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Kolasa M, Arponen O, Kaartinen I, Saarinen E, Solje E, Hirvonen J, Vuorlaakso M. Correlation of cerebral small vessel disease burden with outcome after lower extremity amputation. J Diabetes Complications 2024; 38:108829. [PMID: 39059188 DOI: 10.1016/j.jdiacomp.2024.108829] [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: 06/21/2024] [Revised: 07/21/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024]
Abstract
AIMS This study assessed whether changes associated with cerebral small vessel disease (CSVD) evaluated from head computed tomography (CT) images captured for non-related clinical purposes predict overall survival (OS), leg salvage (LS), and amputation-free survival (AFS) after lower extremity amputation (LEA). METHODS We retrospectively included a cohort of 240 patients who had undergone a lower extremity amputation in Tampere University Hospital between the years 2007 and 2020 and had a head CT scan (within one year before amputation). A neuroradiologist graded the white matter lesions (WMLs) and reported infarcts, and the latter's effects on OS, LS, and AFS were evaluated. RESULTS Altogether, 162 (67.5 %) and 91 (38.1 %) patients had WMLs and infarcts, respectively. Mild/moderate (HR 1.985, CI 95 % 1.317-2.992) and severe (HR 2.259, CI 95 % 1.501-3.399) WMLs and infarcts (HR 1.413, CI 95 % 1.029-1.940) were associated with inferior OS. After a minor amputation, mild/moderate (HR 2.012, CI 95 % 1.054-3.843) and severe (HR 3.879, CI 95 % 2.096-7.180) WMLs were similarly associated with inferior AFS. CONCLUSIONS Overall, WML and infarcts detected on head CT scans were associated with impaired OS after LEA and AFS after minor LEA. Evaluation of CSVD could provide useful prognostic information for clinicians.
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Affiliation(s)
- Marcin Kolasa
- Department of Radiology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Otso Arponen
- Department of Radiology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland; Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Ilkka Kaartinen
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Tampere, Finland
| | - Eva Saarinen
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland; Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Eino Solje
- Neuro Center - Neurology, Kuopio University Hospital, Kuopio, Finland; Institute of Clinical Medicine - Neurology, University of Eastern Finland, Kuopio, Finland
| | - Jussi Hirvonen
- Department of Radiology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland
| | - Miska Vuorlaakso
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Tampere, Finland.
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Yammine K, Honeine MO, Mouawad J, Abou Orm G, Hayek F, Assi C. Early Outcomes and Complications of Surgically Treated Diabetic Hallucal Infection. Ann Vasc Surg 2024; 105:77-81. [PMID: 38570013 DOI: 10.1016/j.avsg.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/12/2023] [Accepted: 01/09/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal diabetic foot infection (DFI) treated with either conservative surgery or amputation. METHODS This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all diabetic foot ulcer (DFU) were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups. RESULTS Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (P = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the reamputation rate for the amputation group was 23.1% (P = 0.2). CONCLUSIONS The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seem to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to magnetic resonance imaging bone infection signal could be considered to minimize the risk of subsequent surgeries and reamputations.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon.
| | - Mohammad Omar Honeine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Joseph Mouawad
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Ghadi Abou Orm
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Fady Hayek
- Division of Vascular Surgery, Department of General Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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McBane RD, Murphree DH, Liedl D, Lopez-Jimenez F, Arruda-Olson A, Scott CG, Prodduturi N, Nowakowski SE, Rooke TW, Casanegra AI, Wysokinski WE, Houghton DE, Muthusamy K, Wennberg PW. Artificial intelligence of arterial Doppler waveforms to predict major adverse outcomes among patients with diabetes mellitus. J Vasc Surg 2024; 80:251-259.e3. [PMID: 38417709 DOI: 10.1016/j.jvs.2024.02.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 02/12/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Patients with diabetes mellitus (DM) are at increased risk for peripheral artery disease (PAD) and its complications. Arterial calcification and non-compressibility may limit test interpretation in this population. Developing tools capable of identifying PAD and predicting major adverse cardiac event (MACE) and limb event (MALE) outcomes among patients with DM would be clinically useful. Deep neural network analysis of resting Doppler arterial waveforms was used to detect PAD among patients with DM and to identify those at greatest risk for major adverse outcome events. METHODS Consecutive patients with DM undergoing lower limb arterial testing (April 1, 2015-December 30, 2020) were randomly allocated to training, validation, and testing subsets (60%, 20%, and 20%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict all-cause mortality, MACE, and MALE at 5 years using quartiles based on the distribution of the prediction score. RESULTS Among 11,384 total patients, 4211 patients with DM met study criteria (mean age, 68.6 ± 11.9 years; 32.0% female). After allocating the training and validation subsets, the final test subset included 856 patients. During follow-up, there were 262 deaths, 319 MACE, and 99 MALE. Patients in the upper quartile of prediction based on deep neural network analysis of the posterior tibial artery waveform provided independent prediction of death (hazard ratio [HR], 3.58; 95% confidence interval [CI], 2.31-5.56), MACE (HR, 2.06; 95% CI, 1.49-2.91), and MALE (HR, 13.50; 95% CI, 5.83-31.27). CONCLUSIONS An artificial intelligence enabled analysis of a resting Doppler arterial waveform permits identification of major adverse outcomes including all-cause mortality, MACE, and MALE among patients with DM.
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Affiliation(s)
- Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN.
| | - Dennis H Murphree
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | - David Liedl
- Gonda Vascular Center, Mayo Clinic, Rochester, MN
| | - Francisco Lopez-Jimenez
- Cardiovascular Department, Mayo Clinic, Rochester, MN; Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN
| | | | | | - Naresh Prodduturi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | - Thom W Rooke
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
| | | | - Paul W Wennberg
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Cardiovascular Department, Mayo Clinic, Rochester, MN
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Rolle NP, Kawaji Q, Morton C, Rosenberg KM, Kalsi R, Blitzer DN, Nagarsheth K. Risk Factors for Lower Extremity Minor Amputation Conversion to Major Amputation. Ann Vasc Surg 2024; 104:166-173. [PMID: 38387800 DOI: 10.1016/j.avsg.2023.12.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Minor lower extremity amputations (LEAs) have become an important part of the limb salvage approach but are not as benign as previously thought. This study investigates the difference in outcome between toe/ray versus midfoot amputations and the risk factors for major amputation conversion associated with each procedure. METHODS We performed retrospective chart review of foot amputation patients at a single tertiary care medical center with a primary end point of conversion to major amputation and secondary end points of 1-year wound healing and mortality rate. We collected data on relevant medical comorbidities, noninvasive vascular imaging, revascularization, repeat amputations, wound healing rate, and 1-year mortality. Patients were separated into toe/ray amputations versus midfoot amputation groups and compared using descriptive statistics, Chi-squared tests, Cox proportional hazards, and a multivariate logistic regression model. RESULTS A total of 375 amputations were included in the analysis. 65.3% (245 patients) included toe/ray amputations and 34.7% (130 patients) included midfoot amputations. We compared these 2 cohorts with regard to their rate of conversion to repeat minor and/or major amputation in addition to overall mortality. The toe/ray group underwent more repeat minor amputations within 1 year after index amputation (34.7% vs. 21.5%, P = 0.008) and wound healing (epithelization) at 90 days was also higher in this group. The midfoot group had a higher conversion to major LEA within 1 year on univariate analysis (20.8 vs. 6.9%, P < 0.001). Overall 1-year mortality was 6.17% and there was no significant difference between groups. CONCLUSIONS While there is a consistency with previous studies that found no significant overall difference in mortality between types of minor LEA, we have extended this previous work by demonstrating the independent risk factors for conversion to major amputation between types of minor LEA. Comparing these 2 groups will assist surgeons in choosing the appropriate level of amputations and will enhance patient's understanding of their chance of wound healing and risk of repeat amputation.
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Affiliation(s)
- Nicholas P Rolle
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA.
| | - Qingwen Kawaji
- Department of Surgery, Medstar Health Baltimore, Baltimore, MD
| | - Claire Morton
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Richa Kalsi
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - David N Blitzer
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Khanjan Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
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Kasiri MM, Mittlboeck M, Gollackner B, Neumayer C. Mortality in Amputees with Peripheral Artery Disease during the Post-COVID Era: A Three-Year Analysis. Diseases 2024; 12:133. [PMID: 39057104 PMCID: PMC11276342 DOI: 10.3390/diseases12070133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Patients with peripheral artery disease (PAD) have 40-70% higher three-year mortality after lower limb amputation compared to non-amputees. In this study, we examined the consequences of delayed treatment for patients with PAD during the coronavirus disease 2019 (COVID-19) pandemic. METHODS This study employed a retrospective single-centre cohort design at a large tertiary care hospital. We compared amputees with PAD during the initial COVID-19 outbreak period in 2020 with a control group of amputees from 2019 after a three-year follow-up. RESULTS In total, 134 amputees with PAD were included due to unsuccessful revascularization (n = 84 in 2020 vs. n = 50 in 2019). Patients in 2020 were significantly younger than those in 2019 (p = 0.01) and mostly admitted with advanced stages of PAD (p < 0.03). The proportion of major limb amputations increased significantly in 2020 (p = 0.03). Non-COVID-19-related deaths among patients in 2020 were more than twice as many as those in 2019, and long-term mortality in 2020 was 49% compared to 39% in 2019 (p = 0.04). Diabetes and renal insufficiency had a significantly negative impact on the survival of amputees with PAD (p < 0.01). CONCLUSIONS Delayed treatment in patients with PAD leads to high long-term mortality risk after amputation, especially in PAD patients with diabetes and renal insufficiency. Therefore, in future pandemics, continuously monitoring patients with PAD will be crucial to prevent delayed treatment and severe short-term and long-term consequences.
