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Ziegler D, Burow S, Landgraf R, Lobmann R, Reiners K, Rett K, Schnell O. Current Practice of Podiatrists in Testing for Diabetic Polyneuropathy and Implementing Foot Care (PROTECT Study Survey 2). Endocr Pract 2024; 30:817-821. [PMID: 38880347 DOI: 10.1016/j.eprac.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/31/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
AIMS Podiatrists constitute a key member of a multidisciplinary foot care team, but their services remain underutilized. We sought to gain insights into the daily practice of podiatrists focusing on screening for and monitoring of diabetic sensorimotor polyneuropathy (DSPN) as well as foot management. METHODS This cross-sectional survey included 125 podiatrists from 12 federal states across Germany who responded to an online questionnaire. RESULTS The majority of patients treated in podiatry practices were referred by general practitioners and diabetologists. Screening for or follow-up of DSPN was performed by 36% of the respondents at least once a year, by 28% only at initial examination, by 21% only at suspicion, and by 10% basically at each treatment visit. Instruments to assess vibration, touch/pressure, and temperature sensation were used by 81% to 94% of the podiatrists. Previously undiagnosed DSPN and foot ulcers were detected frequently/very frequently (≥6 cases/mo) by 24.0 and 18.4% of the podiatrists, respectively. Almost all podiatrists advised daily self-monitoring of feet and appropriate foot care and >50% gave advice on medical treatment. CONCLUSIONS Podiatrists play an important role in the detection, monitoring, and management of both DSPN and diabetic foot ulcers, suggesting that the utilization of their services should be fostered.
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Affiliation(s)
- Dan Ziegler
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University, Düsseldorf, Germany.
| | - Sindy Burow
- Deutscher Verband für Podologie (ZFD) e.V., Kassel, Germany
| | | | - Ralf Lobmann
- Clinic for Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Stuttgart, Germany
| | | | | | - Oliver Schnell
- Forschergruppe Diabetes e.V. at the Helmholtz Center Munich, Neuherberg, Germany
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Atmaca A, Ketenci A, Sahin I, Sengun IS, Oner RI, Erdem Tilki H, Adas M, Soyleli H, Demir T. Expert opinion on screening, diagnosis and management of diabetic peripheral neuropathy: a multidisciplinary approach. Front Endocrinol (Lausanne) 2024; 15:1380929. [PMID: 38952393 PMCID: PMC11215140 DOI: 10.3389/fendo.2024.1380929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/15/2024] [Indexed: 07/03/2024] Open
Abstract
The proposed expert opinion aimed to address the current knowledge on conceptual, clinical, and therapeutic aspects of diabetic peripheral neuropathy (DPN) and to provide a guidance document to assist clinicians for the best practice in DPN care. The participating experts consider the suspicion of the disease by clinicians as a key factor in early recognition and diagnosis, emphasizing an improved awareness of the disease by the first-admission or referring physicians. The proposed "screening and diagnostic" algorithm involves the consideration of DPN in a patient with prediabetes or diabetes who presents with neuropathic symptoms and/or signs of neuropathy in the presence of DPN risk factors, with careful consideration of laboratory testing to rule out other causes of distal symmetric peripheral neuropathy and referral for a detailed neurological work-up for a confirmative test of either small or large nerve fiber dysfunction in atypical cases. Although, the first-line interventions for DPN are currently represented by optimized glycemic control (mainly for type 1 diabetes) and multifactorial intervention (mainly for type 2 diabetes), there is a need for individualized pathogenesis-directed treatment approaches for DPN. Alpha-lipoic acid (ALA) seems to be an important first-line pathogenesis-directed agent, given that it is a direct and indirect antioxidant that works with a strategy targeted directly against reactive oxygen species and indirectly in favor of endogenous antioxidant capacity for improving DPN conditions. There is still a gap in existing research in the field, necessitating well-designed, robust, multicenter clinical trials with sensitive endpoints and standardized protocols to facilitate the diagnosis of DPN via a simple and effective algorithm and to track progression of disease and treatment response. Identification of biomarkers/predictors that would allow an individualized approach from a potentially disease-modifying perspective may provide opportunities for novel treatments that would be efficacious in early stages of DPN, and may modify the natural course of the disease. This expert opinion document is expected to increase awareness among physicians about conceptual, clinical, and therapeutic aspects of DPN and to assist them in timely recognition of DPN and translating this information into their clinical practice for best practice in the management of patients with DPN.
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Affiliation(s)
- Aysegul Atmaca
- Department of Endocrinology and Metabolism, Ondokuz Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Aysegul Ketenci
- Department of Physical Medicine and Rehabilitation, Koc University Faculty of Medicine, Istanbul, Türkiye
| | - Ibrahim Sahin
- Department of Endocrinology and Metabolism, Inonu University Faculty of Medicine, Malatya, Türkiye
| | - Ihsan Sukru Sengun
- Department of Neurology, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
| | - Ramazan Ilyas Oner
- Department of Internal Medicine, Adiyaman University Faculty of Medicine, Adiyaman, Türkiye
| | - Hacer Erdem Tilki
- Department of Neurology, Ondokuz Mayis University Faculty of Medicine, Samsun, Türkiye
| | - Mine Adas
- Department of Endocrinology, Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Türkiye
| | - Hatice Soyleli
- Department of Medical Affairs, Abdi Ibrahim Pharmaceuticals, Istanbul, Türkiye
| | - Tevfik Demir
- Department of Endocrinology and Metabolism, Dokuz Eylul University Faculty of Medicine, Izmir, Türkiye
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AlMajali AS, Richards T, Yusuf SW, Telgenkamp B. Vascular service provision during the COVID-19 pandemic worsened major amputation rates in socially deprived diabetic populations. Front Endocrinol (Lausanne) 2024; 15:1304436. [PMID: 38836223 PMCID: PMC11148210 DOI: 10.3389/fendo.2024.1304436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 04/30/2024] [Indexed: 06/06/2024] Open
Abstract
Introduction The Coronavirus Disease - 2019 (COVID-19) pandemic significantly impacted healthcare service provision and put diabetic patients at increased risk of adverse health outcomes. We aimed to assess the impact of the COVID-19 pandemic on the incidence and demographic shift of major lower-limb amputation in diabetic patients. Methods We performed a retrospective analysis of diabetic patient records undergoing major lower-limb amputation between 01/03/2019 and 01/03/2021 at the Royal Sussex County Hospital, the regional arterial hub for Sussex. Primary outcomes were amputation incidence rates and patient demographics compared between the prepandemic and pandemic cohorts. Results The incidence rate ratio of major lower-limb amputations shows a drop in amputations during the pandemic compared to pre-pandemic (IRR 0.82; 95% CI 0.57-1.18). Data suggests a shift in the social deprivation background of patients receiving amputations to disproportionately affect those in the more deprived 50% of the population (p=0.038). Younger patients received more amputations during the pandemic compared to prepandemic levels (p=0.001). Conclusion Results suggest that during the COVID-19 pandemic there was a paradoxical reduction in amputations compared to prepandemic levels. However, changes to the demographic makeup of patient's receiving amputations are alarming as younger, and more deprived patients have been disproportionately affected by the pandemic.
