectively (p < 0.001). Adverse events occurred in 10 patients, 1 patient stopped cilostazol treatment because of side effects. Conclusions: Three months cilostazol treatment significantly improved quality of life and lower limb functional capacity in patients with intermittent claudication. The WELCH questionnaire is a useful tool for the evaluation of intermittent claudication treatment in the clinical practice.

Potentials, challenges, and limitations of the analysis of administrative data on vascular limb amputations in health care

Although more and more data on lower limb amputations are becoming available by leveraging the widening access to health care administrative databases, the applicability of these data for public health decisions is still limited. Problems can be traced back to methodological issues, how data are generated and to conceptual issues, namely, how data are interpreted in a multidimensional environment. The present review summarised all of the steps from converting the claims data of administrative databases into the analytical data and reviewed the wide array of sources of potential biases in the analysis of such data. The origins of uncertainty of administrative data analysis include uncontrolled confounding due to a lack of clinical data, the left- and right-censored nature of data collection, the non-standardized diagnosis/procedure-based data extraction methods (i.e., numerator/denominator problems) and additional methodological problems associated with temporal and spatial analyses. The existence of these methodological challenges in the administrative data-based analysis should not deter the analysts from using these data as a powerful tool in the armamentarium of clinical research. However, it must be done with caution and a thorough understanding and respect of the methodological limitations. In addition to this requirement, there is a profound need for pursuing further research on methodology and widening the search for other indicators (structural, process or outcome) that allow a deeper insight how the quality of vascular care may be assessed. Effective research using administrative data is based on strong collaboration in three domains, namely expertise in claims data handling and processing, the clinical field, and statistical analysis. The final interpretations of results and the countermeasures on the level of vascular care ought to be grounded on the integrity of research, open discussions and institutionalized mechanisms of science arbitration and honest brokering.

Incidence rates of dysvascular lower extremity amputation changes in Northern Netherlands: A comparison of three cohorts of 1991-1992, 2003-2004 and 2012-2013

Objective

To analyze the incidence rates of dysvascular major lower extremity amputations (LEA) in Northern Netherlands in 2012–2013 compared to previous cohorts in 1991–1992 and 2003–2004.

Design

Retrospective cohort study.

Participants

Adults (N = 343) with first ever dysvascular LEA at ankle disarticulation or more proximal levels. The median age (interquartile range) was 74.2 years (64.5–81.9), 64% were male and 55% had been diagnosed with diabetes mellitus (DM).

Main outcome measures

Crude and age-standardized incidence rates of major LEA per 100.000 person-years.

Results

Crude incidence rate (IR) of first ever major LEA in 2012–2013 was 9.9 per 100.000 person-years, while the age-standardized IR was 7.7 per 100.000 person-years. A Poisson regression analysis showed that amputation rates among men were 2.3 times higher compared to women (95%CI 1.9–2.6), while in 2012–2013 the population aged >63 years had decreased amputation rates compared to 1991–1992. In the DM population the crude IR decreased from 142.6 per 100.000 person-years in 2003–2004 to 89.2 per 100.000 person-years in 2012–2013 (p<0.001).

Conclusions

In 2012–2013 a decrease in age-standardized IR for the general population and a decrease in crude IR for the DM population were observed compared to cohorts from the previous two decades, despite considerable shifts in the age distribution of the Dutch population towards more elderly people and increased prevalence of DM. These findings might suggest that improved treatment of patients at risk of dysvascular amputations is associated with reduced incidence rates of major LEA at the population level.

Improved limb salvage for patients with vascular disease and tissue loss associated with new model of provision targeted at the diabetic foot

AIMS

The establishment of a vascular surgeon-led emergency diabetic foot service in 2006 has evolved to provide lower limb wound care for patients with and without diabetes. We aimed to determine whether the service was associated with sustained, improved limb salvage rates for the whole population, analyse key aspects of service provision and compare outcomes against published studies.

METHODS

The vascular unit serves a largely rural population of approximately 240,000. Data was collected prospectively on lower limb amputations, arterial and minor surgical interventions from 2006 to 2015, and retrospectively retrieved for 2004-2005, prior to service commencement. Data was also collected on referral patterns, volume of patient admissions and attendances, and delays. Lower limb amputation rates were compared against published data and analysis of admission trends and delays employed non-parametric tests.