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Affiliation(s)
- Mohammad Mahdi Kasiri
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Martina Mittlboeck
- Institute of Clinical Biometrics, Center for Medical Data Science, Medical University of Vienna, 1090 Vienna, Austria
| | - Bernd Gollackner
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Neumayer
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, 1090 Vienna, Austria
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Xu Z, Cheng K, Wang K, Gui L. Experiences of middle-aged individuals with lower extremity amputation caused by diabetic foot ulcer after disability in China: A qualitative study. Nurs Open 2024; 11:e2213. [PMID: 38875354 PMCID: PMC11178130 DOI: 10.1002/nop2.2213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 05/31/2024] [Indexed: 06/16/2024] Open
Abstract
AIM To understand the experiences of individuals who undergo LEA due to DFU after disability. DESIGN A descriptive research design in qualitative research. METHODS Semi-structured interviews were used in this qualitative descriptive study. Eleven middle-aged patients (45-59 years) who underwent LEA due to DFU were purposively selected and interviewed. Qualitative data were thematically analysed. RESULTS Three themes and 10 subthemes were identified. The themes were (1) role function confusion, (2) self-concept stress and (3) unreasonable objective support. Subthemes included (1) weakened career role, (2) family role reversal, (3) social role restriction, (4) over-focusing on appearance, (5) immersion in patient experience, (6) living with faith, (7) polarization of independent consciousness, (8) low perceived benefits of peer support, (9) existence of treatment disruption and (10) poor participation in medical decision-making.
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Affiliation(s)
- Ziwei Xu
- School of Nursing, Naval Medical University, Shanghai, China
| | - Kangyao Cheng
- School of Nursing, Naval Medical University, Shanghai, China
| | - Kuan Wang
- School of Nursing, Naval Medical University, Shanghai, China
| | - Li Gui
- School of Nursing, Naval Medical University, Shanghai, China
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Sanpinit S, Chokpaisarn J, Na-Phatthalung P, Sotthibandhu DS, Yincharoen K, Wetchakul P, Limsuwan S, Chusri S. Effectiveness of Ya-Samarn-Phlae in diabetic wound healing: Evidence from in vitro studies and a multicenter randomized controlled clinical trial. JOURNAL OF ETHNOPHARMACOLOGY 2024; 326:117929. [PMID: 38373661 DOI: 10.1016/j.jep.2024.117929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/29/2023] [Accepted: 02/16/2024] [Indexed: 02/21/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Ya-Samarn-Phlae (YaSP) has traditionally been widely used in southern Thailand for treating chronic and infected wounds, including diabetic foot ulcers. However, there are only a limited number of clinical studies supporting the use of this polyherbal formulation. Therefore, the present work aims to provide clinical evidence to support the application of YaSP, prepared according to a standardized traditional procedure (T-YaSP). Additionally, its potential chemical markers and wound healing-related biological activities were examined. MATERIALS AND METHODS The in vitro wound healing-related biological activities of YaSP ethanol extract and T-YaSP, including antibacterial activity against Staphylococcus epidermidis, inhibition and eradication of staphylococcal biofilm, anti-inflammatory effects, and enhancement of human dermal fibroblast migration in scratch wounds, were examined using well-established protocols. The chemical profiles of the ethanol extract of YaSP and T-YaSP were compared, and with promising chemical markers, arecoline, alpha-mangostin, and curcumin were selected and quantified using the HPLC method. A prospective, multicenter, randomized, controlled, parallel-group study was conducted over 12 weeks to evaluate the efficacy of the YaSP solution as an adjunct therapy, combined with standard wound care, for diabetic ulcers compared to standard treatment. RESULTS The YaSP extract reduces NO production and can scavenge NO radicals in LPS-induced RAW 264.7 macrophage cells. Additionally, in a scratch assay, this extract and one of its herbal components, Curcuma longa, enhance the migration of human dermal fibroblasts. T-YaSP, containing 2.412 ± 0.002 mg/g of arecoline, 2.399 ± 0.005 mg/g of curcumin, and 0.017 ± 0.000 mg/g of α-mangostin, has shown the ability to inhibit the development and eradicate the mature biofilm of S. epidermidis. The use of T-YaSP as an adjunct therapy led to a significantly higher proportion of patients achieving healing within six weeks compared to the standard treatment group (36%/9 patients vs. 4%/1 patient; p = 0.013). After 12 weeks, 19 out of 25 patients in the T-YaSP group experienced complete healing, whereas only four patients in the standard treatment group achieved complete wound healing (76% in the T-YaSP group vs. 16% in the control group; p < 0.001). CONCLUSION The results presented here represent the first randomized controlled trial to demonstrate the effectiveness of the traditional polyherbal solution, T-YaSP, which exhibits a wide range of wound healing-related activities. Utilizing T-YaSP as an adjunctive treatment resulted in a significant improvement in the number of type 2 diabetic patients achieving complete healing. However, to explore and utilize YaSP further, conducting a double-blind, randomized controlled trial with a larger population is necessary.
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Affiliation(s)
- Sineenart Sanpinit
- School of Medicine, Walailak University, Thasala, Nakhon Si Thammarat, 80160, Thailand
| | - Julalak Chokpaisarn
- Faculty of Traditional Thai Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90112, Thailand
| | - Pinanong Na-Phatthalung
- The Second Affiliated Hospital, The First Affiliated Hospital, School of Public Health, Institute of Translational Medicine, Cancer Center, State Key Laboratory of Experimental Hematology, Zhejiang University School of Medicine, Hangzhou, 310058, China
| | | | - Kanyatorn Yincharoen
- Department of Thai Traditional Medicine, Faculty of Science and Technology, Rajamangala University of Technology Srivijaya (RMUTSV), Thung Song, Nakhon Si Thammarat, 80110, Thailand
| | - Palika Wetchakul
- School of Medicine, Walailak University, Thasala, Nakhon Si Thammarat, 80160, Thailand
| | - Surasak Limsuwan
- Faculty of Traditional Thai Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90112, Thailand
| | - Sasitorn Chusri
- School of Health Science and Biomedical Technology Research Group for Vulnerable Populations, MaeFah Luang University, Chiang Rai, 57100, Thailand.
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Yammine K, Mouawad J, Honeine MO, Assi C. Interphalangeal Resection Arthroplasty for the Prevention and Treatment of Diabetic Deformities and Ulcers of the Toes: A Systematic Review and Meta-analysis. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241256373. [PMID: 38840785 PMCID: PMC11151763 DOI: 10.1177/24730114241256373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Background Diabetic foot ulcers (DFUs) are serious complications that induce a high risk of lower extremity amputations and mortality. Compared with the standard of care, few reports analyzed the outcome of surgical treatment mainly for diabetic toe deformities and ulcers. The aim of this study is to collate evidence on the outcomes of interphalangeal resection arthroplasty (IP-RA) in preventing and treating diabetic toe ulcers distal to the metatarsophalangeal joint. Methods A search strategy has been developed including electronic databases from inception. Only ulcers distal to the metatarsophalangeal joints were included. Noninfected and infected ulcers were also included at any toe location (dorsal/side/plantar). Outcomes were defined as healing rate, time to heal, ulcer recurrence, ulcer transfer, postintervention infection, wound dehiscence, and additional surgeries including amputation. Proportional meta-analysis was conducted for frequency outcomes. Results Six observational studies comprising 217 patients with 244 IP-RA procedures were included. The mean follow-up period was 23.4 ± 8.2 months. Weighted frequencies were as follows: healing rate (93.6%), ulcer recurrence frequency (4.3%), ulcer transfer frequency (15.4%), postoperative infection (10.5%), wound dehiscence (17.8%), revision surgery (5%), and amputation rate (3.4%). The mean healing time was 4.3 ± 1.8 weeks. Conclusion This review suggests that IP-RA is effective in preventing and treating diabetic toe deformities and ulcers with a modest rate of complications for this specific and often challenging clinical presentation.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
| | - Joseph Mouawad
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Mohammad Omar Honeine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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Espitia O, Del Giudice C, Hartung O, Herquelot E, Schmidt A, Sapoval M, Sobocinski J. Editor's Choice -- Survival, Limb Salvage, and Management of Patients with Lower Limb Acute Ischaemia: A French National Retrospective Observational Study. Eur J Vasc Endovasc Surg 2024; 67:631-642. [PMID: 37926151 DOI: 10.1016/j.ejvs.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2023] [Accepted: 11/01/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE The aim was to describe the baseline characteristics of French patients referred with acute limb ischaemia (ALI), and their clinical management and outcome (death, amputation). METHODS This retrospective observational cohort study used the National Health Data System. All adults hospitalised for ALI who underwent revascularisation with an endovascular or open surgical approach between 1 January 2015 and 31 December 2020 were included and followed up until death or the end of the study (31 December 2021). A one year look back period was used to capture patients' medical history. The risks of death, and major and minor amputations were described using Kaplan-Meier and Aalen-Johansen estimators. A Cox model was used to report the adjusted association between groups and risk of death and Fine-Gray models for the risk of amputations considering the competing risk of death. RESULTS Overall, 51 390 patients (median age 70 years, 69% male) were included and had a median follow up of 2.7 years: 39 411 (76.7%) were treated with an open approach and 11 979 (23.3%) with a percutaneous endovascular approach. The preferred approach for the revascularisation varied between French regions. The one year overall survival was 78.0% and 85.2% in the surgery and endovascular groups, respectively. The surgery group had a higher risk of death (hazard ratio [HR] 1.17, 95% CI 1.12 - 1.21), a higher risk of major amputation (sub-distribution HR 1.20, 95% CI 1.10 - 1.30) and lower risk of minor amputation (sub-distribution HR 0.66, 95% CI 0.60 - 0.71) than the endovascular group. Diabetes and dialysis increased the risk of major amputation by 52% and 78%, respectively. Subsequent ALI was the third most common cause of hospital re-admission within one year. CONCLUSION ALI remains a condition at high risk of death and amputation. Individual risk factors and ALI severity need to be considered to choose between approaches. Continued prevention efforts, improved management, and access to the most suitable approach are necessary.