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Affiliation(s)
- Ali S AlMajali
- Department of Acute Internal Medicine at the Royal Free Hospital, Royal Free London NHS Foundation Trust, London, United Kingdom
- Department of Medical Education, Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Thomas Richards
- University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
| | - Syed Waquar Yusuf
- Department of Medical Education, Brighton and Sussex Medical School, Brighton, United Kingdom
- University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
| | - Bjorn Telgenkamp
- University Hospitals Sussex NHS Foundation Trust, Brighton, United Kingdom
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Andrikopoulou E, Chatzistergos P, Chockalingam N. Exploring the Pathways of Diabetes Foot Complications Treatment and Investigating Experiences From Frontline Health Care Professionals: Protocol for a Mixed Methods Study. JMIR Res Protoc 2024; 13:e54852. [PMID: 38656782 PMCID: PMC11079765 DOI: 10.2196/54852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/31/2024] [Accepted: 03/11/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Diabetes affects more than 4.3 million individuals in the United Kingdom, with 19% to 34% developing diabetes-related foot ulceration (DFU) during their lifespan, which can lead to an amputation. In the United Kingdom, every week, approximately 169 people have an amputation due to diabetes. Preventing first-ever ulcers is the most effective strategy to reduce the occurrence of diabetes-related amputations, but research in this space is lacking. OBJECTIVE This protocol seeks to document the experiences and perspectives of frontline health care professionals who work with people who have diabetes and diabetes-related foot problems. Special attention is given to their perceptions of barriers to effective care, their views about barriers to effective and inclusive engagement with people with diabetes, and their experience with the first-ever DFU. Another aspect of the study is the focus on whether clinical management is affected by data sharing, data availability, and interoperability issues. METHODS This is a mixed methods explanatory protocol, which is sequential, and its purpose is to use the qualitative data to explain the initial quantitative data collected through a survey of frontline health care professionals. Data analysis of quantitative data will be completed first and then synthesized with the qualitative data analysis. Qualitative data will be analyzed using the framework method. This study will use joint displays to integrate the data. Ethical approval has been granted by the ethics committee of Staffordshire University. RESULTS The quantitative data collection started in March 2023 and will close in May 2024. The qualitative interviews commenced in November 2023 with volunteer participants who initially completed the survey. CONCLUSIONS This study's survey focuses on data interoperability and the interviews focus more on the perspectives and experiences of clinicians and their perceived barriers for the effective management of diabetes foot ulcers. Including a geographically relevant and diverse cohort of health care professionals that spans a wide range of roles and care settings involved in diabetes-related foot care is very important for the successful application of this protocol. Special care is given to advertise and promote participation as widely as possible. The qualitative part of this protocol is also limited to 30-40 interview participants, as it is not realistic to interview higher numbers, due to time and resource constraints. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/54852.
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Affiliation(s)
| | - Panagiotis Chatzistergos
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, United Kingdom
| | - Nachiappan Chockalingam
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke on Trent, United Kingdom
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Thomas Z, Bhurchandi SK, Saravanan B, Christina F, Volena R, Rebekah G, Samuel VM, Gaikwad P, Chandy B, Samuel A, Cherian KE, Varghese S, Jebasingh FK, Thomas N. Diabetic foot ulcers, their characteristics, and trends in survival: Real world outcomes at a tertiary care facility in India. Diabetes Metab Syndr 2024; 18:103011. [PMID: 38685187 DOI: 10.1016/j.dsx.2024.103011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 04/08/2024] [Accepted: 04/11/2024] [Indexed: 05/02/2024]
Abstract
AIMS Characteristics of diabetes-related foot ulcers (DFU), association with recurrence and amputation are poorly described in the Asian Indian population. METHODS A prospectively maintained database was reviewed to characterize DFU and its association with amputation and recurrence. RESULTS Of 200 patients, 63.5 % were male, the median age was 62 years (Min-Max:40-86), and median BMI was 27.90 kg/m2 (Min-Max:18.5-42.7). Median duration of Diabetes mellitus was 15 years (Min-Max:2-43). Complete healing occurred at a median of three months (Min-Max:0.23-37.62). Amputation for the current ulcer was required in 43.4 % of individuals. Ulcer recurrence was documented in 42.4 % instances, 66.1 % evolving on the ipsilateral side. Previous amputation was associated with the risk of subsequent amputation (Adjusted OR-3.08,p-0.047). Median time to ulcer recurrence was 4.23 years among those with amputation, in contrast to 9.61 years in those with healing. Cardiovascular death was the commonest cause of mortality, followed by sepsis. At a median follow up of 6.08 years, mortality at 1,3,5 and 10 years was 2.5 %,2.5 %,8.2 % and 30.9 % respectively among those who underwent amputation versus 0 %,0 %,10.1 % and 24.5 % respectively for those who achieved healing. CONCLUSIONS Patients with DFU in India incur amputations at rates higher than conventionally described. With previous amputation, subsequent amputation risk triples. Ten-year mortality is 25%-30 %. Underestimates of the burden of recurrence and mortality are consequential of limited follow-up.
