Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population-based 7-year follow-up study

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Risk factors for failure of limb salvage among veterans with foot ulcers

BACKGROUND

There is limited available information to guide early discussions involving limb salvage for patients with non-traumatic foot ulcers. We hypothesized patient, wound and treatment factors identifiable at initial operative treatment would be associated with failure of attempted limb salvage.

METHODS

We retrospectively assessed United States military veterans treated operatively for non-traumatic foot ulcers at a Veteran's Administration (VA) hospital from 2008 to 2018. Cox proportional hazard analysis assessed for independent associations with eventual above ankle amputation.

RESULTS

Limb salvage failed for 52 of 461 patients (11.0%). Univariable associations included initial wound area ≥1 cm (p < .001), immediate TMA (p < .001), diagnosis of PVD (p < .001) or diabetes (p = .005), nonpalpable pulse (p = .006), CKD (p = .023), creatine ≥ 1.5 (p = .004), and HgA1c ≥ 6.2 (p < .001). Independent associations consisted of initial wound area ≥1 cm (HR 6.0, 95% CI 1.4-25.1, p = .014), immediate TMA (HR 3.5, 95% CI 1.9-6.4, p < .001), and PVD (HR 3.5, 95% CI 1.6-7.5, p = .001). When <2 risk factors were present, 99.1% and 96.8% retained their hindfoot at 5 and 10 years, respectively. However, this decreased to 87.3% and 80.1% with two risk factors and fell to 63.3% and 43.3% with three risk factors.

CONCLUSION

Failure of limb salvage was increasingly likely as the number of identified independent risk factors increased. These results may assist in prognostication and shared decision making between patients and providers.

LEVEL OF EVIDENCE

Prognostic, Level III.

Healing below the ankle is possible in patients with diabetes mellitus and a forefoot gangrene

Background

Forefoot gangrene in patients with diabetes is a severe form of foot ulcers with risk of progress and major amputation. No large cohort studies have examined clinical characteristics and outcome of forefoot gangrene in patients with diabetes. The aim was to examine clinical characteristics and outcome of forefoot gangrene in patients with diabetes admitted to a diabetic foot centre.

Methods

Patients with diabetes and foot ulcer consecutively presenting were included if they had forefoot gangrene (Wagner grade 4) at initial visit or developed forefoot gangrene during follow-up at diabetic foot centre. Patients were prospectively followed up until final outcome, either healing or death. The median follow-up period until healing was 41 (3-234) weeks.

Results

Four hundred and seventy-six patients were included. The median age was 73 (35-95) years and 63% were males. Of the patients, 82% had cardiovascular disease and 16% had diabetic nephropathy. Vascular intervention was performed in 64%. Fifty-one patients (17% of surviving patients) healed after auto-amputation, 150 after minor amputation (48% of surviving patients), 103 had major amputation (33% of surviving patients) and 162 patients deceased unhealed. Ten patients were lost at follow-up. The median time to healing for all surviving patients was 41 (3-234) weeks; for auto-amputated, 48 (10-228) weeks; for minor amputated, 48 (6-234) weeks; and for major amputation, 32 (3-116) weeks.

Conclusion

Healing without major amputation is possible in a large proportion of patients with diabetes and forefoot gangrene, despite these patients being elderly and with extensive co-morbidity.

Diabetic Retinopathy in Patients With Diabetic Foot Ulcer: A Systematic Review

This review discusses the evidence on diabetic retinopathy (DR) in patients with diabetic foot ulceration (DFU). A systematic literature review was performed on PubMed, Medline, Springer Nature, and Scopus, following the PRISMA guidelines, using the following terms, individually or in combination: "diabetic foot ulcer" OR "diabetic foot syndrome" OR "DFU" and "diabetic retinopathy." The initial search yielded 648 articles published between 1975 and 2020. After applying exclusion and inclusion criteria, a total of 9 articles were analyzed, assessing the correlations between DR and DFU. In all cases, DR and especially proliferative diabetic retinopathy were significantly higher in the presence of DFU, though the frequency of DR showed large variability (22.5% to 95.6%). There was a significant correlation between advanced stages of DFU and increased frequency of DR and proliferative diabetic retinopathy. On the other hand, there is a risk of accelerated progression of DR in nonhealing DFUs, possibly related to chronic inflammation and associated infection. Hence, patients with DFUs should be monitored by an ophthalmologist, and those with DR should be promptly referred to a specialized diabetic foot clinic.

Analysis of risk factors of diabetes peripheral neuropathy in type 2 diabetes mellitus and nursing intervention

The aim of the present study was to explore the risk factors of diabetes peripheral neuropathy (DPN) in type 2 diabetes mellitus, and to propose corresponding nursing intervention measures to provide the basis for early diagnosis, treatment and prevention of DPN. A retrospective analysis was performed on 130 patients with type 2 diabetes mellitus (T2DM) in the communities surrounding our hospital from January 2017 to June 2018. They were divided into a DPN group (62 cases) and non-DPN group (control group, 68 cases). First, a univariate analysis was performed. DPN or non-DPN were used as dependent variables, and statistically significant parameters in univariate analysis were used as independent variables. Multivariate logistic regression analysis was included to analyze the peripheral nerves in type 2 diabetes mellitus. At the same time, the patients with DPN were given individualized comprehensive nursing intervention. Univariate analysis showed that body mass index (BMI), diabetes duration, smoking history, drinking history, family history of diabetes, fasting blood glucose (FBG), postprandial blood glucose (PBG), glycosylated hemoglobin (HbA1c), triglyceride (TG), high-density lipoprotein cholesterol (HDL-C), systolic blood pressure, 24-h urine microalbumin excretion (24hmALB), glomerular filtration rate (GFR), serum creatinine in DPN group were significantly different from those in the control group (P<0.05). Logistic regression analysis showed that the duration of diabetes, PBG, glycosylated hemoglobin (HbA1c), HDL-C, 24hmALB, and GFR were independent risk factors for DPN. The quality of life [Physiological function (PF), Role-physical (RP), Role-emotional (RE), General health (GH), Social function (SF), Mental health (MH), Bodily pain (BP), Vitality (VT)] in the DPN group was significantly improved after six months of individualized nursing intervention compared with that before intervention (P<0.05). In conclusion, the high risk factors of DPN should be identified as early as possible, to prevent and delay the occurrence and development of diabetes peripheral neuropathy, so as to improve the quality of life of these patients.

Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis

PURPOSE

A considerable number of diabetic foot ulcer (DFU) patients require amputation every year, which worsens their quality of life, aggravates the social burden, and shortens their life expectancy. Considering these negative effects, it is important to explore the relative risk factors affecting amputation in DFU patients.

METHODS

The PubMed, SCIE and Embase databases were comprehensively searched for prospective or retrospective studies published before October 31, 2019. All English language studies involving DFU patients were included, and RevMan 5.3 software was used to analyse the data.

RESULTS

This meta-analysis includes 21 studies involving 6505 participants, including 2006 patients who required a lower limb amputation. The following variables were associated with an increased risk of amputation: male sex (odds ratios (OR) = 1.30, 95% confidence interval (CI) = 1.16~1.46, P<0.00001), smoking history (OR = 1.19, 95% CI = 1.04~1.35, P = 0.009), a history of foot ulcers (OR = 2.48, 95% CI = 2.00~3.07, P<0.00001), osteomyelitis (OR = 3.70, 95% CI = 3.02~4.53, P<0.00001), gangrene (OR = 10.90, 95% CI = 5.73~20.8, P<0.00001), a lower body mass index (mean difference IV (MD) = -0.88, 95% CI = -1.30~-0.47, P<0.0001), and a higher white blood cell count (MD = 2.42, 95% CI = 2.02~2.82, P<0.00001). However, age (MD = 1.24, 95% CI = -0.45~2.93, P = 0.15), type of diabetes (OR = 0.96, 95% CI = 0.61~1.52, P = 0.86), hypertension (OR = 1.19, 95% CI = 0.96~1.47, P = 0.12), and HbA1c level (MD = 0.02, 95% CI = -0.28~0.33, P = 0.87) were not associated with amputation in patients with DFU.