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Affiliation(s)
- Olivier Espitia
- Nantes Université, CHU Nantes, Department of internal and vascular medicine, F-44000 Nantes, France.
| | | | - Olivier Hartung
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Nord, Marseille, France
| | | | | | - Marc Sapoval
- Radiologie interventionnelle, Hôpital Européen Georges-Pompidou, Paris, France
| | - Jonathan Sobocinski
- Chirurgie vasculaire et endovasculaire, Centre Hospitalier Universitaire de Lille, Lille, France
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Manji A, Basiri R, Harton F, Rommens K, Manji K. Effectiveness of a Multidisciplinary Limb Preservation Program in Reducing Regional Hospitalization Rates for Patients With Diabetes-Related Foot Complications. INT J LOW EXTR WOUND 2024:15347346241238458. [PMID: 38504634 DOI: 10.1177/15347346241238458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVE This study evaluated the toe and flow model (TFM), a limb preservation program led by podiatric surgeons in Alberta, Canada, for its impact on hospitalization rates and length of stay (LOS) in patients with diabetic foot complication (DFC). Diabetes, a leading cause of non-traumatic lower extremity amputations (LEAs) in Canada, often results in diabetic foot ulcers (DFUs), a major cause of infection, amputation, and hospitalization. TFM has reportedly reduced amputation rates by 39% to 56%. METHODS The study analyzed Alberta's health database from 2007 to 2017, focusing on diabetes patients aged 20 and above. It included patients with various DFCs and compared outcomes in regions using TFM and standard of care (SOC). The study also examined data from two major cities, one with TFM and the other without, including rural referrals to Calgary and Edmonton. The data were normalized for the diabetic population and analyzed using a standard Student's t-test. RESULTS TFM regions showed significantly lower hospitalization rates (p = 1.22E-12) than SOC regions. Over 11 years, TFM maintained lower average and median LOS by 0.13 and 0.26 days, respectively. TFM access reduced hospitalization risk by up to 30%, and patients in TFM regions had a 21% shorter LOS compared to SOC regions. CONCLUSION Despite similar demographics and healthcare systems, the TFM region benefited from a dedicated multidisciplinary program and comprehensive limb preservation services. The study shows that TFM effectively reduces hospitalizations and LOS for DFCs, with significantly better outcomes in the TFM region than in SOC regions.
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Affiliation(s)
- Ali Manji
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Reza Basiri
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Institute of Biomedical Engineering, University of Toronto, Ontario, Canada
| | - Francois Harton
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kenton Rommens
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karim Manji
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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11
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes and a foot ulcer. Diabetes Metab Res Rev 2024; 40:e3686. [PMID: 37726988 DOI: 10.1002/dmrr.3686] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this guideline the IWGDF, the European Society for Vascular Surgery and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development, and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, New South Wales, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Department Internal Medicine, MUMC+, Maastricht, The Netherlands
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12
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Coye T, Ansert E, Suludere MA, Chung J, Kang GE, Lavery LA. Healing rates and outcomes following closed transmetatarsal amputations: A systematic review and random effects meta-analysis of proportions. Wound Repair Regen 2024; 32:182-191. [PMID: 38111147 DOI: 10.1111/wrr.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/20/2023] [Accepted: 11/27/2023] [Indexed: 12/20/2023]
Abstract
Transmetatarsal amputation (TMA) is a common surgical procedure for addressing severe forefoot pathologies, such as peripheral vascular disease and diabetic foot infections. Variability in research methodologies and findings within the existing literature has hindered a comprehensive understanding of healing rates and complications following TMA. This meta-analysis and systematic review aims to consolidate available evidence, synthesising data from multiple studies to assess healing rates and complications associated with closed TMA procedures. Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, a systematic search of Medline, Embase, and Cochrane databases was conducted for articles published from January 1st, 1988, to June 1st, 2023. Inclusion criteria comprised studies reporting healing rates in non-traumatic transmetatarsal amputation patients with more than 10 participants, excluding open TMAs. Two independent reviewers selected relevant studies, with disagreements resolved through discussion. Data extracted from eligible studies included patient demographics, healing rates, complications, and study quality. Among 22 studies encompassing 1569 transmetatarsal amputations, the pooled healing rate was 67.3%. Major amputation rates ranged from 0% to 55.6%, with a random-effects pooled rate of 23.9%. Revision rates varied from 0% to 36.4%, resulting in a pooled rate of 14.8%. 30-day mortality ranged from 0% to 9%, with a fixed-effects pooled rate of 2.6%. Post-operative infection rates ranged from 3.0% to 30.7%, yielding a random-effects pooled rate of 16.7%. Dehiscence rates ranged from 1.7% to 60.0%, resulting in a random-effects pooled rate of 28.8%. Future studies should aim for standardised reporting and assess the physiological and treatment factors influencing healing and complications.
