Sustained reduction in major amputations in diabetic patients: 628 amputations in 461 patients in a defined population over a 20-year period

Bioactives of Momordica charantia as Potential Anti-Diabetic/Hypoglycemic Agents

Momordica charantia L., a member of the Curcubitaceae family, has traditionally been used as herbal medicine and as a vegetable. Functional ingredients of M. charantia play important roles in body health and human nutrition, which can be used directly or indirectly in treating or preventing hyperglycemia-related chronic diseases in humans. The hypoglycemic effects of M. charantia have been known for years. In this paper, the research progress of M. charantia phytobioactives and their hypoglycemic effects and related mechanisms, especially relating to diabetes mellitus, has been reviewed. Moreover, the clinical application of M. charantia in treating diabetes mellitus is also discussed, hoping to broaden the application of M. charantia as functional food.

A meta-analysis of mortality after minor amputation among patients with diabetes and/or peripheral vascular disease

OBJECTIVE

Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed.

METHODS

A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality.

RESULTS

A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and "diabetic" results.

CONCLUSIONS

Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients.

Multidisciplinary diabetic foot care in Sweden - A national survey

AIM

To investigate at a national level the multidisciplinary team (MDT) care of patients with diabetes mellitus and foot complications.

METHODS

A questionnaire was sent to all 75 Swedish hospitals with emergency departments, which were grouped according to size.

RESULTS

The response rate was 92%, 58/69 of the hospitals have a foot team. Most teams have access to an internal medicine specialist/diabetologist, podiatrist and orthotist. Fewer teams reported access to an orthopaedic surgeon and infectious diseases specialist and only half to a vascular surgeon. In joint MDT outpatient evaluations, the majority report the presence of an internal medicine specialist, podiatrist and orthotist, but 50% an infectious disease specialist and orthopaedic surgeon and only a few a vascular surgeon. In hospitalized patients, there is a reduction in the presence of all specialists. The registration of amputation rate and healed foot ulcers is low.

CONCLUSIONS

MDT care is mostly adopted among large and medium-sized hospitals in contrast to small ones, which could reflect unequal health care. Vascular surgeons seldom are present at MDT evaluations and there is a reduced regular input of specialists in the evaluation of hospitalized patients. The hospitals' ability to evaluate their work by potential quality control markers is poor.

Increased mortality among patients with diabetes following first-ever transfemoral amputation

AIMS

Transfemoral amputation (TFA) is associated with a high postoperative mortality though it is unclear whether diabetes is associated with an increased mortality or not. The aim was to examine mortality at 1 week and 1 year after first-ever TFA with special reference to diabetes.

METHODS

We included 162 first-ever TFAs from 1996 to 2012. Mortality data were collected with the use of the Swedish personal identification number.

RESULTS

The median age was 85 years. Diabetes mellitus were present in 19% (n = 30) of the patients and 67% (n = 109) had cardiovascular disease. Mortality was significantly higher for patients with diabetes compared to patients without diabetes at 1 week (30% vs. 8%, p = 0.001) and at 1 year (80% vs. 57%, p = 0.02). This difference was significant in multivariable analysis.

CONCLUSIONS

We conclude that postoperative mortality was high. The high mortality rate emphasizes the need for early and adequate evaluation of every patient́s overall condition and whether amputation is beneficial or not. Although further studies are needed to analyze the specific causes of early death in amputees and we suggest close monitoring of blood-sugar in patients with diabetes and early treatment of infections and cardiac events in all patients.

The amputation prevention initiative

BACKGROUND

The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes.

METHODS

To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490).

RESULTS

The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components.

CONCLUSIONS

These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.

Care of Patients with Diabetic Foot Disease in Oman

Diabetes mellitus is a major public health challenge and causes substantial morbidity and mortality worldwide. Diabetic foot disease is one of the most debilitating and costly complications of diabetes. While simple preventative foot care measures can reduce the risk of lower limb ulcerations and subsequent amputations by up to 85%, they are not always implemented. In Oman, foot care for patients with diabetes is mainly provided in primary and secondary care settings. Among all lower limb amputations performed in public hospitals in Oman between 2002-2013, 47.3% were performed on patients with diabetes. The quality of foot care among patients with diabetes in Oman has not been evaluated and unidentified gaps in care may exist. This article highlights challenges in the provision of adequate foot care to Omani patients with diabetes. It concludes with suggested strategies for an integrated national diabetic foot care programme in Oman.