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Affiliation(s)
| | | | | | | | - Ruth Volena
- Department of Endocrinology, Diabetes and Metabolism, India
| | | | | | | | - Bobeena Chandy
- Department of Physical Medicine and Rehabilitation, India
| | | | | | | | | | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, India
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Al-Quwaidhi AJ, AlSaleh EM. Future Projections of Diabetes-Related Amputations in Eastern Saudi Arabia During 2022-2045 Using a Validated Epidemiological Model. Cureus 2023; 15:e45972. [PMID: 37900427 PMCID: PMC10600592 DOI: 10.7759/cureus.45972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2023] [Indexed: 10/31/2023] Open
Abstract
INTRODUCTION Diabetes-related amputations (DRA) are associated with significant morbidity and mortality. There are limited studies on the burden of this condition and its future projections in Saudi Arabia. OBJECTIVES To estimate future forecasts in the burden of DRA (number of cases and mortalities) among adult diabetics (aged ≥20 years) in Al-Ahsa, Eastern Region of Saudi Arabia from 2022 to 2045. METHODS A simulation epidemiological model was designed and validated. It is a simple discrete-state model composed of multiple states, in which diabetics make annual transitions to either 'Major Amputations', 'Minor Amputations', or 'No Amputations' states, and then to two states of mortalities. The data inputs required are minimal, including the total diagnosed cases of diabetes for 2022 and transition parameters obtained from recent published literature. The model used some reasonable assumptions and scenarios for testing potential uncertainties around the model outputs. Model validation was conducted by comparing its estimates with the observed local data from two main hospitals in Al-Ahsa for 2022. RESULTS The model projected that the total number of DRA among diabetics in Al-Ahsa will increase from 129 (uncertainty interval (UI): 103-154) in 2022 to 169 (UI: 136-203) in 2030 and 227 (UI: 182-272) in 2045, assuming that the incidence rates of major and minor amputations among diabetics will remain constant. However, assuming that these incidence rates will show a gradual decline of 20% every three years, the model predicted the total number of DRA to decrease from 103 (UI: 82-124) in 2022 to 91 (UI: 73-110) in 2030 and 61 (UI: 49-74) in 2045. CONCLUSION DRA impose a considerable burden on patients and the healthcare system, despite the possibility of a potential decrease in incidence rates.
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Affiliation(s)
| | - Essa M AlSaleh
- Infection Control, Al-Ahsa Directorate of Health Affairs, Ministry of Health, Hofuf, SAU
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Zhu X, Lee ES, Lim PX, Chen YC, Chan FHF, Griva K. Exploring barriers and enablers of self-management behaviours in patients with diabetic foot ulcers: A qualitative study from the perceptions of patients, caregivers, and healthcare professionals in primary care. Int Wound J 2023; 20:2764-2779. [PMID: 36970982 PMCID: PMC10410341 DOI: 10.1111/iwj.14153] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 08/10/2023] Open
Affiliation(s)
- Xiaoli Zhu
- Nursing ServicesNational Healthcare Group PolyclinicsSingaporeSingapore
- Population/Global Health, Lee Kong Chian School of Medicine, NanyangTechnological UniversitySingaporeSingapore
| | - Eng Sing Lee
- Clinical Research UnitNational Healthcare Group PolyclinicsSingaporeSingapore
- Lee Kong Chian School of MedicineNanyang Technological UniversitySingaporeSingapore
| | - Phoebe X.H. Lim
- Population/Global Health, Lee Kong Chian School of Medicine, NanyangTechnological UniversitySingaporeSingapore
| | - Yee Chui Chen
- Nursing ServicesNational Healthcare Group PolyclinicsSingaporeSingapore
| | - Frederick H. F. Chan
- Population/Global Health, Lee Kong Chian School of Medicine, NanyangTechnological UniversitySingaporeSingapore
| | - Konstadina Griva
- Population/Global Health, Lee Kong Chian School of Medicine, NanyangTechnological UniversitySingaporeSingapore
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Campbell B, Muse S, Welchman S, Hardy T, Guy A. The surgical care of diabetic feet: a survey about clinics, acute care, and the surgical specialists involved. Ann R Coll Surg Engl 2023; 105:623-626. [PMID: 37652087 PMCID: PMC10471430 DOI: 10.1308/rcsann.2023.0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION Diabetic foot problems are becoming increasingly common. Diabetic foot care services are fundamental in managing them, and there is the further issue of acute surgery for foot sepsis. The involvement of different surgical specialists has been variable; this survey aimed to provide information about current service provision. METHODS Questionnaires were emailed to Vascular Society members, and targeted approaches were then undertaken. RESULTS We aimed to obtain information from 61 localities identified as providing shared services, and received informative responses from 46 (75%). These described diabetic foot clinics each day (11%), or once (50%), twice (13%) or three times (17%) weekly - attended regularly by vascular surgeons, and less frequently by orthopaedic surgeons. The frequency of clinics was considered inadequate by 30% of respondents, and only 75% reported written policies for diabetic foot care pathways. Operations for acute foot sepsis are done by vascular surgeons in 98% of localities and by orthopaedic surgeons in 22% (in some localities by both): the latter are orthopaedic foot specialists in all localities but two. Both specialties perform a range of foot procedures, including toe/foot-preserving operations. Major amputations are done by vascular surgeons in 98% of localities and by orthopaedic surgeons in only 9%. All deformity correction procedures are performed by orthopaedic surgeons. CONCLUSION This survey shows that diabetic foot clinics are now held frequently in most localities. There is variation in the involvement of vascular and orthopaedic surgeons. Some localities need to consider increased provision of clinics and better defined pathways of care.