CONCLUSIONS

Our meta-analysis identified several risk factors for amputation in DFU patients, including the male sex, a smoking history, a history of foot ulcers, osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count. Once gangrene occurs, the risk of amputation rapidly increases.

Predictive Factors of Major Lower Extremity Amputations in Diabetic Foot Infections: A Cross-sectional Study at District Hospital in Malaysia

Introduction: Diabetic foot infection, a complication which can lead to lower limb amputation, is a major source of morbidity and mortality in Malaysia. The objective of this study was to determine the predictive factors of major lower limb amputation among patients with diabetes mellitus in a cluster of three district hospitals in Pahang, Malaysia.

Materials and Methods: This cross-sectional study involved 170 patients who had undergone surgical interventions for diabetic foot infections at three district hospitals from 1st of September 2014 to 31st December 2015. The predictors for major amputation of lower limb were determined using simple logistic regression (LR) and forward LR multiple logistic regression.

Results: A total of 21 patients had undergone major amputations of lower limb (15 transtibial and 6 transfemoral). The following factors were associated with major amputation of lower limb; longer duration of disease, age ≥ 60 years, patients from Bentong Hospital, presence of hypertension, presence of fever, history of multiple limb-salvaging surgeries, monomicrobial culture, necrotising fasciitis, anemia and leukocytosis. Upon forward LR multiple logistic regression, only duration of disease, history of more than three previous limb-salvaging surgeries and total white blood cell count ≥15X109/L were found to be significant as predictive factors of major amputation of lower limb.

Conclusion: Among the factors analysed in this study, a longer duration of disease, raised total white blood cell count and history of more than three limb-salvaging surgeries were identified as predictors for major amputation of lower limb in diabetic foot infections using stepwise logistic regression analysis.

Patients' clinical charecteristics and predictors for diabetic foot amputation

INTRODUCTION

Medical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients.

METHODS

In this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed.

RESULTS

Of the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p<0,05). Amputees also exhibited significantly longer smoking histories (p<0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p=0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision.

CONCLUSION

The following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4-5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.

Risk Factors of Diabetic Foot Amputation in Pakistani Type II Diabetes Individuals

Introduction

The major grave outcome of diabetic complications is the amputation of lower limb extremities. Recurrent foot infections, trauma, ischemia, and peripheral neuropathy play a crucial role in predicting foot amputation. The aim of this study is to identify the risk factors of diabetic foot amputations in Pakistani patients.

Methods

Patients admitted with diabetic foot-related complications were followed throughout their hospital stay. Their sociodemographic and disease-related characteristics were recorded. Patients who were advised foot amputation were taken as group A, and patients who were managed conservatively were termed as group B. Their characteristics were then compared.

Results

Out of 226 study participants, there were 51 (22.5%) patients in group A who were advised foot amputation. There were more men in group A as compared to group B (72.5% vs. 30.8%; p<0.00001). Group A also had a longer duration of diabetes (15.23 ± 8.52 years vs. 11.98 ± 9.69; p=0.03). Group B included more patients taking insulin therapy (44.5% vs. 37.3%; p=0.002). All three risk factors of atherosclerosis - smoking, hyperlipidemia, and hypertension - were significantly associated with group A (p≤0.05). This coexistence of diabetic nephropathy and retinopathy were more common in group A (p≤0.05).

Conclusion

The incidence of foot amputation in diabetic patients is high. Crucial risk factors include male gender, smoking, hyperlipidemia, hypertension, cardiac history, and the coexistence of diabetic nephropathy and retinopathy.

Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review

The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.

The Predictive Factors Associated With Comorbidities for Treatment Response in Outpatients With King Classification III Diabetes Foot Ulcers

OBJECTIVE

The aim of this study is to investigate the preexisting predictive factors associated with comorbidities for diabetic foot ulcer (DFU) in King classification III at an outpatient clinic.

METHOD

This prospective study included 100 patients with DFU in King classification III treated at outpatient clinics in Chiayi Chang Gung Memorial Hospital from January 2011 to December 2011. The least follow-up time was 1 year. Medical documentations were in respect of patient's baseline characteristics, associated history, presence of comorbidities, follow-up time, and condition of wounds. Patients were divided into success group (healed or healing with wound reduction), stagnate group, and failure group (amputation or infection, need in-hospital medical service) in accordance with the treatment response of wounds. χ Test, Fisher exact test, and 1-way analysis of variance were used for variables in 3-group comparison, whereas Student t test was applied in 2-group comparison. The predictive factors with P value less than 0.1 were further investigated using the model of univariate logistic regression.

RESULTS

With 3-group stratification according to treatment response-failure (n = 8), stagnate (n = 22), and success (n = 70)-the occurrence rate of retinopathy was higher in the treatment stagnate group (42.1%) than in the treatment failure (14.3%) and success groups (12.5%; P = 0.019); the rate of previous percutaneous transluminal angioplasty (PTA) history was higher in the treatment failure group (25%) than in the treatment stagnate (4.8%) and success groups (1.5%; P = 0.020). With 2-group stratification-failure (n = 8) versus nonfailure (n = 92), and success (n = 70) versus nonsuccess (n = 30)-PTA history was strongly associated with treatment failure (odds ratio [OR], 14.33; 95% confidence interval [CI], 1.71-120.32; P = 0.014), whereas retinopathy (OR, 0.21; 95% CI, 0.07-0.65; P = 0.006) was the major negative predictor for treatment success. Previous debridement met borderline significance to predict treatment nonsuccess (OR, 0.09; 95% CI, 0.01-1.01; P = 0.051). Sex, age, associated history, dyslipidemia, hypertension, coronary artery disease, cerebrovascular accident, chronic kidney disease, and end-stage renal disease and wound condition had no statistical significance.

CONCLUSIONS

Previous PTA and retinopathy, which indicated preexisting severe vasculopathy, are univariate predictive factors for treatment failure and nonsuccess, respectively, in patients with King classification III DFU. With the subdivision of King classification III DFU, medical history taking and fundus examination are acceptable methods for risk screening at an outpatient clinic.

The Preventive Value of Epidural Calcitonin in Patients with Lower Limb Amputation

Background

Postamputation pain is highly prevalent after limb amputation with neuropathic nature; calcitonin may effectively relieve many neuropathic pain states.

Design

Double-blind randomized multicenter study.

Setting

Our study hypothesis is to evaluate the preventive value of epidural calcitonin on postoperative pain, grade of phantom pain, and the development of allodynia and hyperalgesia in patients undergoing lower limb amputation.

Patients

A cohort of 60 diabetic patients of both genders suffering from vascular insufficiency of one or both lower limbs underwent minor or major lower limb amputation. Patients were divided randomly into two equal groups: an epidural bupivacaine-calcitonin-fentanyl (BCF) group and a bupivacaine-fentanyl (BF) group.

Methods

Patients were instructed about the use of a 10 cm visual analog scale (VAS). Phantom limb pain was graded using a four-grade scale. Pin-prick hyperalgesia and allodynia were evaluated at one week, one month, three months, and six months after surgery.

Results

There were no significant differences between groups regarding patients' characteristics. There was no significant difference in the VAS scale between groups. There was statically significant improvement in the grade of phantom pain in the BCF group at six and 12 months after surgery ( P =  0.033 and 0.001, respectively). A significantly higher number of patients developed allodynia in the BF group at six ( P  = 0.039) and 12 ( P = 0.013) months and hyperalgesia at 12 months ( P  = 0.025).