The changing face of diabetes complications

The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.

When and how to audit a diabetic foot service

Quality improvement depends on data collection and audit of clinical services to inform clinical improvements. Various steps in the care of the diabetic foot can be used to audit a service but need defined audit standards. A diabetes foot service should have risk stratification system in place that should compare to the population-based figures of 76% having low-risk feet, 17% moderate risk and 7% being at high risk of ulceration. Resources can then be directed towards those with high-risk feet. Prevalence of foot ulceration needs to be audited. Community-based studies give an audit standard of around 2%, with 2 to 9% having had an ulcer at some stage in the past. Amputation rates should be easier to measure, and the best results are reported to be around 1.5-3 per 1000 people with diabetes. This is a useful benchmark figure, and the rate has been shown to decrease by approximately a third over the last 15 years in some centres. Ulceration rates and ulcer healing rates are the ultimate outcome audit measure as they are always undesirable, whilst occasionally for defined individuals, an amputation can be a good outcome. In addition to clinical outcomes, processes of care can be audited such as provision of clinical services, time from new ulcer to be seen by health care professional, inpatient foot care or use of antibiotics. Measurement of clinical services can be a challenge in the diabetic foot, but it is essential if clinical services and patient outcomes are to be improved.

Implementation of routine foot check in patients with diabetes on hemodialysis: associations with outcomes

OBJECTIVE

Patients with diabetes are at increased risk of foot ulcers, which may result in limb amputations. While regular foot care prevents ulcerations and amputation in those patients with diabetes not on dialysis, evidence is limited in diabetic hemodialysis patients. We investigated the association between the implementation of a routine foot check program in diabetic incident hemodialysis patients, and major lower limb amputations.

METHODS

In 1/2008, monthly intradialytic foot checks were implemented as part of standard clinic care in all Fresenius Medical Care North America hemodialysis facilities. Patients with diabetes who initiated hemodialysis between 1/2004 and 12/2007 constituted the preimplementation cohort, and patients starting hemodialysis between 1/2008 and 12/2011 comprised the postimplementation cohort. In addition, we conducted a sensitivity analysis where we excluded patients from the clinics with <10 patients in the postimplementation period and where percent difference in patient with diabetes number between postimplementation and preimplementation period was <20%. We compared lower limb amputation rates employing Poisson regression models with offset of exposure time in these two cohorts.

RESULTS

We studied 35 513 patients in the preimplementation and 25 779 patients in the postimplementation cohort. In the postimplementation cohort, amputation rate decreased by 17% (p=0.0034). The major lower limb amputation rate was 1.30 per 100 patient years in preimplementation and 1.07 in postimplementation cohort. These beneficial results were corroborated in the multivariate analysis (p=0.0175) and were even more pronounced in the sensitivity analysis (p=0.0083).

CONCLUSION

Monthly foot checks are associated with reduction of major lower limb amputations in diabetic incident hemodialysis patients.

High probability of healing without amputation of plantar forefoot ulcers in patients with diabetes

Diabetic foot ulcer is an important entity which in many cases is the first serious complication in diabetes. Although a plantar forefoot location is common, there are few studies on larger cohorts and in such studies there is often a combination of various types of ulcer and ulcer locations. The purpose of this study is to discern the outcome of plantar forefoot ulcers and their specific characteristics in a large cohort. All patients (n = 770), presenting with a plantar forefoot ulcer at a multidisciplinary diabetes foot clinic from January 1, 1983 to December 31, 2012 were considered for the study. Seven hundred one patients (median age 67 [22-95]) fulfilled the inclusion criteria and were followed according to a preset protocol until final outcome (healing or death). Severe peripheral vascular disease was present in 26% of the patients and 14% had evidence of deep infection upon arrival at the foot clinic. Fifty-five percent (385/701) of the patients healed without foot surgery, 25% (173/701) healed after major debridement, 9% (60/701) healed after minor or major amputation and 12% (83/701) died unhealed. Median healing time was 17 weeks. An ulcer classified as Wagner grade 1 or 2 at inclusion and independent living were factors associated with a higher healing rate. Seventy-nine percent of 701 patients with diabetes and a plantar forefoot ulcer treated at a multidisciplinary diabetes foot clinic healed without amputation. For one third some form of foot surgery was needed to achieve healing.