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Affiliation(s)
- B Campbell
- Royal Devon University Healthcare NHS Foundation Trust, UK
| | - S Muse
- Royal Devon University Healthcare NHS Foundation Trust, UK
| | - S Welchman
- Royal Devon University Healthcare NHS Foundation Trust, UK
| | - T Hardy
- Royal Devon University Healthcare NHS Foundation Trust, UK
| | - A Guy
- Royal Devon University Healthcare NHS Foundation Trust, UK
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Birmpili P, Li Q, Johal AS, Atkins E, Waton S, Chetter I, Boyle JR, Pherwani AD, Cromwell DA. Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study. Br J Surg 2023; 110:958-965. [PMID: 37216910 PMCID: PMC10361679 DOI: 10.1093/bjs/znad134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/12/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Patients with diabetes and peripheral arterial disease are at increased risk of minor amputation. The aim of study was to assess the rate of re-amputations and death after an initial minor amputation, and to identify associated risk factors. METHODS Data on all patients aged 40 years and over with diabetes and/or peripheral arterial disease, who underwent minor amputation between January 2014 and December 2018, were extracted from Hospital Episode Statistics. Patients who had bilateral index procedures or an amputation in the 3 years before the study were excluded. Primary outcomes were ipsilateral major amputation and death after the index minor amputation. Secondary outcomes were ipsilateral minor re-amputations, and contralateral minor and major amputations. RESULTS In this study of 22 118 patients, 16 808 (76.0 per cent) were men and 18 473 (83.5 per cent) had diabetes. At 1 year after minor amputation, the estimated ipsilateral major amputation rate was 10.7 (95 per cent c.i. 10.3 to 11.1) per cent. Factors associated with a higher risk of ipsilateral major amputation included male sex, severe frailty, diagnosis of gangrene, emergency admission, foot amputation (compared with toe amputation), and previous or concurrent revascularization. The estimated mortality rate was 17.2 (16.7 to 17.7) per cent at 1 year and 49.4 (48.6 to 50.1) per cent at 5 years after minor amputation. Older age, severe frailty, comorbidity, gangrene, and emergency admission were associated with a significantly higher mortality risk. CONCLUSION Minor amputations were associated with a high risk of major amputation and death. One in 10 patients had an ipsilateral major amputation within the first year after minor amputation and half had died by 5 years.
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Affiliation(s)
- Panagiota Birmpili
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Qiuju Li
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amundeep S Johal
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Eleanor Atkins
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Hull York Medical School, Hull, UK
| | - Sam Waton
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Ian Chetter
- Hull York Medical School, Hull, UK
- Academic Vascular Surgical Unit, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Arun D Pherwani
- Staffordshire and South Cheshire Vascular Network, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - David A Cromwell
- Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Tian Z, Fan Y, Sun X, Wang D, Guan Y, Zhang Y, Zhang Z, Guo J, Bu H, Wu Z, Wang H. Predictive value of TCM clinical index for diabetic peripheral neuropathy among the type 2 diabetes mellitus population: A new observation and insight. Heliyon 2023; 9:e17339. [PMID: 37389043 PMCID: PMC10300217 DOI: 10.1016/j.heliyon.2023.e17339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/06/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023] Open
Abstract
Aims The objectives of this study were to identify clinical predictors of the Traditional Chinese medicine (TCM) clinical index for diabetic peripheral neuropathy (DPN) in type 2 diabetes mellitus (T2DM) patients, develop a clinical prediction model, and construct a nomogram. Methods We collected the TCM clinical index from 3590 T2DM recruited at the Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine from January 2019 to October 2020. The participants were randomly assigned to either the training group (n = 3297) or the validation group (n = 1426). TCM symptoms and tongue characteristics were used to assess the risk of developing DPN in T2DM patients. Through 5-fold cross-validation in the training group, the least absolute shrinkage and selection operator (LASSO) regression analysis method was used to optimize variable selection. In addition, using multifactor logistic regression analysis, a predictive model and nomogram were developed. Results A total of eight independent predictors were found to be associated with the DPN in multivariate logistic regression analyses: advanced age of grading (odds ratio/OR 1.575), smoke (OR 2.815), insomnia (OR 0.557), sweating (OR 0.535), loose teeth (OR 1.713), dry skin (OR 1.831), purple tongue (OR 2.278). And dark red tongue (OR 0.139). The model was constructed using these eight predictor's medium discriminative capabilities. The area under the curve (AUC) of the training set is 0.727, and the AUC of the validation set is 0.744 on the ROC curve. The calibration plot revealed that the model's goodness-of-fit is satisfactory. Conclusions We established a TCM prediction model for DPN in patients with T2DM based on the TCM clinical index.
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Affiliation(s)
- Zhikui Tian
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Yadong Fan
- Nanjing University of Chinese Medicine, Nanjing, 210023, China
- Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, 210004, China
| | - Xuan Sun
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Dongjun Wang
- College of Traditional Chinese Medicine, North China University of Science and Technology, Tangshan, 063000, China
| | - Yuanyuan Guan
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Ying Zhang
- Fengnan District Hospital of Traditional Chinese Medicine, Tangshan, 063000, China
| | - Zhaohui Zhang
- Surgery of TCM, Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 301617, China
| | - Jing Guo
- Surgery of TCM, Second Affiliated Hospital of Tianjin University of TCM, Tianjin, 301617, China
| | - Huaien Bu
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
| | - Zhongming Wu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
| | - Hongwu Wang
- School of Health Sciences and Engineering, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China
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11
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Vansteenland I, Forss R. What are the current diabetic foot assessment methods in private podiatry practices in Flanders, Belgium: an exploratory mixed method study. J Foot Ankle Res 2023; 16:17. [PMID: 36973800 PMCID: PMC10041772 DOI: 10.1186/s13047-023-00615-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/16/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Diabetic foot assessments detect patients at risk for developing a diabetes-related foot ulceration and can significantly reduce the risk of amputation. In order to organize this assessment effectively, diabetic foot assessment guidelines are required according to the International Working Group of the Diabetic Foot. However, these international guidelines have not been adapted into a national guideline for podiatrists in Flanders, Belgium. This study aims to identify the methods and guidelines currently used to assess the diabetic foot in private podiatry practices in Flanders, Belgium and to explore the podiatrists' opinions on developing a national diabetic foot assessment guideline. METHODS This exploratory mixed method study was composed of an anonymous online survey comprising of open- and closed-ended questions followed by 1:1 online semi-structured interviews. Participants were recruited via e-mail and a closed private Facebook group of podiatry alumni. Data was analyzed using SPSS statistics and thematic analysis described by Braun and Clarke. RESULTS This study showed that the vascular assessment of the diabetic foot exists solely of a medical history and palpation of the pedal pulses. Non-invasive tests such as doppler, toe brachial pressure index or ankle brachial pressure index are seldom used. Only 66% reported to use a guideline for the diabetic foot assessment. There was a variety of reported guidelines and risk stratification systems in use in private podiatry practices in Flanders, Belgium. CONCLUSION Non-invasive tests such as the doppler, ankle brachial pressure index or toe brachial pressure index are rarely used for the vascular assessment of the diabetic foot. Diabetic foot assessment guidelines and risk stratification systems to identify patients at risk for developing a diabetic foot ulcer were not frequently used. International guidelines of the International Working Group of the Diabetic Foot have not yet been implemented in private podiatry practices in Flanders, Belgium. This exploratory research has provided useful information for future research studies.