Conclusion

The preventive use of epidural calcitonin improved the grade of phantom pain and reduced the incidence of allodynia and hyperalgesia in patients undergoing lower limb amputation under combined spinal-epidural anesthesia during one year of follow-up.

Smoking increases the risk of diabetic foot amputation: A meta-analysis

Accumulating evidence suggests that smoking is associated with diabetic foot amputation. However, the currently available results are inconsistent and controversial. Therefore, the present study performed a meta-analysis to systematically review the association between smoking and diabetic foot amputation and to investigate the risk factors of diabetic foot amputation. Public databases, including PubMed and Embase, were searched prior to 29th February 2016. The heterogeneity was assessed using the Cochran's Q statistic and the I² statistic, and odds ratio (OR) and 95% confidence interval (CI) were calculated and pooled appropriately. Sensitivity analysis was performed to evaluate the stability of the results. In addition, Egger's test was applied to assess any potential publication bias. Based on the research, a total of eight studies, including five cohort studies and three case control studies were included. The data indicated that smoking significantly increased the risk of diabetic foot amputation (OR=1.65; 95% CI, 1.09-2.50; P<0.0001) compared with non-smoking. Sensitivity analysis demonstrated that the pooled analysis did not vary substantially following the exclusion of any one study. Additionally, there was no evidence of publication bias (Egger's test, t=0.1378; P=0.8958). Furthermore, no significant difference was observed between the minor and major amputation groups in patients who smoked (OR=0.79; 95% CI, 0.24-2.58). The results of the present meta-analysis suggested that smoking is a notable risk factor for diabetic foot amputation. Smoking cessation appears to reduce the risk of diabetic foot amputation.

Predictive Laboratory Findings of Lower Extremity Amputation in Diabetic Patients: Meta-analysis

Lower extremity amputation is a source of morbidity and mortality among diabetic patients. This meta-analysis aimed to identify significant laboratory data in patients with diabetic foot ulcer with high rates of lower extremity amputation. We performed a systematic literature review and meta-analysis using MEDLINE, EMBASE, and Cochrane databases. We extracted and evaluated 11 variables from the included studies based on amputation rates. This study used the Newcastle-Ottawa Scale to assess the quality of the studies. The search strategy identified 101 publications from which we selected 16 articles for review. We identified HbA1c, fasting blood glucose, white blood cells, C-reactive protein, and erythrocyte sedimentation rate as predictive variables of higher major amputation rate. Although further investigation of long-term and prospective studies is needed, we identified 5 variables as predisposing factors for higher major amputation in diabetic patients through meta-analysis.

Influence of Epidemiologic and Patient Behavior–Related Predictors on Amputation Rates in Diabetic Patients

Amputation of patients with diabetic foot is a major issue worldwide, particularly from a medical and economic standpoint. This meta-analysis aimed to identify significant risk factors of high amputation rate among epidemiologic and patient behavior–related predictors in diabetic patients. A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. Seven variables were extracted from the included studies and evaluated based on amputation rate. The Newcastle-Ottawa scale was used to assess the quality of the studies. The search strategy identified 101 publications. After screening, 33 articles were selected for review. Male sex and smoking were identified as significant risk factors of high amputation rate of diabetic foot. Although further investigation of long-term and randomized controlled studies is needed, we identified 2 variables as significant risk factors for high amputation rate in diabetic patients in this meta-analysis.

Effects of weight-bearing exercise on a mini-trampoline on foot mobility, plantar pressure and sensation of diabetic neuropathic feet; a preliminary study

Objective: Foot and ankle exercise has been advocated as a preventative approach in reducing the risk of foot ulceration. However, knowledge about the appropriate types and intensity of exercise program for diabetic foot ulcer prevention is still limited. The current study aimed to examine the effects of an eight-week mini-trampoline exercise on improving foot mobility, plantar pressure and sensation of diabetic neuropathic feet.

Methods: Twenty-one people with diabetic peripheral neuropathy who had impaired sensation perception were divided into two groups. The exercise group received a foot-care education program plus an eight-week home exercise program using the mini-trampoline (n = 11); whereas a control group received a foot-care education only (n = 10). Measurements were undertaken at the beginning, at the completion of the eight-week program and at a 20-week follow-up.

Results: Both groups were similar prior to the study. Subjects in the exercise group significantly increased the range of the first metatarsophalangeal joint in flexion (left: p = 0.040, right: p = 0.012) and extension (left: p = 0.013) of both feet more than controlled subjects. There was a trend for peak plantar pressure at the medial forefoot to decrease in the exercise group (p = 0.016), but not in the control group. At week 20, the number of subjects in the exercise group who improved their vibration perception in their feet notably increased when compared to the control group (left: p = 0.043; right: p = 0.004).

Conclusions: This is a preliminary study to document the improvements in foot mobility, plantar pressure and sensation following weight-bearing exercise on a flexible surface in people with diabetic neuropathic feet. Mini-trampoline exercise may be used as an adjunct to other interventions to reduce risk of foot ulceration. A larger sample size is needed to verify these findings. This trial is registered with COA No. 097.2/55.

Early Predictors for Lower Extremity Amputation in a Diabetic Population: Results of a Case-Controlled Study

Lower extremity amputation is devastating to any person and is a very real complication for a diabetic. Identifying early risk factors is tantamount to saving a limb. This study used the national hospital discharge survey to identify 2206 control patients and 2098 diabetic patients with a lower extremity amputation. These patients were not limited based on gender or race as in previous studies. The results show that nephropathy and retinopathy are early predictors.

Temporal changes in the prevalence and associates of diabetes-related lower extremity amputations in patients with type 2 diabetes: the Fremantle Diabetes Study

Background

To determine temporal changes in the prevalence and associates of lower extremity amputation (LEA) complicating type 2 diabetes.

Methods

Baseline data from the longitudinal observational Fremantle Diabetes Study (FDS) relating to LEA and its risk factors collected from 1296 patients recruited to FDS Phase 1 (FDS1) from 1993 to 1996 and from 1509 patients recruited to FDS Phase 2 (FDS2) from 2008 to 2011 were analysed. Multiple logistic regression was used to determine associates of prevalent LEA in individual and pooled phases. Generalised linear modelling was used to examine whether diabetes related LEA prevalence and its associates had changed between Phases.

Results

There were 15 diabetes-related LEAs at baseline in FDS1 (1.2 %) and 15 in FDS2 (1.0 %; P = 0.22 after age, sex and race/ethnicity adjustment). In multivariable analysis, independent associates of a baseline LEA in FDS1 were a history of vascular bypass surgery or revascularisation, urinary albumin:creatinine ratio, peripheral sensory neuropathy and cerebrovascular disease (P ≤ 0.035). In FDS2, prevalent LEA was independently associated with a history of vascular bypass surgery or revascularisation, past hospitalisation for/current foot ulcer and fasting serum glucose (P ≤ 0.001). In pooled analyses, a history of vascular bypass or revascularisation, past hospitalisation for/current foot ulcer at baseline, urinary albumin:creatinine ratio (P < 0.001), as well as FDS Phase as a binary variable [odds ratio (95 % confidence interval): 0.28 (0.09–0.84) for FDS2 vs FDS1, P = 0.023] were associated with a lower risk of LEA at study entry.

Conclusions

The risk of prevalent LEA in two cohorts of patients with type 2 diabetes from the same Australian community fell by 72 % over a 15-year period after adjustment for important between-group differences in diabetes-related and other variables. This improvement reflects primary care foot health-related initiatives introduced between Phases, and should have important individual and societal benefits against a background of a progressively increasing diabetes burden.

A 5-Year Follow-up Study to Assess Clinical Outcomes of Patients with Diabetes Undergoing Lower Limb Angiography for Significant Peripheral Artery Disease

INTRODUCTION

The optimal management for patients with diabetes and peripheral vascular disease-intermittent claudication or critical limb ischemia (CLI)-remains undetermined.