Survival of diabetes patients with major amputation is comparable to malignant disease

INTRODUCTION

Almost all studies on diabetic foot syndrome focused on prevention of amputation and did not investigate long-term prognosis and survival of patients as a primary outcome parameter.

METHODS

We did a retrospective cohort study including 314 patients who had diabetic foot syndrome and underwent amputation between December 1995 and January 2001.

RESULTS

A total of 48% of patients received minor amputation (group I), 15% only major amputation (group II) and 36% initially underwent a minor amputation that was followed by a major amputation (group III). Statistically significant differences were observed in comparison of the median survival of group I to group II (51 vs. 40 months; p = 0.016) and of group II to group III (40 vs. 55 months; p = 0.003).

DISCUSSION

The prognosis of patients with major amputation due to diabetic foot syndrome is comparable to patients with malignant diseases. Vascular interventions did not improve the individual prognosis of patients.

Medical strategies to reduce amputation in patients with type 2 diabetes

Lower extremity amputation is a common and disabling complication of Type 2 diabetes. Whilst the introduction of specialist multidisciplinary teams has led to a reduction in the incidence of lower extremity amputation in some centres, the overall prevalence of diabetes-related amputation has actually increased in recent decades. The aetiology of diabetes-related amputation is complex, with neuropathy, macrovascular and microvascular disease contributing significantly. Ulceration, previous amputation, increasing diabetes duration and poor long-term control of glycaemia and lipids are important risk factors for amputation in populations with diabetes. Major randomized intervention trials of blood glucose-lowering or anti-hypertensive therapies in populations with diabetes have shown limited reductions in neuropathy and/or macrovascular disease, and no benefit on amputation rates. In contrast, a recent analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study showed a significantly reduced rate of minor, but not major amputations in patients with Type 2 diabetes treated with fenofibrate. Mechanistic studies are clearly needed to understand the basis of this benefit.

Reduced incidence of lower-extremity amputations in people with diabetes in Scotland: a nationwide study

OBJECTIVE

To establish the incidence of nontraumatic lower-extremity amputation (LEA) in people with diabetes in Scotland.

RESEARCH DESIGN AND METHODS

This cohort study linked national morbidity records and diabetes datasets to establish the number of people with diabetes who underwent nontraumatic major and minor LEA in Scotland from 2004 to 2008.

RESULTS

Two thousand three hundred eighty-two individuals with diabetes underwent a nontraumatic LEA between 2004 and 2008; 57.1% (n = 1,359) underwent major LEAs. The incidence of any LEA among persons with diabetes fell over the 5-year study period by 29.8% (3.04 per 1,000 in 2004 to 2.13 per 1,000 in 2008, P < 0.001). Major LEA rates decreased by 40.7% from 1.87 per 1,000 in 2004 to 1.11 per 1,000 in 2008 (P < 0.001).

CONCLUSIONS

There has been a significant reduction in the incidence of LEA in persons with diabetes in Scotland between 2004 and 2008, principally explained by a reduction in major amputation.

Trends in educational inequalities in old age mortality in Norway 1961-2009: a prospective register based population study

BACKGROUND

The vast majority of deaths occur in older adults. Paradoxically, knowledge on long-term trends in mortality inequalities among the aged, and particularly for those aged 80 years and over, is sparse. The historical trends in size and impact of socioeconomic inequalities on old age mortality are important to monitor because they may give an indication on future burden of inequalities. We investigated trends in absolute and relative educational inequalities in old age mortality in Norway between 1961 and 2009.

METHODS

We did a register-based population study covering the entire Norwegian population aged 65-94 in the years 1961-2009 (1,534,513 deaths and 29,312,351 person years at risk). By examining 1-year mortality rates by gender, age and educational level we estimated trends in mortality rate ratios and rate differences.

RESULTS

On average, age-standardised absolute inequalities increased by 0.17 deaths per 1000 person-years per year in men (P<0.001), and declined by 0.07 deaths per 1000 person-years per year in women (P<0.001). Trends in rate differences were largest in men aged 75-84 years, but differed in direction by age group in women. The corresponding mean increase in age-standardised relative inequalities was 0.4% and 0.1% per year in men and women, respectively (P<0.001). Trends in rate ratios were largest in the youngest age groups for both genders and negligible among women aged 85-94 years.