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Affiliation(s)
- Irene Vansteenland
- School of Sport & Health Sciences, University of Brighton, 49 Darley Road, Eastbourne, BN20 7UR, UK.
- Podoconsult Vansteenland Irene BV, Hendrik Consciencelaan 54, 9950, Lievegem, Belgium.
| | - Rachel Forss
- Centre for Regenerative Medicine and Devices, University of Brighton, Brighton, UK
- School of Sport and Health Sciences, University of Brighton, 49 Darley Road, Eastbourne, BN20 7UR, UK
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12
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McDermott K, Fang M, Boulton AJ, Selvin E, Hicks CW. Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers. Diabetes Care 2023; 46:209-221. [PMID: 36548709 PMCID: PMC9797649 DOI: 10.2337/dci22-0043] [Citation(s) in RCA: 169] [Impact Index Per Article: 169.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 11/02/2022] [Indexed: 12/24/2022]
Abstract
Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.
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Affiliation(s)
- Katherine McDermott
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael Fang
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Andrew J.M. Boulton
- Faculty of Biology, Medicine and Health, University of Manchester, Manchester, U.K
| | - Elizabeth Selvin
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Yelland AC, Meace C, Knighton P, Holman N, Wild SH, Michalowski J, Young B, Jeffcoate WJ. Impact of case-mix adjustment on observed variation in the healing of diabetic foot ulcers at 12 weeks using data from the National Diabetes Foot Care Audit of England and Wales: A cohort study. Diabet Med 2023; 40:e14959. [PMID: 36114737 DOI: 10.1111/dme.14959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 07/05/2022] [Accepted: 08/18/2022] [Indexed: 11/29/2022]
Abstract
AIM This cohort study investigates the extent to which variation in ulcer healing between services can be explained by demographic and clinical characteristics. METHODS The National Diabetes Foot Care Audit collated data on people with diabetic foot ulcers presenting to specialist services in England and Wales between July 2014 and March 2018. Logistic regression models were created to describe associations between risk factors and a person being alive and ulcer-free 12 weeks from presentation, and to investigate whether variation between 120 participating services persisted after risk factor adjustment. RESULTS Of 27,030 people with valid outcome data, 12,925 (47.8%) were alive and ulcer-free at 12 weeks, 13,745 (50.9%) had an unhealed ulcer and 360 had died (1.3%). Factors associated with worse outcome were male sex, more severe ulcers, history of cardiac or renal disease and a longer time between first presentation to a non-specialist healthcare professional and first expert assessment. After adjustment for these factors, four services (3.3%) were more than 3SD above and seven services (5.8%) were more than 3SD below the national mean for proportions that were alive and ulcer-free at follow-up. CONCLUSIONS/INTERPRETATIONS Variation in the healing of diabetic foot ulcers between specialist services in England and Wales persisted after adjusting for demographic characteristics, ulcer severity, smoking, body mass index and co-morbidities. We conclude that other factors contribute to variation in healing of diabetic foot ulcers and include the time to specialist assessment.
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Affiliation(s)
| | | | | | - Naomi Holman
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Sarah H Wild
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | | | - Bob Young
- National Diabetes Audit, Diabetes UK, London, UK
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14
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Transmetatarsal amputations in patients with diabetes mellitus: A contemporary analysis from an academic tertiary referral centre in a developing community. PLoS One 2022; 17:e0277117. [PMID: 36327256 PMCID: PMC9632785 DOI: 10.1371/journal.pone.0277117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Transmetatarsal amputation (TMA) involves the surgical removal of the distal portion of metatarsals in the foot. It aims to maintain weight-bearing and independent ambulation while eliminating the risk of spreading soft tissue infection or gangrene. This study aimed to explore the risk factors and surgical outcomes of TMA in patients with diabetes at an academic tertiary referral center in Jordan. Medical records of all patients with diabetes mellitus who underwent TMA at King Abdullah University Hospital, Jordan, between January 2017 and January 2019 were retrieved. Patient characteristics along with clinical and laboratory findings were analyzed retrospectively. Pearson’s chi-square test of association, Student’s t-test, and multivariate regression analysis were used to identify and assess the relationships between patient findings and TMA outcome. The study cohort comprised 81 patients with diabetes who underwent TMA. Of these, 41 (50.6%) patients achieved complete healing. Most of the patients were insulin-dependent (85.2%). Approximately half of the patients (45.7%) had severe ankle-brachial index (ABI). Thirty patients (37.1%) had previous revascularization attempts. The presence of peripheral arterial disease (P<0.05) exclusively predicted poor outcomes among the associated comorbidities. Indications for TMA included infection, ischemia, or both. The presence of severe ABI (≤0.4, P<0.01) and a previous revascularization attempt (P<0.05) were associated with unfavorable outcomes of TMA. Multivariate analysis that included all demographic, clinical, and laboratory variables in the model revealed that insulin-dependent diabetes, low albumin level (< 33 g/L), high C-reactive protein level (> 150 mg/L), and low score of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC, <6) were the main factors associated with poor TMA outcomes. TMA is an effective technique for the management of diabetic foot infection or ischemic necrosis. However, attention should be paid to certain important factors such as insulin dependence, serum albumin level, and LRINEC score, which may influence the patient’s outcome.