RESULTS

Age/gender adjusted major lower limb amputations for the populations with and without diabetes were 412/100,000 in 2004 and 15/100,000 in 2005 respectively. Following service introduction, major amputations reduced and since 2012 have been sustained at between 15-44/100,000 and 1-3/100,000 for patients with and without diabetes respectively, comparing favourably with published data. Vascular interventions have remained static, but referrals of patients directly to the service and numbers of minor procedures have increased.

CONCLUSIONS

The sustained decreases in all major lower limb amputations that have coincided with the development of a core team approach to providing rapid access and comprehensive care for patients with emergency diabetic foot problems may indicate that this service design benefits patients with and without diabetes.

Results of One-Stage or Staged Amputations of Lower Limbs Consequent to Critical Limb Ischemia and Infection

BACKGROUND

Amputations of lower limbs can be conducted as one-stage amputation (OSA) or staged amputation (SA) procedures. The objective of this study was to analyze technical success and mortality rates of both techniques, as well as factors that might influence outcomes in patients with critical limb ischemia (CLI).

METHODS

A retrospective study of 185 consecutive patients with CLI who underwent amputations in the period 2004-2011. Primary end points were rates of technical success (healing without dehiscence or reintervention) and mortality. The influence on outcomes of demographic data, clinical status, and comorbidities was also analyzed by logistic regression.

RESULTS

A total of 101 SA (91 patients) and 106 OSA (94 patients) were analyzed. SA had proportionally higher success rate (SA 77.2% vs. OSA 66.0%, P = 0.0253), lower perioperative mortality rate (SA, 10.9% vs. OSA, 20.7%, P = 0.0247), and lower 30-day mortality rate (SA, 12.2% vs. OSA, 23.8%, P = 0.0220) in spite of more cases with Rutherford classes 5 and 6 (SA, 87.1% vs. OSA, 72.6%, P = 0.0047), diabetes (71.2% vs. 55.6%, P = 0.0076), and infection (44.5% vs. 28.3%, P = 0.0061). Logistic regression demonstrated that in SA, success was more frequent in patients with diabetes who did not use insulin (P = 0.0072), in those with transfemoral amputations (P = 0.0392), with no coronary artery disease (P = 0.0053), and in foot infection (P = 0.0446), while for OSA success was more frequent in nondiabetic patients (P = 0.0077), limbs without infection (P = 0.0298), amputations at foot level (P = 0.0155), or transfemoral amputations (P = 0.0030).

CONCLUSIONS

SA had a higher rate of technical success and lower mortality rates than OSA, even with greater number of patients with diabetes and more severe cases of ischemia and infection. However, prospective studies comparing both techniques are needed for further evidence.

Risk factors for wound complications and 30-day mortality after major lower limb amputations in patients with peripheral arterial disease

Purpose Risk factors for wound complications or 30-day mortality after major amputation in patients with peripheral arterial disease remain unclear. We investigated the outcomes of major amputation in patients with peripheral arterial disease. Methods Patients who underwent major amputation from 2008 to 2015 were retrospectively analyzed. The main outcome measures were risk factors for wound complications and 30-day mortality after major lower limb amputations. Major amputation was defined as above-knee amputation or below-knee amputation. Wound complications were defined as surgical site infection or wound dehiscence. Results In total, 106 consecutive patients underwent major amputation. The average age was 77.3 ± 11.2 years, 67.9% of patients had diabetes mellitus and 35.8% were undergoing hemodialysis. Patients who underwent primary amputation constituted 61.9% of the cohort, and the proportions of above-knee amputation and below-knee amputation were 66.9% and 33.1%, respectively. The wound complication rate was 13.3% overall, 10.3% in above-knee amputation, and 19.5% in below-knee amputation. Multivariate analysis showed that the risk factors for wound complications were female sex (hazard ratio, 4.66; 95% confidence interval, 1.40-17.3; P = 0.01) and below-knee amputation (hazard ratio, 4.36; 95% confidence interval, 1.20-17.6; P = 0.03). The 30-day mortality rate was 7.6%, pneumonia comprised the most frequent cause of 30-day mortality, followed by sepsis and cardiac death. Multivariate analysis showed that a low serum albumin concentration (hazard ratio, 3.87; 95% confidence interval, 1.12-16.3; P = 0.03) was a risk factor for 30-day mortality. Conclusions Female sex and below-knee amputation were risk factors for wound complications. A low serum albumin concentration was a risk factor for 30-day mortality after major amputation in Japanese patients with peripheral arterial disease.