CONCLUSIONS

While relative educational inequalities in old age mortality increased for both genders, absolute educational inequalities increased only temporarily in men and changed little among women. Our study show the importance of including absolute measures in inequality research in order to present a more complete picture of the burden of inequalities to policy makers. As even in older ages, inequalities represent an unexploited potential to public health, old age inequalities will become increasingly important as many countries are facing aging populations.

Preoperative medical treatment in patients undergoing diabetic foot surgery with a Wagner Grade-3 or higher ulcer: a retrospective analysis of 52 patients

Diabetic foot ulcers (DFU) are one of the most important complications in people with diabetes mellitus. The present study was aimed to retrospectively review the efficacy of at least 1-week medical treatment before any surgical intervention in patients with Grade-3 and higher DFU according to Wagner's classification. A total of 52 patients (36 males and 16 females) hospitalized and treated between June 2006 and February 2009 and had initially received therapeutic treatment (local wound care, antibiotic therapy and blood glucose regulation) for a period of at least 1 week were included in the study. The level of amputation, rates of reulceration and mortality in both groups were recorded in the following period of 2 years. Group 1 (did not respond to preoperative medical intervention) included 16 patients where a surgical debridement, flap or skin graft surgery was performed in 2 (12.5%) patients, major amputation was performed in another 2 (12.5%) patients and minor amputation was performed in the remaining 12 (75%) patients. Of 36 patients in Group 2 (did respond to preoperative medical intervention), 5 (13.9%) patients underwent the surgical debridement, flap or skin graft surgery, 8 (22.2%) patients had a major amputation and the remaining 23 (63.9%) patients lead to a minor amputation. The ulcer recurrence and mortality rates were obtained as 2 (12.5%) and 2 (12.5%) in Group 1 and 2 (5.6%) and 1 (2.8%) in Group 2, respectively. Despite the lower rates of ulcer recurrence and mortality in patients having adequate responses to initial treatment before surgical procedures were performed, no statistically significant difference was observed between the 2 groups. In addition, there was no statistically significant difference between the levels of amputation in both groups.

A retrospective analysis of amputation rates in diabetic patients: can lower extremity amputations be further prevented?

Background

Lower extremity amputations are costly and debilitating complications in patients with diabetes mellitus (DM). Our aim was to investigate changes in the amputation rate in patients with DM at the Karolinska University Hospital in Solna (KS) following the introduction of consensus guidelines for treatment and prevention of diabetic foot complications, and to identify risk groups of lower extremity amputations that should be targeted for preventive treatment.

Methods

150 diabetic and 191 nondiabetic patients were amputated at KS between 2000 and 2006; of these 102 diabetic and 99 nondiabetic patients belonged to the catchment area of KS. 21 diabetic patients who belonged to KS catchment area were amputated at Danderyd University Hospital. All patients' case reports were searched for diagnoses of diabetes, vascular disorders, kidney disorders, and ulcer infections of the foot.

Results

There was a 60% reduction in the rate of amputations performed above the ankle in patients with DM during the study period. Patients with DM who underwent amputations were more commonly affected by foot infections and kidney disorders compared to the nondiabetic control group. Women with DM were 10 years older than the men when amputated, whereas men with DM underwent more multiple amputations and had more foot infections compared to the women. 88% of all diabetes-related amputations were preceded by foot ulcers. Only 30% of the patients had been referred to the multidisciplinary foot team prior to the decision of amputation.

Conclusions

These findings indicate a reduced rate of major amputations in diabetic patients, which suggests an implementation of the consensus guidelines of foot care. We also propose further reduced amputation rates if patients with an increased risk of future amputation (i.e. male sex, kidney disease) are identified and offered preventive treatment early.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The ulcerated leg: when to revascularize