METHODS

In a single-center retrospective analysis, we compared 1- and 5-year amputation-free survival rates in patients undergoing angiography subsequently treated with medical therapy or revascularization.

RESULTS

78 patients were included, 56 with CLI (mean age 77 years); 22 with claudication (mean age 75 years). Of the CLI cohort, 30 patients were medically treated. Their 1-year amputation-free survival rate was similar to those treated with revascularization (46.7% versus 50.0%, respectively). 8 patients in the claudicant cohort were treated conservatively. The 1-year amputation-free survival rate was 75.0% for conservative treatment versus 78.6% in those revascularized. Within the CLI cohort, in those conservatively treated 20% underwent major, and 16.7% minor amputations, compared to 15.4% and 23.1% in those revascularized. At 5 years in the claudicant cohort, the amputation-free survival rate was 37.5% with medical treatment, versus 71.4% for those treated with revascularization. For CLI, the 5-year amputation-free survival rate was 10% for conservative treatment, versus 26.9% for revascularization.

CONCLUSION

We found similar rates of amputation at 1 year for patients treated medically or revascularized. However, at 5 years, the amputation-free survival rate was markedly higher in revascularized patients compared to those medically managed. Our study highlights the potential role of predicting life expectancy when considering treatment, with the option of surgical treatment offered to those in whom survival is predicted to be longer than 5 years. However, larger studies with matched cohorts are now needed to confirm these findings.

Epidemiology of Type 2 Diabetic Foot Problems and Predictive Factors for Amputation in China

To determine incidence and clinically relevant risk factors for diabetic amputation in a large cohort study of diabetic foot ulceration patients in China, we investigated a total of 669 diabetic foot ulceration patients, who were assessed at baseline for demographic information, medical and social history, peripheral neuropathy screening, periphery artery disease screening, assessment of nutritional status and diabetic control, physical examination including foot deformity in 15 Grade III-A hospitals. Of the 669 patients, 435 were male and 201 were female, with the mean age being 64.0 years. Of all patients, 110 had neuropathic ulcers, 122 had ischemic ulcers, 276 had neuroischemic ulcers, and 12 cases were unclassified. Wagner classification showed 61 cases were grade I, 216 cases grade II, 159 cases grade III, 137 cases grade IV, and 7 cases grade V. The overall amputation rate among diabetic foot patients was 19.03%, and major and minor amputation rates were 2.14% and 16.88%, respectively. By univariate analysis, statistically significant differences were found in smoking, rest pain, ulcer history, revascularization history, amputation history, gangrene, infection, Wagner grades, duration of diabetes, and postprandial blood glucose, aldehyde, total protein, globulin, albumin, white blood cell (WBC), hemoglobin, HbA1c, ulcer property, body mass index, as well as creatinine. Binary logistic regression model showed that increased WBC (odds ratio 1.25) and ulcer history (odds ratio 6.8) were associated with increased risks from diabetic foot ulcer to major amputation; increased duration of diabetes (odds ratio 1.004), WBC (odds ratio 1.102), infection (odds ratio 2.323), foot deformity (odds ratio 1.973), revascularization history (odds ratio 2.662), and decreased postprandial blood sugar (odds ratio 0.94) were associated with increased risks from diabetic foot ulcer to minor amputation. It is of great importance to give better management to diabetic patients at early stages. Following a diagnosis of DFU more intensive surveillance and aggressive care may improve outcome.

Timing of access to secondary healthcare services and lower extremity amputations in patients with diabetes: a case-control study

OBJECTIVE

To investigate the association between timing of patient access to secondary healthcare services for diabetes management and lower extremity amputation (LEA) among patients with diabetes.

RESEARCH DESIGN AND METHODS

A case-control study was conducted in the secondary healthcare system in Ireland. Cases were 116 patients with diabetes who underwent a first major non-traumatic LEA between 2006 and 2012. Controls were 348 patients with diabetes, over 45 years, admitted to the same hospital as an emergency or electively, frequency-matched for gender, type of diabetes, and year. Data were collected for 7 years prior to the event year. ORs for LEA in patients with diabetes comparing early versus late referral from primary to secondary healthcare were calculated.

RESULTS

Statistically significant risk factors associated with LEA in patients with diabetes included being single, chronic kidney disease, hypertension, and hyperglycemia. Documented retinopathy was a significant protective factor. In unconditional logistic regression analysis adjusted for potential confounders, there was no evidence of a reduced risk of LEA among patients referred earlier to secondary healthcare for diabetes management.

CONCLUSIONS

Specialist referral may need to occur earlier than the 7-year cut-off used to demonstrate an effect on reducing LEA risk. Documented retinopathy was associated with reduced risk of LEA, most likely as a proxy for better self-care. Variation in the management of diabetes in primary care may also be impacting on outcomes. Efforts to develop more integrated care between primary and secondary services may be beneficial, rather than focusing on timing of referral to secondary healthcare.

[Peripheral arterial disease of the lower limbs in African diabetic patients: ultrasonography and determining factors]

INTRODUCTION

Diabetic peripheral arterial disease (PAD) of the lower limbs is underdiagnosed.

METHODOLOGY

This was a prospective study conducted over a six-month period from November 2012 to April 2013. A total of 308 diabetic patients were included from three diabetes centers in Abidjan (Ivory Coast).

AIM

To screen for PAD of the lower limbs in a diabetic population and to identify the determining factors.

RESULTS

Among the 308 patients, the ankle-brachial index (ABI) was<0.9 in 68 (22.07%) patients considered to have PAD; the ABI was>1.3 in 56 (18.2%) patients who had suspected mediacalcosis. The average age of the PAD patients was 60.2 years. Female gender predominated (55.9%). The mean duration of diabetes was 9.6 years: 97.1% type 2 diabetes. The other cardiovascular risk factors in this population were hypertension (58.8%) and dyslipidemia (40.9%). Smoking was present in 29.4% of patients and obesity in 23.9%. PAD of the lower limbs was mild in 46 patients (67.6%), moderate in 16 (23.5%) and severe in 6 (8.8%). Duplex Doppler commonly showed lesions of the tibial arteries. Determining factors of diabetic PAD of the lower limbs were hypertension (58.8% vs 36.6%; OR=2.46; 95% CI: 1.13-5.36; P=0.034) and dyslipidemia (40.9% vs 8.3%; OR=7.6; 95% CI: 2.31-25.08; P=0.0009). For mediacalcosis, male gender (71.5% vs 39.7; OR=0.26 95% CI/0.10-0.64. P=0.004) was the only factor identified.

CONCLUSION

Hypertension and dyslipidemia were predictive factors for diabetic PAD of the lower limbs in our African population.

A study of prognostic factors in Chinese patients with diabetic foot ulcers

OBJECTIVE

Few studies have identified factors as predictors of clinical prognosis of patients with diabetic foot ulcers (DFUs), especially of Chinese patients. In this study, we assessed the prognostic factors of Chinese patients with DFUs.

METHODS AND MATERIALS

This was a retrospective study (January 2009-January 2011) of 194 DFUs conducted in an inpatient population at PLA 454 Hospital in Nanjing, China, to determine the prognostic influential factors of DFUs in Chinese patients. All of the studied patients were grouped into an amputation group, a non-healing group, and a cured group, according to the clinical prognosis. Patient parameters, including gender, age, smoking habits, education level, family history of diabetes mellitus, medical history, duration of foot lesions and complications, ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), urinary albumin/creatinine ratio (Alb/Cr), fundus oculi, electrocardiogram, DFU characteristics, bacterial nature, and neuropathy, were cross-studied among the three groups.