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Affiliation(s)
- Tyler Coye
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Elizabeth Ansert
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Mehmet A Suludere
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jayer Chung
- Michael E DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Gu Eon Kang
- Department of Bioengineering, The University of Texas, Dallas, Texas, USA
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern, Dallas, Texas, USA
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13
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Chuter V, Schaper N, Mills J, Hinchliffe R, Russell D, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, van den Berg JC, Venermo M, Fitridge R. Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: A systematic review. Diabetes Metab Res Rev 2024; 40:e3683. [PMID: 37477087 DOI: 10.1002/dmrr.3683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 07/22/2023]
Abstract
As a progressive disease process, early diagnosis and ongoing monitoring and treatment of lower limb peripheral artery disease (PAD) is critical to reduce the risk of diabetes-related foot ulcer (DFU) development, non-healing of wounds, infection and amputation, in addition to cardiovascular complications. There are a variety of non-invasive tests available to diagnose PAD at the bedside, but there is no consensus as to the most diagnostically accurate of these bedside investigations or their reliability for use as a method of ongoing monitoring. Therefore, the aim of this systematic review was to first determine the diagnostic accuracy of non-invasive bedside tests for identifying PAD compared to an imaging reference test and second to determine the intra- and inter-rater reliability of non-invasive bedside tests in adults with diabetes. A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective and retrospective investigations of the diagnostic accuracy of bedside testing in people with diabetes using an imaging reference standard and reliability studies of bedside testing techniques conducted in people with diabetes were eligible. Included studies of diagnostic accuracy were required to report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) which were the primary endpoints. The quality appraisal was conducted using the Quality Assessment of Diagnostic Accuracy Studies and Quality Appraisal of Reliability quality appraisal tools. From a total of 8517 abstracts retrieved, 40 studies met the inclusion criteria for the diagnostic accuracy component of the review and seven studies met the inclusion criteria for the reliability component of the review. Most studies investigated the diagnostic accuracy of ankle -brachial index (ABI) (N = 38). In people with and without DFU, PLRs ranged from 1.69 to 19.9 and NLRs from 0.29 to 0.84 indicating an ABI <0.9 increases the likelihood of disease (but the extent of the increase ranges from a small to large amount) and an ABI within the normal range (≥0.90 and <1.3) does not exclude PAD. For toe-brachial index (TBI), a threshold of <0.70 has a moderate ability to rule PAD in and out; however, this is based on limited evidence. Similarly, a small number of studies indicate that one or more monophasic Doppler waveforms in the pedal arteries is associated with the presence of PAD, whereas tri- or biphasic waveform suggests that PAD is less likely. Several forms of bedside testing may also be useful as adjunct tests and 7 studies were identified that investigated the reliability of bedside tests including ABI, toe pressure, TBI, transcutaneous oxygen pressure (TcPO2 ) and pulse palpation. Inter-rater reliability was poor for pulse palpation and moderate for TcPO2. The ABI, toe pressure and TBI may have good inter- and intra-rater reliability, but margins of error are wide, requiring a large change in the measurement for it to be considered a true change rather than error. There is currently no single bedside test or a combination of bedside tests that has been shown to have superior diagnostic accuracy for PAD in people with diabetes with or without DFU. However, an ABI <0.9 or >1.3, TBI of <0.70, and absent or monophasic pedal Doppler waveforms are useful to identify the presence of disease. The ability of the tests to exclude disease is variable and although reliability may be acceptable, evidence of error in the measurements means test results that are within normal limits should be considered with caution and in the context of other vascular assessment findings (e.g., pedal pulse palpation and clinical signs) and progress of DFU healing.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco (UCSF) Medical Centre, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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14
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Yammine K, Abdallah R, Stiban S, Helou M, Hayek F, Assi C. Monitoring negative pressure wound therapy for diabetic foot ulcers using WhatsApp. J Tissue Viability 2024; 33:1-4. [PMID: 38220561 DOI: 10.1016/j.jtv.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/24/2023] [Accepted: 01/10/2024] [Indexed: 01/16/2024]
Abstract
Foot complications of patients with diabetes could lead to amputations and early death. Diabetic foot ulcers (DFU) are usually difficult to treat and impose huge financial burden. Monitoring wound progress is the mainstay of any treatment and alternatives to face-to-face consultations such as tele-medicine have been proposed. Very few papers explored the utility and effectiveness of monitoring DFU through instant messaging application such as WhatsApp. The aim of this study is to evaluate the validity of WhatsApp in monitoring diabetic wounds treated with negative pressure wound therapy (NPWT). Twenty-two patients were prospectively recruited. All patients had an initial face-to-face consultation and debridement. Dressings were changed twice per week at patient's residence and media files were sent by the wound nurse via Short Message Service (SMS). A subsequent face to face consultation was scheduled whenever a complication was suspected. The primary outcomes were the percentages of accurate cases a) where a new or recurrent infection was suspected, and a b) where a debridement was thought to be needed. Complete healing of the defect using NPWT was achieved in 10 patients and a skin graft procedure was needed in another 4 patients. Five patients needed further surgical debridement. Failure to heal was observed in 3 patients. Out of the seven cases where a new infection was suspected, five (71.5%) were confirmed on face-to-face consultation. No confirmed cases of infection were observed during follow-up for those estimated as clean. Out of the 11 cases where debridement was favored based on WhatsApp media files, confirmation of a needed debridement was recorded in 8 (73%) cases. NPWT monitoring of for diabetic foot and leg ulcers using WhatsApp application was found to be an excellent method to document and track the wound process and complications. The excellent specificity and high sensibility should encourage for common use by healthcare. The results of this study could be also valuable for patients living in rural areas and in case of future pandemics.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon.
| | - Ralph Abdallah
- Faculty of Arts and Science, University of Toronto, Canada
| | - Sonia Stiban
- Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Mariana Helou
- Department of Emergency Medicine, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Fady Hayek
- Division Vascular Surgery, Department General Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
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15
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Lauwers P, Wouters K, Vanoverloop J, Avalosse H, Hendriks JMH, Nobels F, Dirinck E. The impact of diabetes on mortality rates after lower extremity amputation. Diabet Med 2024; 41:e15152. [PMID: 37227722 DOI: 10.1111/dme.15152] [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: 01/31/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018. METHODS Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed. RESULTS Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes. CONCLUSIONS In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.
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Affiliation(s)
- Patrick Lauwers
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Center (CTC), CRC Antwerp, Edegem, Belgium
| | - Johan Vanoverloop
- IMA/AIM (Intermutualistisch Agentschap/Agence Intermutualiste), Brussels, Belgium
| | - Hervé Avalosse
- IMA/AIM (Intermutualistisch Agentschap/Agence Intermutualiste), Brussels, Belgium
- Landsbond der Christelijke Mutualiteiten/Alliance Nationale des Mutualités Chrétiennes, Brussels, Belgium
| | - Jeroen M H Hendriks
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Frank Nobels
- Department of Endocrinology, Onze Lieve Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Eveline Dirinck
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium
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16
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Truong DH, Ngoo AK, Tsai S, Yang AK, Wukich DK, Lavery LA. Success of transmetatarsal amputation for limb salvage in patients with peripheral artery disease. Int Wound J 2024; 21:e14360. [PMID: 37622404 PMCID: PMC10781589 DOI: 10.1111/iwj.14360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
Limb salvage is a difficult path for patients to travel as there is no guarantee of the outcome, often the major factor is perfusion. For patients who underwent transmetatarsal amputation (TMA), success rate is crucial as the next option is most likely a major amputation. We performed a 10 years (2010-2020) retrospective review of patients that underwent a TMA and had an angiogram or computed tomography angiography (CTA) perioperatively at the Dallas VA Medical Center. Failure after TMA was defined as a patient requiring a proximal amputation within 1 year. There were 125 TMAs performed between 2010 and 2020 at the institution. Forty-four (35.2%) patients had an angiogram/CTA peri-operative and met the inclusion criteria. Seventeen subjects (38.6%) had a higher level of amputation. Of the 17 failures, 2 (11.8%) patients had no patent vessel runoff to the foot, 9 (52.9%) had one vessel, 4 (23.5%) had two vessels, and 2 (11.8%) had three vessels runoff. One vessel runoff to the foot yielded a high rate of poor outcomes (56.3%) defined as a higher level of amputation. Two or more vessels runoff to the foot had over 75% success of limb salvage with a TMA.
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Affiliation(s)
- David H. Truong
- Surgical Service, Podiatry SectionVeterans Affairs North Texas Health Care SystemDallasTexasUSA
- Department of Orthopaedic SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Anthony K. Ngoo
- Medical Service, Infectious Disease SectionVeterans Affairs North Texas Health Care SystemDallasTexasUSA
| | - Shirling Tsai
- Surgical Service, Vascular SectionVeterans Affairs North Texas Health Care SystemDallasTexasUSA
- Department of Surgery, Division of Vascular & Endovascular SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Anna K. Yang
- Foundation Foot & Ankle CenterNapervilleIllinoisUSA
| | - Dane K. Wukich
- Department of Orthopaedic SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Lawrence A. Lavery
- Department of Orthopaedic SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
- Department of Plastic SurgeryUniversity of Texas Southwestern Medical CenterDallasTexasUSA
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Demirkoparan M, Vahabi A, Özbek B, Mert M, Yıldırım Şimşir I, Erdem HA, Öztürk AM, Çetinkalp Ş. Efficacy of telemedicine applications in patients with diabetic foot ulcers: A focus on mortality and major amputation rates. Int Wound J 2023; 20:3955-3962. [PMID: 37340728 PMCID: PMC10681535 DOI: 10.1111/iwj.14283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/22/2023] Open
Abstract
Amputations related to diabetic foot ulcers (DFU) are associated with high morbidity and mortality rates. Glycaemic control and close follow-up protocols are essential to prevent such ulcers. Coronavirus disease (COVID) related restrictions and regulations might have a negative impact on patients who are with DFU or candidates for DFU. We retrospectively analysed 126 cases that had DFU underwent amputation surgery. Comparative analyses were done between cases that were admitted before COVID restrictions (Group A) and cases admitted after COVID restrictions (Group B). Two groups were homogenic demographically. There was no significant difference between groups in terms of mortality (p = 0.239) and amputation rates (p = 0.461). The number of emergent cases in the pandemic period doubled the number in pre-pandemic period even though this finding was not statistically significant (p = 0.112). Fastly adapted consulting practice and follow-up protocols to compensate for the problems created by COVID-related regulations seem to be effective in terms of mortality and amputation rates.