The role of peripheral arterial disease in ulcerated diabetic feet has long been underestimated. Progressive claudication, rest pain and the extent of irreversible tissue loss have frequently been indications for revascularization for neuroischaemic ulcers in diabetic patients. These typical ischaemic symptoms are warning signs that are less frequent in diabetic individuals with ischaemia than those without diabetes. Consequently, 30-50% of individuals with diabetes and foot ulcers already have gangrene at admission and are therefore often considered unsuitable for revascularization. Furthermore, the healing of a neuroischaemic ulcer is worsened by microvascular dysfunction, causing arteriovenous shunting, capillary ischaemia, leakage and venous pooling. Therefore, the threshold of revascularizing neuroischaemic ulcers should be lower than that of purely ischaemic ulcers. Comorbidity, ulcer characteristics and infection affect the decision as to when to intervene, as do the severity and extent of occlusive arterial lesions. The window of opportunity for vascular intervention in the neuroischaemic diabetic foot should not be missed, and the need for early vascular intervention as an integrated part of a strategy to achieve healing should be emphasized. Noninvasive vascular testing should be performed on all individuals with an ulcerated diabetic foot. The arterial tree should be imaged if noninvasive tests indicate ischaemia or when mild or questionable ischaemia is diagnosed and conservative treatment does not promote ulcer healing in 6 weeks. Revascularization should be performed whenever feasible to repair distal perfusion to achieve ulcer healing.

[Resources and models for diabetic foot care in Catalonia (Spain): a descriptive study on areas of improvement]

OBJECTIVES

To identify areas of improvement in diabetic foot care as regards the availability of materials and specialties in primary and secondary care. To determine the model of care for surgical centres and hospitals caring for diabetic foot problems and their relation to amputations.

DESIGN

Cross-sectional study

SETTING AND PARTICIPANTS

Random sample of 36 basic health areas (BHA) and all hospital surgery centres in Catalonia (Spain).

MEASUREMENTS

Information was collected by structured interview of managers of each centre on: availability of specialists, material off-loading and examination. The models were established according to the classification of Van Acker, and amputations from hospital discharge records.

RESULTS

An endocrinologist was available in 36.1% [confidence interval (CI) 95%:19.0-53.2] of the BHA and 11.1% [95% CI: 3.1-26.1] had a podiatrist,100% [95% CI: 90.3-100.0] had Doppler, 91.7% [95% CI:77.5-98.2] a monofilament, 5.6% [95% CI: 0.7-18.7] a quantitative tuning fork, 11.1% [95% CI:3,1-26, 1] material off-loading, and 8.3% [95% CI: 1.8 - 22.5] a specialist reference centre. A total of 85 surgical centres and hospitals dealt with these problems: 11(13.0%) excellent model, 29 (34.1%) intermediate and 45 (52.9%) basic/insufficient. Centres with a basic model/insufficient performed 12.5% of the amputation, intermediate models, 56.4%, and 31.1% in excellent models.

CONCLUSIONS

The proportion of ABS with materials, specialists and/or specialist reference centres was low. The basic/insufficient model was the most common among surgical/hospital centres. Most amputations were performed in centres with excellent and intermediate model; nevertheless, a considerable percentage was performed in centres with basic/insufficient models.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Limb salvage in severe diabetic foot infection

BACKGROUND

The purpose of our study was to determine the efficacy of a management algorithm that includes negative pressure wound therapy (NPWT) in diabetic feet with limb-threatening infection.

MATERIALS AND METHODS

Forty-five septic diabetic feet were treated with NPWT between 2006 and 2008. After emergent abscess evacuation, early vascular intervention was performed if necessary. Debridement, with or without partial foot amputation, was followed by NPWT. Wound progress was measured using a digital scanner. A limb was considered salvaged if complete healing was achieved without any or with minor amputation through or below the ankle. The mean followup after complete wound healing was 17 (range, 6 to 35) months.

RESULTS

Thirty-two cases (71%) were infected with two or more organisms. Negative pressure wound therapy was applied for 26.2±14.3 days. The median time to achieve more than 75% wound area granulation was 23 (range, 4 to 55) days and 104 (range, 38 to 255) days to complete wound healing. Successful limb salvage was achieved in 44 cases (98%); 14 (31%) without any amputation and 30 (67%) with partial foot amputations. Total number of operations per limb was 2.4±1.3. One case of repeated infection and necrosis was managed with a transtibial amputation. There were no complications associated with NPWT.

CONCLUSION

This study provides the outcome of a management algorithm which includes NPWT in salvaging severely infected diabetic feet. With emergent evacuation of abscess, early vascular intervention and appropriate debridement, NPWT can be a useful adjunct to the management of limb-threatening diabetic foot infections.

Lower limb amputations in Trondheim, Norway

BACKGROUND AND PURPOSE

In the city of Trondheim, Norway, diabetic lower-limb amputations accounted for one-third of all lower-limb amputations (LLAs). In an attempt to reduce this rate, a diabetic foot team was established in 1996. We present the incidence of LLA in Trondheim as measured 10 years later.