RESULTS

Compared with the other two groups, the amputation group showed a higher number of males, older in age, lower ABI and TcPO2 levels, higher Wagner wound grading and size, and significantly higher urinary Alb/Cr ratio, blood urea nitrogen, serum creatinine, white blood cell count, and erythrocyte sedimentation rate. Compared to the cured group (162 patients), more patients with an older age, smoking, family history of diabetes mellitus, medical history of foot ulcerations, lower ABI and TcPO2 levels, higher urine Alb/Cr ratio, and serum creatinine were found in the non-healing group. Regression analysis was used to study the correlation between various factors and clinical prognosis, and the results were as follows: age, Wagner wound classification, and heel ulcerations were negatively correlated to the DFU prognosis, whereas the female population, ABI, and TcPO2 were positively correlated with DFU prognosis.

CONCLUSION

In this retrospective study, we conclude that the DFU prognosis may be related to age, gender, wound location (heel), Wagner wound classification, ABI, and TcPO2 levels in the Chinese population.

Current and future management of diabetic retinopathy: a personalized evidence-based approach

Diabetic retinopathy (DR) is the leading cause of new-onset blindness in working-age individuals in the USA and represents a growing worldwide epidemic. Classic risk factors for onset or progression of DR include poor glycemic control, hypertension and hyperlipidemia; however, these factors account for only a small proportion of the risk of DR. New systemic risk factors are emerging, which may allow for personalized risk profiling and targeted treatment by physicians. In addition, early studies of vitreous fluid in patients with DR have resulted in a new paradigm: diabetes causes inflammation in the retina, which is mediated by multiple small signaling molecules that induce angiogenesis and vascular permeability. Future treatment of DR may involve two approaches: early vitreous analysis, followed by drug treatment targeted to the unique vitreous composition of the patient; and collaboration between ophthalmologists and primary care providers to address the unique systemic risk profile of each diabetic patient.

Timing of access to secondary healthcare services for diabetes management and lower extremity amputation in people with diabetes: a protocol of a case-control study

BACKGROUND

Lower extremity amputation (LEA) is a complication of diabetes and a marker of the quality of diabetes care. Clinical and sociodemographic determinants of LEA in people with diabetes are well known. However, the role of service-related factors has been less well explored. Early referral to secondary healthcare is assumed to prevent the occurrence of LEA. The objective of this study is to investigate a possible association between the timing of patient access to secondary healthcare services for diabetes management, as a key marker of service-related factors, and LEA in patients with diabetes.

METHODS/DESIGN

This is a case-control study. The source population is people with diabetes. Cases will be people with diabetes who have undergone a first major LEA, identified from the hospital discharge data at each of three regional centres for diabetes care. Controls will be patients with diabetes without LEA admitted to the same centre either electively or as an emergency. Frequency-matching will be applied for gender, type of diabetes, year and centre of LEA. Three controls per case will be selected from the same population as the cases. With a power of 90% to detect OR of 0.4 for an association between 'good quality care' and LEA in people with diabetes, 107 cases and 321 controls are required. Services involved in diabetes management are endocrinology, ophthalmology, renal, cardiology, vascular surgery and podiatry; timing of first contact with any of these services is the main exploratory variable. Using unconditional logistic regression, an association between this exposure and the outcome of major LEA in people with diabetes will be explored, while adjusting for confounders.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals, Ireland. Results will be presented at conferences and published in peer-reviewed journals.

A developing world experience with distal foot amputations for diabetic limb salvage

OBJECTIVES

To evaluate the functional outcome, morbidity, and viability of foot salvage in diabetic patients.

MATERIALS AND METHODS

This prospective case series was conducted from March 2007 to December 2012 at the department of surgery Pakistan Ordnance Factories Hospital, Wah Cantt, Pakistan. 123 males and 26 female patients were included in the study. All the patients were treated after getting admitted in the hospital and wounds were managed with daily dressings, nursing care and debridement of necrotic tissue with adequate antibiotic coverage.

RESULTS

In total, 149 patients (mean age: 56±7.52 years) with 171 amputations were included in the study. The mean duration of diabetes mellitus (DM) was 9±4.43 years. Ninety-seven percent of the patients were diagnosed with type 2 DM. Wound debridement was performed under general anesthesia in 48 (33.2%) patients, whereas local anesthesia was used for the rest of the patients after having good glycemic control and improvement in general health. The most common pathogen isolated from the infected wounds was Staphylococcus aureus in approximately 46% cases. Regarding the types of amputation, partial toe amputation was performed in 21 (12.2%) cases, second-toe amputation in 60 (35%) cases, hallux amputation in 41 (24%) cases, multiple toe amputations in 29 (17%) cases, bilateral feet involvement was observed in 16 (9.3%) cases, and transmetatarsal amputation was performed in 4 (2.3%) cases. The wounds healed well except in 19 cases where amputation had to be revised to a more proximal level. Thirty-nine patients died during the study period: 3 died of wound-related complications and 36 died of systemic complications.

CONCLUSION

With the ever-increasing epidemic of DM, the number of patients with diabetic foot ulcers has also significantly risen. Early surgical management with good glycemic control and foot care with close monitoring can decrease amputations and thus foot salvage can be successfully achieved.

Predicting development of proliferative diabetic retinopathy

OBJECTIVE

Identifying individuals most at risk for diabetic retinopathy progression and intervening early can limit vision loss and reduce the costs associated with managing more advanced disease. The purpose of this study was to identify factors associated with progression from nonproliferative diabetic retinopathy (NPDR) to proliferative diabetic retinopathy (PDR).

RESEARCH DESIGN AND METHODS

This was a retrospective cohort analysis using a claims database of all eye care recipients age ≥ 30 years enrolled in a large managed-care network from 2001 to 2009. Individuals with newly diagnosed NPDR were followed longitudinally. Multivariable Cox regression analyses identified factors associated with progression to PDR. Three- and five-year probabilities of retinopathy progression were determined.

RESULTS

Among the 4,617 enrollees with incident NPDR, 307 (6.6%) developed PDR. After adjustment for confounders, every 1-point increase in HbA1c was associated with a 14% (adjusted hazard ratio 1.14 [95% CI 1.07-1.21]) increased hazard of developing PDR. Those with nonhealing ulcers had a 54% (1.54 [1.15-2.07]) increased hazard of progressing to PDR, and enrollees with nephropathy had a marginally significant increased hazard of progressing to PDR (1.29 [0.99-1.67]) relative to those without these conditions. The 5-year probability of progression for low-risk individuals with NPDR was 5% (range 2-8) and for high-risk patients was 38% (14-55).

CONCLUSIONS

Along with glycemic control, nonophthalmologic manifestations of diabetes mellitus (e.g., nephropathy and nonhealing ulcers) are associated with an increased risk of diabetic retinopathy progression. Our retinopathy progression risk score can help clinicians stratify patients who are most at risk for disease progression.

A study of regional variation in the inpatient cost of lower extremity amputation among patients with diabetes in the United States

OBJECTIVE

Understanding of the effects of providers' cost on regional variation in healthcare spending is still very limited. The objective of this study is to assess cross-state and cross-region variations in inpatient cost of lower extremity amputation among diabetic patients (DLEA) in relation to patient, hospital, and state factors.

METHODS

Patient and hospital level data were obtained from the 2007 US Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP). State level data were obtained from the US Census Bureau and the Kaiser Family Foundation websites. Regression models were implemented to analyze the association between in-patient cost and variables at patient, hospital, and state levels.

RESULTS

This study analyzed data on 9066 DLEA hospitalizations from 39 states. The mean cost per in-patient stay was $17,103. Four out of the five most costly states were located on the East and West coasts (NY and NJ, CA and OR). Age, race, length of stay, level of amputation, in-patient mortality, primary payer, co-morbidities, and type of hospital were significantly correlated with in-patient costs and explained 55.3% of the cost variance. Based on the means of costs unexplained by those factors, the three West coast states had the highest costs, followed by five Midwestern states, and four Southern states, and Kansas were the least costly.