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Affiliation(s)
- Mesut Demirkoparan
- Department of Orthopedics and TraumatologyEge University School of MedicineIzmirTurkey
| | - Arman Vahabi
- Department of Orthopedics and TraumatologyEge University School of MedicineIzmirTurkey
| | - Berker Özbek
- Department of Orthopedics and TraumatologyEge University School of MedicineIzmirTurkey
| | - Merve Mert
- Department of Infectious Diseases and Clinical MicrobiologyEge University School of MedicineIzmirTurkey
| | - Ilgın Yıldırım Şimşir
- Department of Internal Medicine, Division of Endocrinology and Metabolism DisordersEge University School of MedicineIzmirTurkey
| | - Hüseyin Aytaç Erdem
- Department of Infectious Diseases and Clinical MicrobiologyEge University School of MedicineIzmirTurkey
| | - Anıl Murat Öztürk
- Department of Orthopedics and TraumatologyEge University School of MedicineIzmirTurkey
| | - Şevki Çetinkalp
- Department of Internal Medicine, Division of Endocrinology and Metabolism DisordersEge University School of MedicineIzmirTurkey
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18
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Yammine K, Honeine M, Assi C. Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm. Foot Ankle Surg 2023; 29:593-596. [PMID: 37482478 DOI: 10.1016/j.fas.2023.07.004] [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: 03/30/2023] [Revised: 06/25/2023] [Accepted: 07/13/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes. METHODS This is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation. RESULTS Outcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level. CONCLUSIONS Bone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Lebanon.
| | - Mohammad Honeine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Lebanon
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19
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Kothadiya D, Rehman A, Abbas S, Alamri FS, Saba T. Attention-based deep learning framework to recognize diabetes disease from cellular retinal images. Biochem Cell Biol 2023; 101:550-561. [PMID: 37473447 DOI: 10.1139/bcb-2023-0151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/22/2023] Open
Abstract
A medical disorder known as diabetic retinopathy (DR) affects people who suffer from diabetes. Many people are visually impaired due to DR. Primary cause of DR in patients is high blood sugar, and it affects blood vessels available in the retinal cell. The recent advancement in deep learning and computer vision methods, and their automation applications can recognize the presence of DR in retinal cells and vessel images. Authors have proposed an attention-based hybrid model to recognize diabetes in early stage to prevent harmful clauses. Proposed methodology uses DenseNet121 architecture for convolution learning and then, the feature vector will be enhanced with channel and spatial attention model. The proposed architecture also simulates binary and multiclass classification to recognize the infection and the spreading of disease. Binary classification recognizes DR images either positive or negative, while multiclass classification represents an infection on a scale of 0-4. Simulation of the proposed methodology has achieved 98.57% and 99.01% accuracy for multiclass and binary classification, respectively. Simulation of the study also explored the impact of data augmentation to make the proposed model robust and generalized. Attention-based deep learning model has achieved remarkable accuracy to detect diabetic infection from retinal cellular images.
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Affiliation(s)
- Deep Kothadiya
- Artificial Intelligence and Data Analytics Lab (AIDA), CCIS, Prince Sultan University, Riyadh 11586, Saudi Arabia
- U & P U Patel Department of Computer Engineering, Chandubhai S. Patel Institute of Technology (CSPIT), Faculty of Technology (FTE), Charotar University of Science and Technology (CHARUSAT), Changa, India
| | - Amjad Rehman
- Artificial Intelligence and Data Analytics Lab (AIDA), CCIS, Prince Sultan University, Riyadh 11586, Saudi Arabia
| | - Sidra Abbas
- Department of Computer Science, COMSATS University Islamabad, Islamabad, Pakistan
| | - Faten S Alamri
- Department of Mathematical Sciences, College of Science, Princess Nourah Bint Abdulrahman University, P.O. Box 84428, Riyadh 11671, Saudi Arabia
| | - Tanzila Saba
- Artificial Intelligence and Data Analytics Lab (AIDA), CCIS, Prince Sultan University, Riyadh 11586, Saudi Arabia
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20
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Hu Z, Zhao K, Chen X, Zhou M, Chen Y, Ye X, Zhou F, Ding Z, Zhu B. A Berberine-Loaded Bletilla striata Polysaccharide Hydrogel as a New Medical Dressing for Diabetic Wound Healing. Int J Mol Sci 2023; 24:16286. [PMID: 38003478 PMCID: PMC10671592 DOI: 10.3390/ijms242216286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/10/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023] Open
Abstract
The healing process of a diabetic wound (DW) is often impeded by a series of interrelated factors, including severe infection, persistent inflammation, and excessive oxidative stress. Therefore, it is particularly crucial to develop a medical dressing that can address these issues simultaneously. To this end, different ratios of Bletilla striata polysaccharide (BSP) and berberine (BER) were physically blended with Carbomer 940 (CBM940) to develop a composite hydrogel as a medical dressing. The BSP/BER hydrogel was characterized using SEM, FTIR, rheological testing and other techniques. The anti-inflammatory, antioxidant, and antibacterial properties of the hydrogel were evaluated using cell and bacterial models in vitro. A DW model of ICR mice was established to evaluate the effect of the hydrogel on DW healing in vivo. The hydrogel exhibited excellent biocompatibility and remarkable antibacterial, anti-inflammatory, and antioxidant properties. In addition, animal experiments showed that the BSP/BER hydrogel significantly accelerated wound healing in DW mice. Among the different formulations, the LBSP/BER hydrogel (2% BSP, mBER:mBSP = 1:40) demonstrated the most remarkable efficacy. In conclusion, the BSP/BER hydrogel developed exhibited immense properties and great potential as a medical dressing for the repair of DW, addressing a crucial need in clinical practice.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Bingqi Zhu
- School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou 310053, China
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21
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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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22
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The intersocietal IWGDF, ESVS, SVS guidelines on peripheral artery disease in people with diabetes mellitus and a foot ulcer. J Vasc Surg 2023; 78:1101-1131. [PMID: 37724985 DOI: 10.1016/j.jvs.2023.07.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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23
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Fitridge R, Chuter V, Mills J, Hinchliffe R, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, Russell D, van den Berg JC, Venermo M, Schaper N. The Intersocietal IWGDF, ESVS, SVS Guidelines on Peripheral Artery Disease in People With Diabetes Mellitus and a Foot Ulcer. Eur J Vasc Endovasc Surg 2023:S1078-5884(23)00586-5. [PMID: 37724984 DOI: 10.1016/j.ejvs.2023.07.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Diabetes related foot complications have become a major cause of morbidity and are implicated in most major and minor amputations globally. Approximately 50% of people with diabetes and a foot ulcer have peripheral artery disease (PAD) and the presence of PAD significantly increases the risk of adverse limb and cardiovascular events. The International Working Group on the Diabetic Foot (IWGDF) has published evidence based guidelines on the management and prevention of diabetes related foot complications since 1999. This guideline is an update of the 2019 IWGDF guideline on the diagnosis, prognosis, and management of peripheral artery disease in people with diabetes mellitus and a foot ulcer. For this updated guideline, the IWGDF, the European Society for Vascular Surgery, and the Society for Vascular Surgery decided to collaborate to develop a consistent suite of recommendations relevant to clinicians in all countries. This guideline is based on three new systematic reviews. Using the Grading of Recommendations, Assessment, Development and Evaluation framework clinically relevant questions were formulated, and the literature was systematically reviewed. After assessing the certainty of the evidence, recommendations were formulated which were weighed against the balance of benefits and harms, patient values, feasibility, acceptability, equity, resources required, and when available, costs. Through this process five recommendations were developed for diagnosing PAD in a person with diabetes, with and without a foot ulcer or gangrene. Five recommendations were developed for prognosis relating to estimating likelihood of healing and amputation outcomes in a person with diabetes and a foot ulcer or gangrene. Fifteen recommendations were developed related to PAD treatment encompassing prioritisation of people for revascularisation, the choice of a procedure and post-surgical care. In addition, the Writing Committee has highlighted key research questions where current evidence is lacking. The Writing Committee believes that following these recommendations will help healthcare professionals to provide better care and will reduce the burden of diabetes related foot complications.
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Affiliation(s)
- Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital Adelaide, Australia.
| | - Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Australia
| | | | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- University of California, San Francisco Medical Centre, CA, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Nicolaas Schaper
- Division of Endocrinology, Dept. Internal Medicine, MUMC+, The Netherlands
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24
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Yammine K, Abou Orm G, Mouawad J, Assi C. Basic haematological tests as inflammatory performance markers of patients treated either by conservative surgery or minor amputation for infected diabetic foot ulcers. Wound Repair Regen 2023; 31:627-634. [PMID: 37329515 DOI: 10.1111/wrr.13104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/10/2023] [Accepted: 06/06/2023] [Indexed: 06/19/2023]
Abstract
Basic inflammatory markers have been extensively studied to differentiate between non-infected and infected diabetic foot ulcers (DFUs). Very rarely, basic haematological tests such as white cell count (WCC) and platelet counts were used as performance markers for DFU infection severity. The aim is to investigate these biomarkers in patients with DFU treated exclusively with surgery. In this retrospective comparative study, we included 154 procedures comparing a conservative surgery group (n = 66 for infected DFU) and a minor amputation group (n = 88 for infected DFU with osteomyelitis). Outcomes were set as the preoperative values of: WCC, neutrophils (N), lymphocytes (L), Monocytes (M), Platelets (P), red cell distribution width (RDW) and the ratios N/L, L/M and P/L. Area under curve (AUC) of the receiver operating characteristic (ROC) was calculated based on the diagnosis of minor amputation as a positive result. Cutoff point values with the highest sensitivity and specificity were obtained for each outcome. The highest AUC values were for WCC (0.68), neutrophils (0.68), platelets (0.7) and P/L ratio (0.69) with corresponding cut-off values of 10,650/mm3 , 76%, 234,000/mcL and 265, respectively. The highest sensitivity was for the platelet count (81.5%) while the highest specificity was for L/M (89%) and P/L ratios (87%). Postoperative values showed similar results. Simple routine blood tests could serve as inflammatory performance markers to help predict the severity of infection in patients treated surgically for infected DFU.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Jdeideh, Lebanon
| | - Ghadi Abou Orm
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Jdeideh, Lebanon
| | - Joseph Mouawad
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Jdeideh, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Jdeideh, Lebanon
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25
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Hu Y, Xiong Y, Zhu Y, Zhou F, Liu X, Chen S, Li Z, Qi S, Chen L. Copper-Epigallocatechin Gallate Enhances Therapeutic Effects of 3D-Printed Dermal Scaffolds in Mitigating Diabetic Wound Scarring. ACS APPLIED MATERIALS & INTERFACES 2023; 15:38230-38246. [PMID: 37535406 PMCID: PMC10436249 DOI: 10.1021/acsami.3c04733] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023]
Abstract
Morbid dermal templates, microangiopathy, and abnormal inflammation are the three most critical reasons for the scarred healing and the high recurrence rate of diabetic wounds. In this present study, a combination of a methacrylated decellularized extracellular matrix (ECMMA, aka EM)-based hydrogel system loaded with copper-epigallocatechin gallate (Cu-EGCG) capsules is proposed to fabricate bio-printed dermal scaffolds for diabetic wound treatment. Copper ions act as a bioactive element for promoting angiogenesis, and EGCG can inhibit inflammation on the wound site. In addition to the above activities, EM/Cu-EGCG (E/C) dermal scaffolds can also provide optimized templates and nutrient exchange space for guiding the orderly deposition and remodeling of ECM. In vitro experiments have shown that the E/C hydrogel can promote angiogenesis and inhibit the polarization of macrophages to the M1 pro-inflammatory phenotype. In the full-thickness skin defect model of diabetic rats, the E/C dermal scaffold combined with split-thickness skin graft transplantation can alleviate pathological scarring via promoting angiogenesis and driving macrophage polarization to the anti-inflammatory M2 phenotype. These may be attributed to the scaffold-actuated expression of angiogenesis-related genes in the HIF-1α/vascular endothelial growth factor pathway and decreased expression of inflammation-related genes in the TNF-α/NF-κB/MMP9 pathway. The results of this study show that the E/C dermal scaffold could serve as a promising artificial dermal analogue for solving the problems of delayed wound healing and reulceration of diabetic wounds.
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Affiliation(s)
- Yanke Hu
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Yahui Xiong
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Yongkang Zhu
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Fei Zhou
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Xiaogang Liu
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Shuying Chen
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Zhanpeng Li
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Shaohai Qi
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
| | - Lei Chen
- Department
of Burn, Wound Repair & Reconstruction, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Guangdong
Provincial Engineering Technology Research Center of Burn and Wound
Accurate Diagnosis and Treatment Key Technology and Series of Products, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
- Institute
of Precision Medicine, The First Affiliated
Hospital, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China
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26
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Yammine K, Otayek J, Haikal E, Daher M, El Alam A, Boulos K, Assi C. Analysis of systemic risk factors between diabetic/vascular patients having primary lower limb amputations and re-amputations. Vascular 2023:17085381231194964. [PMID: 37552100 DOI: 10.1177/17085381231194964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
Background: Patients with diabetes mellitus (DM) are known to be predisposed to many complications in the lower extremities such as neuropathy, peripheral artery disease (PAD) and infection. Diabetic foot ulcers are complications of diabetes that can lead to lower extremity amputations, re-amputations and high mortality rates.Purpose: The aim of this study is to evaluate the risk factors associated with higher re-amputation rates in diabetic foot disease.Research Design: This is a mono-centric retrospective comparative study.Study Sample: the study included 136 patients, with a total of 193 procedures (111 primary amputations and 82 re-amputations) between 2011 and 2021.Data Analysis: The t-student test and Spearman correlation were used to look for mean differences and any relevant association, respectively. Multivariate logistic regression analysis was computed to look for independent variables.Results: Twenty-two (27%) and 60 (50%) of those who had major and minor amputations, respectively, had a re-amputation (p = 0.006). Besides diabetes (89%), the commonest risk factor associated with amputation was hypertension (86.7%), be it for primary amputation or re-amputation, followed by peripheral (PAD) and coronary artery diseases. Only three risk factors showed independent correlation with re-amputation; chronic kidney disease (r = 15%, p = 0.03), smoking (r = 15%, p = 0.03), and simultaneous presence of DM + PAD (r = 13.7%, p = 0.05).Conclusions: Factors that were significantly correlated with increased re-amputation rates have a clear pathologic pathway that affects vascularity and wound healing. Further studies should be aimed at developing a clear scoring system that can be used to stratify patient for re-amputation risk, and to better predict the results according to the severity of diabetes.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
| | - Joeffroy Otayek
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Emil Haikal
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Mohammad Daher
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Anthony El Alam
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Karl Boulos
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, School of Medicine, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon
- Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Beirut, Lebanon
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27
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Yang D, Shu H, Lun Y, Li C, Yang Y. The Influence of Diabetes Mellitus on Mortality of Patients After Lower Extremity Amputation: A Systematic Review and Meta-analysis. World J Surg 2023; 47:2076-2084. [PMID: 37084108 DOI: 10.1007/s00268-023-07019-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 04/22/2023]
Abstract
OBJECTIVE The influence of diabetes mellitus (DM) on mortality following lower extremity amputation (LEA) remains controversial. This systematic review and meta-analysis aimed to determine the influence of DM on long-term mortality (LTM) and short-term mortality (STM) after amputation. MATERIALS AND METHODS The Medline, the Cochrane library, and Embase databases were searched. The primary and secondary outcomes were LTM and STM following amputation. One-year and 30-day all-cause mortality after amputation were considered as LTM and STM, respectively. A random-effects model was utilized to pool results. To evaluate the stability of results, subgroup analyses and sensitivity analyses were conducted. RESULTS Twenty-three cohort studies with a total of 58,219 patients were included, among which 31,750 (54.5%) patients had DM. The mean score of included studies evaluated by Newcastle-Ottawa Scale was 7.65, indicating moderate to high quality. The pooled results showed no significant difference in 1-year LTM (risk ratio [RR], 0.96; 95% CI 0.86-1.07) after amputation. However, 3-year (RR, 1.22; 95% CI 1.01-1.47) and 5-year (RR, 1.18; 95% CI 1.07-1.31) LTMs of DM patients were obviously higher than that of NDM (non-diabetes mellitus) patients. The STM of the DM group was significantly lower than the NDM group (RR, 0.80; 95% CI 0.64-0.98). CONCLUSIONS The current study revealed that DM patients had an obvious lower STM following LEA, but the risk of DM on LTM after amputation was gradually increased with time. More attention should be paid to the long-term survival of DM patients after LEA.
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Affiliation(s)
- Dong Yang
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, People's Republic of China
| | - Hongxin Shu
- The Second Clinical Medical School, Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yu Lun
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, People's Republic of China
| | - Cong Li
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, People's Republic of China
| | - Yu Yang
- Department of Vascular and Thyroid Surgery, The First Affiliated Hospital, China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, People's Republic of China.
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Samah T. Identifying health research in the era of COVID-19: A scoping review. SAGE Open Med 2023; 11:20503121231180030. [PMID: 37324118 PMCID: PMC10262656 DOI: 10.1177/20503121231180030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Background Health improvements are considered one of the most important fields of research. Since the coronavirus disease 2019 was declared a pandemic, it might have impacted clinical and public health research in various forms. Objectives The goal of this study is to explore health research approaches in the era of coronavirus disease 2019. Methods In this scoping review, we reviewed published medical full-text studies and identified potential areas of interest of health research in the era the coronavirus disease 2019 pandemic during the last 3 years within a higher educational setting. A bibliometric analysis was used to compare among published works. Results Among the 93 studies that met the inclusion criteria, most focused on mental health (n = 23; 24.7%). Twenty-one publications targeted coronavirus disease 2019 and its consequences on general health. Other studies have described hemato-oncological, cardiovascular, respiratory, and endocrinological diseases. 42 studies were cross-sectional or cohort studies and most of them published in Q1 journals. Almost half of them belonged to the Faculty of Medicine (49.5%) followed by the School of Arts, Sciences, and Psychology (26.9%). Conclusions Health research has been demonstrated to be important, at all times, especially during crises. Therefore, researchers need to invest more efforts into seeking new medical updates in various health-related fields, regardless of their correlation with coronavirus disease 2019.