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Kasenda S, Crampin A, Davies J, Malava JK, Manganizithe S, Kumambala A, Sandford B. Prevalence and risk factors of lower extremity disease in high risk groups in Malawi: a stratified cross-sectional study. BMJ Open 2022; 12:e055501. [PMID: 35948375 PMCID: PMC9379496 DOI: 10.1136/bmjopen-2021-055501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 06/08/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Low/middle-income countries face a disproportionate burden of cardiovascular diseases. However, among cardiovascular diseases, burden of and associations with lower extremity disease (LED) (peripheral arterial disease and/or neuropathy) is neglected. We investigated the prevalence and factors associated with LED among individuals known to have cardiovascular disease risk factors (CVDRFs) in Malawi, a low-income country with a significant prevalence of CVDRFs. DESIGN This was a stratified cross-sectional study. SETTING This study was conducted in urban Lilongwe Area 25, and the rural Karonga Health and Demographic Surveillance Site. PARTICIPANTS Participants were at least 18 years old and had been identified to have two or more known CVDRFs. MAIN OUTCOME MEASURES LED-determined by the presence of one of the following: neuropathy (as assessed by a 10 g monofilament), arterial disease (absent peripheral pulses, claudication as assessed by the Edinburgh claudication questionnaire or Ankle Brachial Pulse Index (ABPI) <0.9), previous amputation or ulceration of the lower limbs. RESULTS There were 806 individuals enrolled into the study. Mean age was 52.5 years; 53.5% of participants were men (n=431) and 56.7% (n=457) were from the rural site. Nearly a quarter (24.1%; 95% CI: 21.2 to 27.2) of the participants had at least one symptom or sign of LED. 12.8% had neuropathy, 6.7% had absent pulses, 10.0% had claudication, 1.9% had ABPI <0.9, 0.9% had an amputation and 1.1% had lower limb ulcers. LED had statistically significant association with increasing age, urban residence and use of indoor fires. CONCLUSIONS This study demonstrated that a quarter of individuals with two or more CVDRFs have evidence of LED and 2.4% have an amputation or signs of limb threatening ulceration or amputation. Further epidemiological and health systems research is warranted to prevent LED and limb loss.
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Affiliation(s)
- Stephen Kasenda
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Amelia Crampin
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Justine Davies
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Annie Kumambala
- Malawi Epidemiology and Intervention Research Unit, Lilongwe, Malawi
| | - Becky Sandford
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, UK
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16
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Røikjer J, Werkman NCC, Ejskjaer N, van den Bergh JPW, Vestergaard P, Schaper NC, Jensen MH, Klungel O, de Vries F, Nielen JTH, Driessen JHM. Incidence, hospitalization and mortality and their changes over time in people with a first ever diabetic foot ulcer. Diabet Med 2022; 39:e14725. [PMID: 34657300 DOI: 10.1111/dme.14725] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 10/15/2021] [Indexed: 01/13/2023]
Abstract
AIMS A diabetic foot ulcer (DFU) is a severe condition associated with morbidity and mortality. Population-based studies are rare and limited by access to reliable data. Without this data, efforts in primary prevention cannot be evaluated. Therefore, we examined the incidence and changes over time for the first DFU in people with diabetes. We also examined hospitalization and all-cause mortality and their changes over time. METHODS From the UK primary care CPRD GOLD database (2007-2017), we identified 129,624 people with diabetes by a prescription for insulin or a non-insulin anti-diabetic drug. DFUs were identified using Read codes and expressed as incidence rates (IRs). Changes over time were described using Poisson and logistic regression and expressed as incidence rate ratios (IRRs) and odds ratios (ORs) respectively. RESULTS The mean IR of first registered DFUs was 2.5 [95% CI: 2.1-2.9] per 1000 person-years for people with type 2 diabetes and 1.6 [1.3-1.9] per 1000 person-years for people with type 1. The IRs declined for people with type 2 diabetes (IRR per year: 0.97 [0.96-0.99]), while no changes were observed for people with type 1 diabetes (IRR per year: 0.96 [0.89-1.04]). Average hospitalization and 1-year mortality risk for people with type 2 diabetes were 8.2% [SD: 4.7] and 11.7% [SD: 2.2] respectively. Both declined over time (OR: 0.89 [0.84, 0.94] and 0.94 [0.89, 0.99]). CONCLUSION The decline in all IRs, hospitalizations and mortality in people with type 2 diabetes suggests that prevention and care of the first DFU has improved for this group in primary care in the UK.
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Affiliation(s)
- Johan Røikjer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Nikki C C Werkman
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University medical Centre+, Maastricht, the Netherlands
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Joop P W van den Bergh
- Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Internal Medicine, VieCuri Medical Centre, Venray, the Netherlands
- Biomedical Research Centre, Hasselt University, Hasselt, Belgium
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark
| | - Nicolaas C Schaper
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
- Division of Endocrinology, Department of Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Morten Hasselstrøm Jensen
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Olaf Klungel
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Frank de Vries
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University medical Centre+, Maastricht, the Netherlands
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
| | - Johannes T H Nielen
- Department of Clinical Pharmacy and Toxicology, Maastricht University medical Centre+, Maastricht, the Netherlands
| | - Johanna H M Driessen
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
- Department of Clinical Pharmacy and Toxicology, Maastricht University medical Centre+, Maastricht, the Netherlands
- Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University Medical Center, Maastricht, the Netherlands
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Liew H, Bates M, Vas P, Rashid H, Kavarthapu V, Edmonds M, Manu C. Resource use within a multidisciplinary foot team clinic. J Wound Care 2022; 31:154-161. [PMID: 35148630 DOI: 10.12968/jowc.2022.31.2.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The establishment of multidisciplinary foot team clinics reduces the risk of amputation, but little is known about its resource requirement. This study evaluates the service's resource use for first visit attendees to an established multidisciplinary foot team clinic. METHOD A retrospective evaluation was performed for new referrals to the clinic over six months, including demographics, resource use and clinical outcome. Data were extracted electronically with retrospective review of electronic clinical notes. RESULTS A total of 240 first visit attendees were analysed. Mean age was 64±15years, 63% were male, 72% had type 2 diabetes, 16% had type 1 diabetes, 15% had a previous amputation, and 40% had a previous ulceration. Common presentations were ulcers (62%), osteomyelitis (11%), Charcot foot (19%), foot ischaemia (17%), post-surgical wounds (13%), and osteomyelitis (11%). At first attendance, 79% of patients required specialist services including diabetologist (45%), joint vascular review (23%), joint orthopaedics services (8%), dermatologist (2%), and orthotics services (1%). A total of 4% of patients had complex debridement, 0.4% total nail excision, 0.8% pus drainage, 3% cast-related procedures, and 1% vacuum-assisted dressing. Of the patients, 4% were admitted to hospital, 38% had vascular duplex investigations, 7% had a deep vein thrombosis scan, 16% had magnetic resonance imagine (MRI), and 5% had a bone scan. CONCLUSION A functional multidisciplinary foot team clinic requires significant resources-both clinical and administrative-for prompt investigations and revascularisation to sustain low amputation rates. Regular appraisal of resource use helps with clinic and pathway planning.