CONCLUSIONS

Over 40% of the variations in DLEA hospital costs could not be explained by major patient-, hospital-, and state-level variables. Further research is needed to examine whether similar patterns exist for other costly surgical procedures among diabetic patients.

Risk factors for lower extremity amputation in diabetic foot disease categorized by Wagner classification

AIMS

To elucidate the risk factors for lower extremity amputation (LEA) in patients of diabetic foot disease with different Wagner gradings.

METHODS

This study was conducted in a multidisciplinary diabetic foot care center. Demographic characteristics, laboratory data, disease history, ankle brachial pressure index (ABI) and Wagner classification were considered as independent variables to predict the therapeutic outcome (major LEA, minor LEA, and non-amputation). Risk factors for LEA in different Wagner grades were further analyzed. Multivariate stepwise ordinal logistic regression was performed.

RESULTS

Of 789 study subjects, 19.9% received major LEA and 22.9% received minor LEA. Higher Wagner grade, lower ABI, serum albumin and hemoglobin, and elevated white blood cell (WBC) count were significantly associated with an increased risk of LEA. When stratified by Wagner classification, most of the above predictors and estimated glomerular filtration (eGFR) were detected only in grade 3. While in grades 2 and 4, WBC count was identified as primary predictor positively associated with an increased risk of LEA.

CONCLUSIONS

Wagner classification remarkably influenced the potential risk factors for LEA, showing different predictors in different grades. The traditionally recognized predictors for diabetic foot amputation such as lower ABI, albumin or eGFR were almost exclusively found in patients with Wagner grade 3.

Blood urea level and diabetes duration are independently associated with ankle-brachial index in type 2 diabetic patients

AIM

The purpose of the study was to determine factors of ankle-brachial index (ABI) in a population of patients with type 2 diabetes and coronary artery disease.

MATERIAL AND METHODS

370 patients (mean age 60.3 ± 8.3 years and diabetes duration 8.6 ± 6.2 years) with type 2 diabetes and coronary artery disease were enrolled in a cross sectional study during 2006-2007. Multivariable linear regression analysis was conducted to determine the factors of ABI, considering systolic and diastolic blood pressure, weight, body mass index, waist circumference, glycemia, urea, creatinin, triglycerides, total cholesterol, LDL- and HDL-cholesterol.

RESULTS

Peripheral arterial disease was detected in 82.35% (280 pts). Mean ABI value of 0.97 ± 0.33, and its minimal value of 0.95 ± 0.38 was detected in this study population. Regression analysis demonstrated that mean and minimal values of ABI were independently associated with diabetes duration (β 0.120, 95% CI -0.014, -0.001) and blood urea level (β -0.126, 95% CI -0.020, -0.002).

CONCLUSION

Results might have clinical implications for patients with type 2 diabetes and coronary artery disease in defining those with a long diabetes duration and a higher blood urea level to have greater probability of detecting pathological ankle-brachial index.

Minor amputation in patients with diabetes mellitus and severe foot ulcers achieves good outcomes

OBJECTIVE

To analyse the outcome of minor amputations (through, or distal to, the ankle joint) in patients with diabetes.

METHOD

All diabetic patients in a defined population undergoing one or more minor amputation between 1982 and 2006 were investigated according to a standardised protocol and were followed until final outcome (healing or death). A total of 410 consecutive amputations in 309 patients with a median age of 73 (32-93) years were identified.

RESULTS

In 94% of amputations, deep infection (39%) and/or gangrene (55%) was present. Severe peripheral vascular disease or critical limb ischaemia was present in 61% of amputations. 261/410 (64%) of the amputations healed at a level below the ankle joint; 69/410 (17%) healed after a re-amputation above the ankle joint; in 76/410 of amputations (19%), the patient died before healing could occur. In surviving patients, 79% of the amputations healed below the ankle. Median healing time for amputations that healed below the ankle was 26 (2-250) weeks; 21% of amputations required a re-amputation above the ankle. None of the analysed parameters excluded the possibility of healing below the ankle.

CONCLUSION

In this population-based survey, the goal of avoiding major amputation was achieved in almost two thirds of minor amputations, but at the price of long healing times. In almost all amputations, the patient had deep infection and/or gangrene. In spite of this, 64% of all amputations, and 79% of amputations in surviving patients, healed at a level below the ankle. This indicates that minor amputations in these patients are worthwhile.

DECLARATION OF INTEREST

None.

Incidence, risk factors for amputation among patients with diabetic foot ulcer in a Chinese tertiary hospital

OBJECTIVES

The aim of this study was to evaluate the incidence of amputation among patients with diabetic foot ulcer (DFU) and risk factors for amputations.

METHODS

This is a retrospective study of 450 inpatients treated in a multi-discipline based diabetic centre, 306th Hospital of PLA during the period of January 2000-September 2009. Hospital admission and discharge information including patient profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. The risk factors for amputation were determined using univariate and stepwise logistic regression analysis.

RESULTS

The overall amputation rate among DFU was 21.5%. Significant univariate risk factors for amputation were peripheral vascular disease (PVD), white blood cell (WBC) counts, neutrophil granulocyte percentage, hemoglobin, triglyceride, cholesterol, LDL-C, HDL-C and serum sCRP. Upon stepwise logistic regression analysis, only PVD (odds ratio 4.529, 95% CI 1.500-13.676), WBC (odds ratio 1.146, 95% CI 1.075-1.222), sCRP (odds ratio 1.041, 95% CI 1.002-1.082) and triglyceride (odds ratio -0.488, 95% CI 0.433-0.869) were significant risk factors.

CONCLUSIONS

The risk factors for amputation were presence of PVD, increased WBC, sCRP and decreased triglyceride.

The assessment of clinical distal symmetric polyneuropathy in type 1 diabetes: a comparison of methodologies from the Pittsburgh Epidemiology of Diabetes Complications Cohort

Distal symmetrical polyneuropathy (DSP) is the most common type of diabetic neuropathy, but often difficult to diagnose reliably. We evaluated the cross-sectional association between three point-of-care devices, Vibratron II, NC-stat(®), and Neurometer(®), and two clinical protocols, MNSI and monofilament, in identifying those with DSP, and/or amputation/ulcer/neuropathic pain (AUP), the two outcomes of major concern. This report presents data from 195 type 1 diabetic participants of the Epidemiology of Diabetes Complications (EDC) Study attending the 18-year examination (2004-2006). Participants with physician-diagnosed DSP, AUP or who were abnormal on the NC-stat, and the Vibratron II, MNSI, and monofilament were older (p<0.05) and had a longer duration of diabetes (p < 0.05). There was no difference by sex for DSP, AUP, or any testing modality, with the exception of NCstat (motor). The Vibratron II and MNSI showed the highest sensitivity for DSP (>87%) and AUP (>80%), whereas the monofilament had the highest specificity (98% DSP, 94% AUP) and positive predictive value (89% DSP, 47% AUP), but lowest sensitivity (20% DSP, 30% AUP). The MNSI also had the highest negative predictive value (83%) and Youden's Index (37%) and currently presents the single best combination of sensitivity and specificity of DSP in type 1 diabetes.

Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation

OBJECTIVES

The incidence of minor amputation may vary significantly, and determinants of minor amputation have not been studied systematically. We evaluated minor amputation rate, the determinants of minor amputation and differences in amputation rate between European centres.

METHODS

In the Eurodiale study, a prospective cohort study of 1232 patients (1088 followed until end-point) with a new diabetic foot ulcer were followed on a monthly basis until healing, death, major amputation or up to a maximum of 1 year. Ulcers were treated according to international guidelines. Baseline characteristics independently associated with minor amputation were examined using multiple logistic regression modelling. Based on the results of the multivariable analysis, a disease severity score was calculated for each patient.