PATIENTS AND METHODS

In 2004-07, we registered all LLAs performed in Trondheim and then compared the data with previously published data from 1994-1997. From 1996 through 2006, we registered the activity of the diabetic foot team and we also registered the number of vascular procedures performed on citizens of Trondheim from 1998 through 2006.

RESULTS

Comparing the two 3-year periods 1994-97 and 2004-07, we observed a decrease in all non-traumatic LLAs. The incidence of diabetic major LLAs per 10³ diabetics per year decreased from 4.0 to 2.4, and in patients with peripheral vascular disease we observed a decrease in LLAs from 18 to 12 per 10⁵ inhabitants per year. 5,915 consultations on diabetic subjects were conducted by the diabetic foot team during the period 1996-2006. From 1998 to 2006, the rate of vascular procedures decreased in the non-diabetic population, and was unchanged in diabetic subjects.

INTERPRETATION

In the population of Trondheim city there appears to have been a reduction in the rate of vascular obstructive lower-limb disease between the two 3-year periods 1994-97 and 2004-07. In our judgment, the decline in diabetic LLA also reflects better care of the diabetic foot.

Matching the numerator with an appropriate denominator to demonstrate low amputation incidence associated with a London hospital multidisciplinary diabetic foot clinic

AIMS

To establish a method to assess amputation incidence that addresses the problems matching a numerator with an appropriate denominator in London and to demonstrate low amputation incidence associated with the activity of our multidisciplinary diabetic foot clinic.

METHODS

Hospital-coded inpatient data was examined to derive the numerator: the number of non-traumatic amputations performed on subjects with diabetes each financial year where the Primary Care Trust commissioner code was our main local Primary Care Trust. Denominators were derived from the main local Primary Care Trust's Quality and Outcomes Framework data sets. Not all Primary Care Trust subjects with diabetes receive inpatient care at our hospital, so that the denominators were corrected for the hospital's percentage market share for the provision of inpatient diabetes care for the Primary Care Trust each financial year, derived from the Dr Foster database.

RESULTS

Between April 2004 and April 2009, 44 Primary Care Trust subjects with diabetes underwent 34 minor and 10 major amputations at the hospital. Although the Primary Care Trust populations with and without diabetes increased, the hospital's Primary Care Trust percentage market share decreased, so that overall denominators decreased. The mean annual incidence of minor, major and total amputations over the five financial years was 14.7, 4.2 and 18.9 per 10 000 subjects with diabetes,respectively, and 3.9, 1.1 and 5.0 per 100 000 of the general population, respectively.

CONCLUSIONS

We report for the first time amputation incidence in a London population. Acknowledging the limitations of accurately defining incidence in London, we demonstrate low amputation incidence associated with our multidisciplinary diabetic foot clinic.

Cutaneous anaesthesia of the lower leg can improve sensibility in the diabetic foot. A double-blind, randomized clinical trial

AIMS

Impaired sensory function in the sole of the foot in diabetic patients is a substantial problem caused by unknown mechanisms. Hand or foot sensibility can be improved by cutaneous anaesthesia of the forearm or lower leg, respectively, in healthy subjects. Hypothetically, cutaneous anaesthesia induces a silent area in the primary somatosensory cortex, allowing adjacent cortical areas to expand; thus, resulting in enhanced sensory processing. Our aim was to improve sensory function in the foot in Type 1 and Type 2 diabetic patients by application of an anaesthetic cream to the lower leg.

METHODS

In a double-blind study, 37 patients with Type 1 or Type 2 diabetes were randomly assigned to cutaneous application of either an anaesthetic cream (EMLA) or a placebo cream to the skin of the lower leg for 1.5 h. Sensibility at five points of the sole of the foot was assessed before and after 1.5 and 24 h. Vibrotactile sense was also assessed. Primary outcome was change of touch threshold at the first metatarsal head from pretreatment to 1.5 h assessment.

RESULTS

Anaesthetic cream on the lower leg resulted in a significant improvement of touch threshold at the first metatarsal head after 1.5 and 24 h. In addition, improvement of touch thresholds was also observed at the other four assessment sites, together with a decreased vibration threshold at 125 Hz.

CONCLUSIONS

The findings of improved touch thresholds open up new possibilities in treatment of sensibility disturbances in the diabetic foot, using a simple and non-invasive method.