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Affiliation(s)
- Huiling Liew
- Diabetic Foot Clinic, King's College Hospital, UK.,Department of Diabetes and Endocrinology, Tan Tock Seng Hospital, Singapore
| | | | | | | | | | | | - Chris Manu
- Diabetic Foot Clinic, King's College Hospital, UK
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18
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Štotl I, Blagus R, Urbančič-Rovan V. Individualised screening of diabetic foot: creation of a prediction model based on penalised regression and assessment of theoretical efficacy. Diabetologia 2022; 65:291-300. [PMID: 34741637 DOI: 10.1007/s00125-021-05604-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 08/23/2021] [Indexed: 01/22/2023]
Abstract
AIMS/HYPOTHESIS A large proportion of people with diabetes do not receive proper foot screening due to insufficiencies in healthcare systems. Introducing an effective risk prediction model into the screening protocol would potentially reduce the required screening frequency for those considered at low risk for diabetic foot complications. The main aim of the study was to investigate the value of individualised risk assignment for foot complications for optimisation of screening. METHODS From 2015 to 2020, 11,878 routine follow-up foot investigations were performed in the tertiary diabetes clinic. From these, 4282 screening investigations with complete data containing all of 18 designated variables collected at regular clinical and foot screening visits were selected for the study sample. Penalised logistic regression models for the prediction of loss of protective sensation (LOPS) and loss of peripheral pulses (LPP) were developed and evaluated. RESULTS Using leave-one-out cross validation (LOOCV), the penalised regression model showed an AUC of 0.84 (95% CI 0.82, 0.85) for prediction of LOPS and 0.80 (95% CI 0.78, 0.83) for prediction of LPP. Calibration analysis (based on LOOCV) presented consistent recall of probabilities, with a Brier score of 0.08 (intercept 0.01 [95% CI -0.09, 0.12], slope 1.00 [95% CI 0.92, 1.09]) for LOPS and a Brier score of 0.05 (intercept 0.01 [95% CI -0.12, 0.14], slope 1.09 [95% CI 0.95, 1.22]) for LPP. In a hypothetical follow-up period of 2 years, the regular screening interval was increased from 1 year to 2 years for individuals at low risk. In individuals with an International Working Group on the Diabetic Foot (IWGDF) risk 0, we could show a 40.5% reduction in the absolute number of screening examinations (3614 instead of 6074 screenings) when a 10% risk cut-off was used and a 26.5% reduction (4463 instead of 6074 screenings) when the risk cut-off was set to 5%. CONCLUSIONS/INTERPRETATION Enhancement of the protocol for diabetic foot screening by inclusion of a prediction model allows differentiation of individuals with diabetes based on the likelihood of complications. This could potentially reduce the number of screenings needed in those considered at low risk of diabetic foot complications. The proposed model requires further refinement and external validation, but it shows the potential for improving compliance with screening guidelines.
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Affiliation(s)
- Iztok Štotl
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia.
| | - Rok Blagus
- Institute for Biostatistics and Medical Informatics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Sports, University of Ljubljana, Ljubljana, Slovenia
| | - Vilma Urbančič-Rovan
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Lin CH, Armstrong DG, Liu PH, Lin CW, Huang CH, Huang YY. Survival of Patients Following First Diagnosis of Diabetic Foot Complications: A Nationwide 15-Year Longitudinal Analysis. Front Endocrinol (Lausanne) 2021; 12:801324. [PMID: 34966361 PMCID: PMC8711267 DOI: 10.3389/fendo.2021.801324] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 11/22/2021] [Indexed: 01/22/2023] Open
Abstract
Background and Aims The long-term survival in people with type 2 diabetes following first diagnosis of diabetic foot complications (FDDFC) is unclear. The object is to evaluate the mortality rate in subjects with type 2 diabetes following FDDFC and the impacts of the major cardiovascular comorbidities. Methods Nationwide data were analyzed for subjects with T2D and DFC between 2003 and 2017 according to ICD-9 coding. DFC was defined with the codes of ulcers, infections, or severe peripheral artery disease that required intervention (PAD) to mimic the real world diagnosis. Criteria of FDDFC were preceded by a period without any DFC for at least 5 years. Major cardiovascular comorbidities: established PAD and cardiovascular diseases (CVD: including coronary heart disease (CHD), stroke, or heart failure) before the index date as well as lower-extremity amputations (LEA) at the index episode were analyzed. Results Among 300,115 subjects with DFC, a total of 103,396 patients had FDDFC. The mean 5-year survival rate of these subjects was 81.05%. Using subjects without associated major cardiovascular comorbidity as baseline, the adjusted hazard ratios (aHR) were1.43 (95% confidence interval 1.38-1.49) in group PAD-/CVD+, followed by 1.70 (1.59-1.80) in PAD+/CVD- and 1.98 (1.89-2.08) in PAD+/CVD+. The aHR was further increased in patients with PAD who additionally had heart failure (3.77, 3.50-4.05), stroke (2.06, 1.95-2.18), or CHD (1.89, 1.79-2.00). Subjects with PAD rather than other CVD were associated with LEA at FDDFC. Patients with major LEA (above the ankle) at FDDFC episode had lower 5-year survival rate (65.01%) followed by those with minor LEA (72.24%) and without LEA (81.61%). Conclusions Cardiovascular comorbidity as well as LEA status at the event of FDDFCs were both associated with patient survival outcomes. Earlier identification of this large population could lead to higher survival rates.
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Affiliation(s)
- Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - David G. Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, United States
| | - Pi-Hua Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Linkou, Taiwan
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Ponkilainen VT, Vuorlaakso M, Kaartinen I, Kiiski J, Saarinen E, Huttunen TT, Paloneva J, Mattila VM. The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study. Eur J Vasc Endovasc Surg 2021; 63:138-146. [PMID: 34774371 DOI: 10.1016/j.ejvs.2021.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.