RESULTS

One hundred and ninety-four (18%) patients underwent a minor amputation. Predictors of minor amputation were depth of the ulcer (odds ratio 6.08, confidence interval 4.10-9.03), peripheral arterial disease (odds ratio 1.84, confidence interval 1.30-2.60), infection (odds ratio 1.56, confidence interval 1.05-2.30) and male sex (odds ratio 1.42, confidence interval 0.99-2.04). Minor amputation rate varied between 2.4 and 34% in the centres. Minor amputation rate in centres correlated strongly with disease severity score at the moment of presentation to the foot clinic (r=0.75).

CONCLUSIONS

Minor amputation is performed frequently in diabetic foot centres throughout Europe and is determined by depth of the ulcer, peripheral arterial disease, infection and male sex. There are important differences in amputation rate between the European centres, which can be explained in part by severity of disease at presentation. This may suggest that early referral to foot clinics can prevent minor amputations.

Predictive factors for lower extremity amputations in diabetic foot infections

The objective of this study was to evaluate the epidemiology of diabetic foot infections (DFIs) and its predictive factors for lower extremity amputations. A prospective study of 100 patients with DFIs treated at the National University Hospital of Singapore were recruited in the study during the period of January 2005-June 2005. A protocol was designed to document patient's demographics, type of DFI, presence of neuropathy and/or vasculopathy and its final outcome. Predictive factors for limb loss were determined using univariate and stepwise logistic regression analysis. The mean age of the study population was 59.8 years with a male to female ratio of about 1:1 and with a mean follow-up duration of about 24 months. All patients had type 2 diabetes mellitus. Common DFIs included abscess (32%), wet gangrene (29%), infected ulcers (19%), osteomyelitis (13%), necrotizing fasciitis (4%) and cellulitis (3%). Thirteen patients were treated conservatively, while surgical debridement or distal amputation was performed in 59 patients. Twenty-eight patients had major amputations (below or above knee) performed. Forty-eight percent had monomicrobial infections compared with 52% with polymicrobial infections. The most common pathogens found in all infections (both monomicrobial and polymicrobial) were Staphylococcus aureus (39.7%), Bacteroides fragilis (30.3%), Pseudomonas aeruginosa (26.0%) and Streptococcus agalactiae (21.0%). Significant univariate predictive factors for limb loss included age above 60 years, gangrene, ankle-brachial index (ABI) <0.8, monomicrobial infections, white blood cell (WBC) count ≥ 15.0×10(9)/L, erythrocyte sedimentation rate ≥100 mm/hr, C-reactive protein ≥15.0 mg/dL, hemoglobin (Hb) ≤10.0g/dL and creatinine ≥150 µmol/L. Upon stepwise logistic regression, only gangrene, ABI <0.8, WBC ≥ 15.0×10(9)/L and Hb ≤10.0g/dL were significant.

Predictive factors for lower extremity amputations in diabetic foot infections

The objective of this study was to evaluate the epidemiology of diabetic foot infections (DFIs) and its predictive factors for lower extremity amputations. A prospective study of 100 patients with DFIs treated at the National University Hospital of Singapore were recruited in the study during the period of January 2005-June 2005. A protocol was designed to document patient's demographics, type of DFI, presence of neuropathy and/or vasculopathy and its final outcome. Predictive factors for limb loss were determined using univariate and stepwise logistic regression analysis. The mean age of the study population was 59.8 years with a male to female ratio of about 1:1 and with a mean follow-up duration of about 24 months. All patients had type 2 diabetes mellitus. Common DFIs included abscess (32%), wet gangrene (29%), infected ulcers (19%), osteomyelitis (13%), necrotizing fasciitis (4%) and cellulitis (3%). Thirteen patients were treated conservatively, while surgical debridement or distal amputation was performed in 59 patients. Twenty-eight patients had major amputations (below or above knee) performed. Forty-eight percent had monomicrobial infections compared with 52% with polymicrobial infections. The most common pathogens found in all infections (both monomicrobial and polymicrobial) were Staphylococcus aureus (39.7%), Bacteroides fragilis (30.3%), Pseudomonas aeruginosa (26.0%) and Streptococcus agalactiae (21.0%). Significant univariate predictive factors for limb loss included age above 60 years, gangrene, ankle-brachial index (ABI) <0.8, monomicrobial infections, white blood cell (WBC) count ≥ 15.0×10(9)/L, erythrocyte sedimentation rate ≥100 mm/hr, C-reactive protein ≥15.0 mg/dL, hemoglobin (Hb) ≤10.0g/dL and creatinine ≥150 µmol/L. Upon stepwise logistic regression, only gangrene, ABI <0.8, WBC ≥ 15.0×10(9)/L and Hb ≤10.0g/dL were significant.

Prevalence of other diabetes-associated complications and comorbidities and its impact on health care charges among patients with diabetic neuropathy

INTRODUCTION

Diabetic neuropathy (DN) is a common complication associated with diabetes. This study assesses the prevalence of other diabetes-related complications or comorbidities among DN patients and its marginal contribution to health care charges.

METHODS

Using administrative claims database, we studied commercially insured patients below 65 years old with at least one claim of DN anytime from July 2004 through June 2005 (Year 1). Using propensity scoring, a 10:1 ratio of demographically matched controls with diabetes but no DN was constructed. Both DN patients and controls had 12 months of continuous enrollment in Year 1 and Year 2 (July 2005-June 2006). We compared the Year 1 prevalence of other diabetes-associated complications or comorbidities between DN patients and diabetic controls. Controlling for comorbidities, we used multivariate regressions to examine the incremental impact of DN or any other diabetes-related complication or comorbidity on Year 2 health care charges.

RESULTS

A higher percentage of DN patients had at least one other diabetes-related complication or comorbidity than diabetic controls. Individuals with DN had a higher prevalence of each individual other diabetes-related complication or comorbidity. Controlling for comorbidities, the presence of any other diabetes-related complication or comorbidity was statistically associated with higher outpatient pharmacy and total charges for both DN patients and controls. Total and outpatient pharmacy charges were also significantly higher for DN patients than for controls, among those with or without any other diabetes-related complications or comorbidities.

CONCLUSIONS

DN can occur in the absence of other diabetes-related complications or comorbidities. The presence of DN and any other diabetes-related complications or comorbidities significantly increases health care charges.

Impact of comorbid depression or anxiety on patterns of treatment and economic outcomes among patients with diabetic peripheral neuropathic pain

OBJECTIVE

The objective of this retrospective analysis was to assess the correlation of comorbid depression and/or anxiety to patterns of treatment, healthcare utilization, and associated costs among diabetic peripheral neuropathic pain (DPNP) patients, employing a large US administrative claims database.

RESEARCH DESIGN AND METHODS

Patients under age 65 with commercial insurance and patients aged 65 and older with employer-sponsored Medicare supplemental insurance were selected for the study if they had at least one diagnosis of DPNP in 2005. The first observed DPNP claim was considered the 'index date.' All individuals had a 12-month pre-index and 12-month follow-up period. For both populations, two subgroups were constructed for individuals with depression and/or anxiety (DPNP-DA cohort) or without these disorders (DPNP-only cohort). Patients' demographic characteristics, clinical characteristics, and medication use were compared over the pre-index period. Healthcare expenditures and resource utilization were measured for the post-index period. Two-part models were used to examine the impact of comorbid depression and/or anxiety on healthcare utilization and costs, controlling for demographic and clinical characteristics.

RESULTS

The study identified 11,854 DPNP-only and 1512 DPNP-DA patients in the Medicare supplemental cohort, and 11,685 and 2728 in the commercially insured cohort. Compared to DPNP-only patients over the follow-up period, a significantly higher percentage of DPNP-DA patients were dispensed pain and DPNP-related medication. All components of healthcare utilization, except home healthcare visits and physician office visits, were more likely to be provided to DPNP-DA patients versus the DPNP-only cohort (all p < 0.01). Controlling for differences in demographic and clinical characteristics, DPNP-DA patients had significantly higher total costs than those of DPNP-only patients for Medicare ($9134, p < 0.01) and commercially insured patients ($11,085, p < 0.01).