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Affiliation(s)
- Tawil Samah
- School of Medicine, Lebanese American University, Beirut, Lebanon
- Institut National de Santé Publique d’Épidémiologie Clinique et de Toxicologie-Liban (INSPECT-LB), Beirut, Lebanon
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Lin X, Wu Y, Huang H, Peng R, Huang F, Hong L, Chen W. Antibiotic-loaded bone substitutes therapy in the management of the moderate to severe diabetic foot infection: A meta-analysis. Wound Repair Regen 2023; 31:205-226. [PMID: 36519343 DOI: 10.1111/wrr.13061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 09/16/2022] [Accepted: 10/13/2022] [Indexed: 12/23/2022]
Abstract
In recent years, local antibiotic-loaded bone substitutes (ALBS) have been used increasingly in the treatment of diabetic foot infection (DFI). The meta-analysis aimed to analyse the efficacy of ALBS on patients with moderate to severe DFI (with or without osteomyelitis). With an appropriate search strategy, 7 studies were selected for analysis (2 RCTs and 5 cohort studies). The result showed that the application of ALBS effectively reduced the length of hospital stay (WMD -5.55; 95% CI: -9.85 to -1.26; P = 0.01), the recurrence rates (RR 0.33; 95% CI: 0.15 to 0.69; P = 0.003) and the mortality rates (RR 0.22; 95% CI: 0.06 to 0.82; P = 0.02). Compared to the control groups, however, there was no difference in healing rates (RR 1.06; 95% CI: 0.96 to 1.18; P = 0.26), healing time (WMD -1.44; 95% CI: -3.37 to -0.49; P = 0.14), the number of debridement (WMD -1.98; 95% CI: -4.08 to 0.12; P = 0.06) and major amputation rates (RR 0.76; 95% CI: 0.35 to 1.61; P = 0.47). The ALBS appears to have some beneficial effects as an adjunct to standard surgery in the treatment of DFI with or without osteomyelitis, as it reduces recurrence rates, mortality rates, and length of hospital stay, but there was no statistically significant difference in enhancing wound healing.
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Affiliation(s)
- Xinyi Lin
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong Province, China.,Shantou University Medical College, Shantou, Guangdong Province, China
| | - Yan Wu
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Hong Huang
- School of Nursing, Guangzhou University of Chinese Medicine, Guangzhou, Guangdong Province, China
| | - Ruihan Peng
- Shantou University Medical College, Shantou, Guangdong Province, China
| | - FuHua Huang
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Lvrong Hong
- Guangzhou Women and Children's Medical Center, Guangzhou, Guangdong Province, China
| | - WenZhuan Chen
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
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Henderson AW, Turner AP, Leonard C, Sayre G, Suckow B, Williams SL, Norvell DC, Czerniecki JM. Mortality Conversations Between Male Veterans and Their Providers Prior to Dysvascular Lower Extremity Amputation. Ann Vasc Surg 2023; 92:313-322. [PMID: 36746270 PMCID: PMC10121889 DOI: 10.1016/j.avsg.2023.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 02/06/2023]
Abstract
BACKGROUND Among patients facing lower extremity amputation due to dysvascular disease, the mortality risk is very high. Given this, as well as the importance of a patient-centered approach to medical care, informing patients about their possible risk of dying may be important during preoperative shared decision-making. The goal of this investigation was to gain an understanding of patient and provider experiences discussing mortality within the context of amputation within the Veterans Health Administration. METHODS Semistructured interviews were performed with Veterans with peripheral arterial disease and/or diabetes, vascular and podiatric surgeons, and physical medicine and rehabilitation physicians. Interviews were analyzed using team-based content analysis to identify themes related to amputation-level decisions. RESULTS We interviewed 22 patients and 21 surgeons and physicians and identified 3 themes related to conversations around mortality: (1) both patients and providers report that mortality conversations are not common prior to amputation; (2) while most providers find value in mortality conversations, some express concerns around engaging in these discussions with patients; and (3) some patients perceive mortality conversations as unnecessary, but many are open to engaging in the conversation. CONCLUSIONS Providers may benefit from introducing the topic with patients, including providing the context for why mortality conversations may be valuable, with the understanding that patients can always decline to participate should they not be interested or comfortable discussing this issue.
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Affiliation(s)
- Alison W Henderson
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA.
| | - Aaron P Turner
- VA Puget Sound Health Care System, Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Chelsea Leonard
- VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Denver Seattle COIN, VA Eastern Colorado Healthcare System, Aurora, CO; Health Systems, Management and Policy, University of Colorado, School of Public Health, Aurora, CO
| | - George Sayre
- VA Puget Sound Health Care System, Seattle, WA; Qualitative Research Core, HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA; VA Collaborative Evaluation Center (VACE), Seattle, WA; Department of Health Services, University of Washington, Seattle, WA
| | - Bjoern Suckow
- Department of Vascular Surgery, White River Junction VA Medical Center, White River Junction, VT; Department of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Sienna L Williams
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA
| | - Daniel C Norvell
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Joseph M Czerniecki
- VA Puget Sound Health Care System, Seattle, WA; VA Center for Limb Loss and MoBility (CLiMB), Seattle, WA; Department of Rehabilitation Medicine, University of Washington, Seattle, WA
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McDermott K, Fang M, Boulton AJ, Selvin E, Hicks CW. Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care 2023; 46:209-221. [PMID: 36548709 PMCID: PMC9797649 DOI: 10.2337/dci22-0043] [Citation(s) in RCA: 133] [Impact Index Per Article: 133.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/02/2022] [Indexed: 12/24/2022]
Abstract
Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.
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Affiliation(s)
- Katherine McDermott
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Fang
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew J.M. Boulton
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Elizabeth Selvin
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Ezzatvar Y, García-Hermoso A. Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis. Diabetes Res Clin Pract 2023; 195:110194. [PMID: 36464091 DOI: 10.1016/j.diabres.2022.110194] [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: 08/15/2022] [Revised: 10/31/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
AIMS/HYPOTHESIS This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020. METHODS Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated. RESULTS 23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men. CONCLUSIONS Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.
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Affiliation(s)
- Yasmin Ezzatvar
- Department of Nursing, Universitat de València, Valencia, Spain.
| | - Antonio García-Hermoso
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
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Vuorlaakso M, Kiiski J, Majava M, Helminen M, Kaartinen I. Retrospective cohort study of long-term outcomes and prognostic factors for survival after lower extremity amputation in patients with diabetes. J Diabetes Complications 2023; 37:108377. [PMID: 36525903 DOI: 10.1016/j.jdiacomp.2022.108377] [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: 09/26/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
AIMS Lower extremity amputation (LEA) is a pivotal event for patients with diabetes. This study aimed to provide updated data on the outcomes and prognostic factors after LEA for patients with diabetes. METHODS This retrospective cohort study included all LEAs (n = 1081) performed at Tampere University Hospital between February 2007 and September 2020. Overall survival (OS) and major amputation-free survival were evaluated. RESULTS Index amputation level was below ankle in 65 % (n = 704) of patients, below knee in 14 % (n = 154) of patients, and above knee in 21 % (n = 223) of patients. In the whole population, OS was 75.8 % (CI 95 %: 73.3-78.3) at one year and 38.3 % (CI 95 %: 34.7-41.7) at five years. Higher age, peripheral artery disease (PAD), more proximal amputation level, and lower glomerular filtration rate (GFR) reduced OS. Multiple amputations and diagnosed dyslipidemia or hypertension associated with improved OS. Further, age, PAD, and GFR were identified as significant factors for major amputation free survival. CONCLUSIONS OS after LEA is poor. After major amputation, the risk for death is higher compared to minor amputation. Recurrent amputation is associated with improved OS. Further, ischemia and renal disease are significant factors for inferior OS.