Análise dos fatores de risco relacionados às amputações maiores e menores de membros inferiores em hospital terciário

Contexto

As amputações dos membros inferiores, sejam definidas como maiores ou menores, são um grave problema de saúde, com altos índices de morbimortalidade e de relevante impacto social. Diferentes características clínicas dos pacientes parecem estar relacionadas aos diferentes tipos de amputação realizados.

Objetivos

Analisar os fatores de risco presentes em pacientes submetidos a amputações de membros inferiores em hospital terciário.

Métodos

Estudo retrospectivo, transversal, envolvendo 109 pacientes submetidos a amputação de membro inferior em um período de 31 meses, através da análise de gênero e idade, 15 dados clínicos e cinco parâmetros laboratoriais presentes no momento da admissão. Os dados foram submetidos a estatística descritiva e comparativa através do teste t de Student não pareado (para variáveis numéricas), e dos testes de Mann-Whitney e exato de Fisher (para variáveis categóricas).

Resultados

Das 109 amputações realizadas, 59 foram maiores e 50 menores. A maioria dos pacientes era do gênero masculino (65%), e a média de idade foi de 65 anos (mín. 39, máx. 93). Dentre os fatores de risco observados, idade avançada, acidente vascular encefálico, isquemia, sepse e níveis baixos de hemoglobina e hematócrito estavam estatisticamente mais relacionados às amputações maiores (p < 0,05). Diabetes melito, neuropatia e pulsos distais palpáveis foram fatores mais associados às amputações menores.

Conclusões

Os níveis das amputações de membros inferiores estão relacionados a diferentes fatores de risco. Os quadros isquêmicos mais graves e de maior morbidade estiveram associados a amputações maiores, enquanto a neuropatia e perfusão preservada, mais relacionados às amputações menores.

Administrative data are not sensitive for the detection of peripheral artery disease in the community

We sought to evaluate whether case ascertainment using administrative health data would be a feasible way to identify peripheral artery disease (PAD) patients from the community. Subjects' ankle-brachial index (ABI) scores from two previous prospective observational studies were linked with International Classification of Diseases (ICD) and Canadian Classification of Interventions (CCI) codes from three administrative databases from April 2002 to March 2012, including the Alberta Inpatient Hospital Database (ICD-10-CA/CCI), Ambulatory Care Database (ICD-10-CA/CCI), and the Practitioner Payments Database (ICD-9-CM). We calculated diagnostic statistics for putative case definitions of PAD consisting of individual code or sets of codes, using an ABI score ⩽ 0.90 as the gold standard. Multivariate logistic regression was performed to investigate additional predictive factors for PAD. Different combinations of diagnostic codes and predictive factors were explored to find out the best algorithms for identifying a PAD study cohort. A total of 1459 patients were included in our analysis. The average age was 63.5 years, 66% were male, and the prevalence of PAD was 8.1%. The highest sensitivity of 34.7% was obtained using the algorithm of at least one ICD diagnostic or procedure code, with specificity 91.9%, positive predictive value (PPV) 27.5% and negative predictive value (NPV) 94.1%. The algorithm achieving the highest PPV of 65% was age ⩾ 70 years and at least one code within 443.9 (ICD-9-CM), I73.9, I79.2 (ICD-10-CA/CCI), or all procedure codes, validated with ABI < 1.0 (sensitivity 5.56%, specificity 99.4% and NPV 84.6%). In conclusion, ascertaining PAD using administrative data scores was insensitive compared with the ABI, limiting the use of administrative data in the community setting.