LIMITATIONS

Due to the use of a retrospective administrative claims database, limitations of this study include the potential for selection bias between study cohorts, mis-identification of DPNP and/or depression, and inability to assess indirect costs as well as use and cost of over-the-counter medications.

CONCLUSIONS

These findings indicate that the healthcare costs were significantly higher for DPNP patients comorbid with depression and/or anxiety relative to those without such disorders.

Four-fold increase in foot ulcers in type 2 diabetic subjects without an increase in major amputations by a multidisciplinary setting

AIMS

We observed a large increase in type 2 diabetic subjects with foot ulcers in our diabetic outpatient foot clinic and wanted to identify the amputations rate and individuals at risk of amputations by comparing those who had had a regular control in the multidisciplinary foot clinic prior to the amputations and those who had not.

METHODS

We examined all clinical records from the orthopaedic surgery department and the diabetic outpatient foot clinic of diabetic patients who underwent amputations for 6 years.

RESULTS

Eighty-eight patients with type 2 diabetes underwent 142 amputations; 42 major and 100 minor amputations. There was no increase in the number of major amputations in this period. In the group not followed in the foot clinic prior to amputations we showed a greater major amputations rate (p<0.05), although this group had a shorter duration of diabetes and less retinopathy, nephropathy and AMI/stroke. Everyone in both groups had severe neuropathy and ischemia.

CONCLUSION

A multidisciplinary diabetic foot clinic may decrease the risk of major amputations in type 2 diabetic subjects with foot ulcers. Severe neuropathy and ischemia were the most important risk factors.

Healthcare charges and utilization associated with diabetic neuropathy: impact of Type 1 diabetes and presence of other diabetes-related complications and comorbidities

AIMS

The aim was to examine the impact of Type 1 diabetes and having any other diabetes-related complication or comorbidity on healthcare charges and utilization in patients with diabetic neuropathy (DN).

METHODS

We selected individuals aged < 65 years who continuously enrolled in a large US commercial plan from July 2004 to June 2006 and who received at least one diagnosis of DN at any time from July 2004 to June 2005. We compared the prevalence of other diabetes-related complications or comorbidities between patients with Type 1 and with Type 2 diabetes. In patients with DN with or without any other diabetes-related complication or comorbidity, we used multivariate regression to assess the marginal contribution of Type 1 diabetes on healthcare charges and utilization from July 2005 until June 2006.

RESULTS

The majority of DN patients had at least one other diabetes-related complication or comorbidity. Most of the DN patients had Type 2 diabetes. DN patients with Type 1 diabetes had more comorbid medical conditions than those with Type 2 diabetes. Compared with Type 2, Type 1 patients had a higher prevalence of each individual non-DN diabetes-related complication or comorbidity, except heart disease. Controlling for comorbidities, Type 1 and Type 2 patients with DN but no other diabetes-related complication or comorbidity had similar healthcare utilization. However, Type 1 patients had significantly higher charges than those with any other diabetes-related complication or comorbidity.

CONCLUSIONS

Many patients with DN have Type 1 diabetes and other common diabetes-related complications or comorbidities, which can have a significant impact on healthcare charges and utilization.

[Epidemiology of diabetic foot problems]

Since diabetes mellitus is growing at epidemic proportions worldwide, the prevalence of diabetes-related complications is bound to increase. Diabetic foot disorders, a major source of disability and morbidity, are a significant burden for the community and a true public health problem. Many epidemiological data have been published on the diabetic foot but they are difficult to interpret because of variability in the methodology and in the definitions used in these studies. Moreover, there is a lack of consistency in population characteristics (ethnicity, social level, accessibility to care) and how results are expressed. In westernized countries, two of 100 diabetic patients are estimated to suffer from a foot ulcer every year. Amputation rates vary considerably: incidence ranges from 1 per thousand in the Madrid area and in Japan to up to 20 per thousand in some Indian tribes in North America. In metropolitan France, the incidence of lower-limb amputation is approximately 2 per thousand but with marked regional differences, and in French overseas territories, the incidence rate is much higher. Nevertheless, the risk for ulceration and amputation is much higher in diabetics compared to the nondiabetic population: the lifetime risk of a diabetic individual developing an ulcer is as high as 25% and it is estimated that every 30s an amputation is performed for a diabetic somewhere in the world. As reviewed in this paper, peripheral neuropathy, arterial disease, and foot deformities are the main factors accounting for this increased risk. Age and sex as well as social and cultural status are contributing factors. Knowing these factors is essential to classify every diabetic using a risk grading system and to take preventive measures accordingly.

Six-year incidence of lower extremity arterial disease and associated risk factors in Type 1 diabetic African-Americans

AIMS

To report the 6-year incidence of, and risk factors for, lower extremity arterial disease (LEAD) in African-Americans with Type 1 diabetes mellitus.

METHODS

African-Americans (n = 483) with Type 1 diabetes were re-examined 6 years after an original visit. At both visits, patients underwent a structured clinical interview which included history of amputation or leg angioplasty because of poor circulation in lower extremities; ocular examination; masked grading of seven stereoscopic fundus photographs; and blood pressure measurements. Biological tests included blood and urine assays.

RESULTS

Of the 483 patients who had a 6-year follow-up, 457 had no LEAD at the baseline examination. Of these 457 patients, 26 (5.7%) developed LEAD over the 6-year follow-up. Six-year incidence of LEAD was significantly associated with baseline older age (P = 0.0002) and longer duration of diabetes (P < 0.0001). Multiple logistic regression analysis showed that baseline longer duration of diabetes, male gender, higher systolic blood pressure, retinopathy severity, and presence of foot ulcers were significant and independent risk factors for incidence of LEAD.

CONCLUSIONS

Blood pressure control and prevention and treatment of foot ulcers may be helpful in reducing the morbidity associated with LEAD in African-Americans with Type 1 diabetes.

Epidemiology of diabetic foot problems and predictive factors for limb loss

OBJECTIVES

The aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major amputations (below- and above-knee).

METHODS

This is a prospective study of 202 patients treated in National University Hospital (NUH) during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for limb loss were determined using univariate and stepwise logistic regression analysis.

RESULTS

One hundred ninety-two patients had Type 2 diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays (P=.0015) and Indians (P=.036) and significantly lower in Chinese (P<.05). Of patients, 72.8% had poor endocrine control (GHb level >7%), and 42.1% of patients had sensory neuropathy based on 5.07 Semmes-Weinstein Monofilament test. Common DFP included gangrene (31.7%), infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcot's osteoarthropathy (2.0%). Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in 6.9%).

CONCLUSIONS

This is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP. Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) <0.8, gangrene, infection, and pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression analysis, only PVD and infection were significant.

Frequency of risk factors for foot ulceration in individuals with chronic kidney disease

BACKGROUND

Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group.

METHODS

One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.

RESULTS

Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end-stage kidney failure.

CONCLUSION

Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end-stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.

Epidemiology, classification, and modifiable risk factors of peripheral arterial disease

Peripheral arterial disease (PAD) is part of a global vascular problem of diffuse atherosclerosis. PAD patients die mostly of cardiac and cerebrovascular-related events and much less frequently due to obstructive disease of the lower extremities. Aggressive risk factors modification is needed to reduce cardiac mortality in PAD patients. These include smoking cessation, reduction of blood pressure to current guidelines, aggressive low density lipoprotein lowering, losing weight, controlling diabetes and the use of oral antiplatelet drugs such as aspirin or clopidogrel. In addition to quitting smoking and exercise, cilostazol and statins have been shown to reduce claudication in patients with PAD. Patients with critical rest limb ischemia or severe progressive claudication need to be treated with revascularization to minimize the chance of limb loss, reduce symptoms, and improve quality of life.