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Affiliation(s)
- M Vuorlaakso
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, 13530 Hämeenlinna, Finland.
| | - J Kiiski
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Elämänaukio 2, 33521 Tampere, Finland
| | - M Majava
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Elämänaukio 2, 33521 Tampere, Finland
| | - M Helminen
- Tays Research Services, Tampere University Hospital, Arvo Ylpön katu 6, 33521 Tampere, Finland; Faculty of Social Sciences, Health Sciences, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - I Kaartinen
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Elämänaukio 2, 33521 Tampere, Finland
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Yammine K, Boulos K, Assi C, Hayek F. Amputation and mortality frequencies associated with diabetic Charcot foot arthropathy: a meta-analysis. Foot Ankle Surg 2022; 28:1170-1176. [PMID: 36028441 DOI: 10.1016/j.fas.2022.08.004] [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: 03/05/2022] [Revised: 07/12/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Five-year mortality and amputation frequencies after new-onset diabetic ulceration have been reported up to 55% and 74%, respectively. for patients with lower-extremity amputation. Following Charcot arthropathy, these frequencies were reported with wide variations. The aim of this meta-analysis is to provide a quantitative evaluation of amputation and mortality frequencies in a diabetic patient with a Charcot foot arthropathy. METHODS Electronic search strategy was applied on Medline, Web of Science, Cochrane Library and Google Scholar since inception to December 2021. Extracted data included study design, sample and patients characteristics, diabetes type and duration, lab results, ulcers at diagnosis, co-morbidities and follow up period. Meta-analysis reporting random-effects values was used to generate the weights results. RESULTS A total of 16 studies were included in the quantitative meta-analysis with a pooled sample of 2250 patients with 2272 Charcot feet. Two studies including 255 patients yielded a 1-year mortality frequency of 4% (95% CI = 0.018-0.065). Seven studies including 1706 patients reported a 5-year mortality frequency of 24.5% (95% CI = 0.172-0.326, I² = 88.5%). Four studies including 277 patients yielded a seven plus year mortality frequency of 16% (95% CI = 0.065-0.289, I² = 84.3%). Ten studies including 871 foot yielded an amputation frequency of 15% (95% CI = 0.067-0.258, I² = 93.6%) where 9% where major amputations (95% CI = 0.062-0.127, I² = 60%) and 5% were minor amputations (95% CI = 0.004-0.126, I² = 94.7%) CONCLUSION: Diabetic Charcot arthropathy yields marked risk of amputation and mortality. However, mortality frequencies were unexpectedly lesser compared to those related to the published frequencies associated with diabetic foot ulcers.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research.
| | - Karl Boulos
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research
| | - Fady Hayek
- Division of Vascular Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
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Zhang D, Li Y, Kalbaugh CA, Shi L, Divers J, Islam S, Annex BH. Machine Learning Approach to Predict In-Hospital Mortality in Patients Admitted for Peripheral Artery Disease in the United States. J Am Heart Assoc 2022; 11:e026987. [PMID: 36216437 DOI: 10.1161/jaha.122.026987] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Peripheral artery disease (PAD) affects >10 million people in the United States. PAD is associated with poor outcomes, including premature death. Machine learning (ML) has been increasingly used on big data to predict clinical outcomes. This study aims to develop ML models to predict in-hospital mortality in patients hospitalized for PAD based on a national database. Methods and Results Inpatient hospitalization data were obtained from the 2016 to 2019 National Inpatient Sample. A total of 150 921 inpatients were identified with a primary diagnosis of PAD and PAD-related procedures using codes of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) and International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS). Four ML models, including logistic regression, random forest, light gradient boosting, and extreme gradient boosting models, were trained to predict the risk of in-hospital death based on a selection of variables, including patient characteristics, comorbidities, procedures, and hospital-related factors. In-hospital mortality occurred in 1.8% of patients. The performance of the 4 models was comparable, with the area under the receiver operating characteristic curve ranging from 0.83 to 0.85, sensitivity of 77% to 82%, and specificity of 72% to 75%. These results suggest adequate predictability for clinical decision-making. In all 4 models, the total number of diagnoses and procedures, age, endovascular revascularization procedure, congestive heart failure, diabetes, and diabetes with complications were critical predictors of in-hospital mortality. Conclusions This study demonstrates the feasibility of ML in predicting in-hospital mortality in patients with a primary PAD diagnosis. Findings highlight the potential of ML models in identifying high-risk patients for poor outcomes and guiding personalized intervention.
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Affiliation(s)
- Donglan Zhang
- Division of Health Services Research, Department of Foundations of Medicine New York University Long Island School of Medicine Mineola NY
| | - Yike Li
- Department of Otolaryngology-Head and Neck Surgery, Bill Wilkerson Center Vanderbilt University Medical Center Nashville TN
| | | | - Lu Shi
- Department of Public Health Sciences Clemson University Clemson SC
| | - Jasmin Divers
- Division of Health Services Research, Department of Foundations of Medicine New York University Long Island School of Medicine Mineola NY
| | - Shahidul Islam
- Division of Health Services Research, Department of Foundations of Medicine New York University Long Island School of Medicine Mineola NY
| | - Brian H Annex
- Department of Medicine and Vascular Biology Center Medical College of Georgia Augusta GA
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Tarricone A, Gee A, De La Mata K, Primavera L, Trepal M, Axman W, Perake V, Krishnan P. Health Disparities in Non-Traumatic Lower Extremity Amputations. A Systematic Review and Meta-Analysis. Ann Vasc Surg 2022; 88:410-417. [DOI: 10.1016/j.avsg.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/28/2022]
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Yammine K, El Alam A, Alqaysi B, Assi C. The internal pedal amputation as a salvage procedure in diabetic and ischemic foot infection. A meta-analysis. Foot Ankle Surg 2022; 28:159-165. [PMID: 33752981 DOI: 10.1016/j.fas.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 02/18/2021] [Accepted: 03/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND Osteomyelitis of the diabetic foot is a very challenging condition and amputation is often indicated. In some cases where the infection is localized and the surrounding soft tissue is mildly involved, an internal pedal amputation (IPA) based on resection and limited excision of the infected bone have been suggested as a viable option. This systematic review aims to look for the effectiveness of this technique in treating selected cases of diabetic foot osteomyelitis. METHODS A systematic literature search was conducted using multiple electronic databases from inception. Eight studies met the inclusion criteria; one retrospective comparative study, six retrospective observational studies and one prospective observational study. RESULTS Based on a pooled sample of 545 patients followed over a mean period of 27.7 ± 15.2 months, the weighted results were as follows: (a) healing rate was 87.7% (95% CI = 0.757-0.959), (b) time for healing was 7.1 ± 2.9 weeks, (c) wound infection rate was 5.6% (95% CI = 0.030-0.089), (d) wound dehiscence rate was 8% (95% CI = 0.010-0.204), (e) ulcer recurrence rate was of 10% (95% CI = 0.037-0.188), and (f) amputation rate was 2.8% (95% CI = 0.001-0.085) whilst all were minor amputations. CONCLUSION The findings support the selection of toe/ray sparing surgery via IPA as a viable surgical option for selected cases of focal osteomyelitis secondary to diabetic foot infection. The results would indicate that when the ulcer size could be adequately reduced, removing the infected bone while preserving the soft tissue envelope could yield high chance of success with few serious complications.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Lebanon.
| | - Anthony El Alam
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Bilal Alqaysi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research, Lebanon
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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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Meng L, Graves N, Du RC, Lee JY, Chue KM, Binte Taufiq Chong Ah Hoo NNF, Nazeha N, Ng YZ, Harding K, Ho P. Major limb amputation and mortality in patients with neuro-ischaemic lower extremity wounds managed in a tertiary hospital: Focus on the differences among patients with diabetes, peripheral arterial disease and both. Int Wound J 2021; 19:1298-1308. [PMID: 34913257 PMCID: PMC9493209 DOI: 10.1111/iwj.13724] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/30/2021] [Accepted: 11/15/2021] [Indexed: 12/25/2022] Open
Abstract
A majority of lower extremities neuro‐ischaemic wounds (NIU) are related to: (a) only diabetes (DM); (b) only peripheral artery disease (PAD); (c) co‐existing diabetes and peripheral artery disease (DM‐PAD). This study aims to characterise the major clinical outcomes of forementioned three groups of lower extremity wound patients in Singapore. Patients hospitalised for lower extremity NIU between January 2014 and October 2017 in a tertiary hospital in Singapore were analysed. Patients' major limb amputation and mortality were assessed using Cox regression models. Cumulative survival and amputation‐free survival among the three classified groups were calculated using Kaplan‐Meier analysis. Compared with patients with only DM, those in the PAD group and the DM‐PAD group had higher risk of major limb amputation (adjusted hazard ratio: 2.47, 95% CI: 1.65‐3.70; adjusted hazard ratio: 2.01, 95% CI: 1.53‐2.65 respectively) and mortality (adjusted hazard ratio: 2.36, 95% CI: 1.57‐3.55; adjusted hazard ratio: 2.46, 95% CI: 1.86‐3.26 respectively). The 3‐year survival and amputation‐free survival were lowest in the DM‐PAD group (52.1% and 41.5% respectively), followed by the PAD group (53.3% and 44.6% respectively) and the DM group (74.2% and 68.5% respectively). Lower extremity NIU patients with PAD or DM‐PAD were found to have poorer clinical prognosis than those with DM only.
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Affiliation(s)
- Lingyan Meng
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Nicholas Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Ruo Chen Du
- Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Jia Yi Lee
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore, Singapore
| | - Koy Min Chue
- Wound Care Innovation for the Tropics Programme, Skin Research Institute of Singapore, A*STAR, Singapore, Singapore
| | | | - Nuraini Nazeha
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Yi Zhen Ng
- Wound Care Innovation for the Tropics Programme, Skin Research Institute of Singapore, A*STAR, Singapore, Singapore
| | - Keith Harding
- Wound Care Innovation for the Tropics Programme, Skin Research Institute of Singapore, A*STAR, Singapore, Singapore
| | - Pei Ho
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Wound Care Innovation for the Tropics Programme, Skin Research Institute of Singapore, A*STAR, Singapore, Singapore
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Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
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Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
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