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Affiliation(s)
| | - Miska Vuorlaakso
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Ilkka Kaartinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Juha Kiiski
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Eva Saarinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland; The Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Juha Paloneva
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ville M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland; COXA Hospital for Joint Replacement, Tampere, Finland
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Zhao N, Zhou Q, Hu J, Huang W, Xu J, Qi M, Peng M, Luo W, Li X, Bai J, Wu L, Yu L, Fu X. Construction and verification of an intelligent measurement model for diabetic foot ulcer. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2021; 46:1138-1146. [PMID: 34911845 PMCID: PMC10930231 DOI: 10.11817/j.issn.1672-7347.2021.200938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The measurement of diabetic foot ulcers is important for the success in diabetic foot ulcer management. At present, it lacks the accurate and convenient measurement tools in clinical. In recent years, artificial intelligence technology has demonstrated the potential application value in the field of image segmentation and recognition. This study aims to construct an intelligent measurement model of diabetic foot ulcers based on the deep learning method, and to conduct preliminary verification. METHODS The data of 1 042 diabetic foot ulcers clinical samples were collected. The ulcers and color areas were manually labeled, of which 782 were used as the training data set and 260 as the test data set. The Mask RCNN ulcer tissue color semantic segmentation and RetinaNet scale digital scale target detection were used to build a model. The training data set was input into the model and iterated. The test data set was used to verify the intelligent measurement model. RESULTS This study established an intelligent measurement model of diabetic foot ulcers based on deep learning. The mean average precision@.5 intersection over union (mAP@.5IOU) of the color region segmentation in the training set and the test set were 87.9% and 63.9%, respectively; the mAP@.5IOU of the ruler scale digital detection in the training set and the test set were 96.5% and 83.4%, respectively. Compared with the manual measurement result of the test sample, the average error of the intelligent measurement result was about 3 mm. CONCLUSIONS The intelligent measurement model has good accuracy and robustness in measuring the diabetic foot ulcers. Future research can further optimize the model with larger-scale data samples.
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Affiliation(s)
- Nan Zhao
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008.
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha 410008.
| | - Qiuhong Zhou
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008.
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha 410008.
| | - Jianzhong Hu
- Mobile Health" Ministry of Education-China Mobile Joint Laboratory, Chengdu 610041
| | - Weihong Huang
- Mobile Health" Ministry of Education-China Mobile Joint Laboratory, Chengdu 610041
| | - Jingcan Xu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha 410008
| | - Min Qi
- Department of Plastic and Cosmetic Surgery, Xiangya Hospital, Central South University, Changsha 410008
| | - Min Peng
- Third Comprehensive Division, Guangdong Provincial People's Hospital, Guangdong Medical Institute, Guangdong Research Institute of Geriatric Medicine, Guangzhou 510080
| | - Wenjing Luo
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha 410008
| | - Xinyi Li
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008
- Department of Endocrinology, Xiangya Hospital, Central South University, Changsha 410008
| | - Jiaojiao Bai
- Department of Nursing, Huadong Hospital Affiliated to Fudan University, Shanghai 200040, China
| | - Liaofang Wu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008
| | - Ling Yu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008
| | - Xiaoai Fu
- Teaching and Research Section of Clinical Nursing, Xiangya Hospital, Central South University, Changsha 410008
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22
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Tehan PE, Hawes MB, Hurst J, Sebastian M, Peterson BJ, Chuter VH. Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study. Wound Repair Regen 2021; 30:24-33. [PMID: 34698428 DOI: 10.1111/wrr.12978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/19/2021] [Accepted: 10/05/2021] [Indexed: 11/29/2022]
Abstract
Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.
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Affiliation(s)
- Peta Ellen Tehan
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Morgan Brian Hawes
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Joanne Hurst
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, Scotland, UK
| | - Mathew Sebastian
- Department of Surgery, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Benjamin John Peterson
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Vivienne Helaine Chuter
- School of Health Sciences, Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
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23
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Pran L, Harnanan D, Baijoo S, Short A, Cave C, Maharaj R, Cawich SO, Naraynsingh V. Major Lower Limb Amputations: Recognizing Pitfalls. Cureus 2021; 13:e16972. [PMID: 34540383 PMCID: PMC8423325 DOI: 10.7759/cureus.16972] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2021] [Indexed: 11/21/2022] Open
Abstract
Major lower extremity amputations have been an area of much concern in the Caribbean population. Hence, the purpose of this research was to investigate the current trends in major lower-extremity amputations. Data regarding all major lower-extremity amputations performed at a tertiary care institution in Trinidad and Tobago, from January 2010 to December 2016 were reviewed. The variation of yearly trends, gender, type of amputation and reason for amputation were analysed. The yearly amputation rate demonstrated a progressive increase from 2010 to 2016, the average for the seven years was 28 per 105/year. Males accounted for 59% of cases, and 60% of amputations were done above the level of the knee joint. The most common reason for amputation was control of sepsis in 71.5% of cases. A strong association between major amputations and prior intervention for a foot-related problem was observed, as 52% of the sample had a pre-existing wound or a prior minor amputation (32%). Overall, 14.5% of all amputees were able to acquire a prosthesis. Diabetes mellitus was the most consistently associated co-morbidity occurring in 91% of the study population. Major limb amputations continue to affect our population significantly, with a rise in the amputation rate despite the introduction of a Vascular Surgical Unit. Diabetes and its foot-related complications are one of the leading causes of major lower extremity amputations. Prosthetic limb acquisition for our amputee population continues to be lacking, reflected by the low prosthetic acquisition rate observed.
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Affiliation(s)
- Lemuel Pran
- Vascular Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Dave Harnanan
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Shanta Baijoo
- Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Andy Short
- Statistics, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Cristo Cave
- Surgery, Eric Williams Medical Sciences Complex, Mount Hope, TTO
| | - Ravi Maharaj
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Shamir O Cawich
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Vijay Naraynsingh
- Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
- Surgery, Medical Associates Hospital, St. Joseph, TTO
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24
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Clinical Study of MEBO Combined with Jinhuang Powder for Diabetic Foot with Infection. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:5531988. [PMID: 34335813 PMCID: PMC8294956 DOI: 10.1155/2021/5531988] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/30/2021] [Indexed: 02/08/2023]
Abstract
Background To investigate the efficacy and safety of MEBO combined with Jinhuang powder for the treatment of diabetic foot with infection. Methods From August 2015 to August 2019, patients with diabetic foot in our hospital were divided into the treatment group and control group. The treatment group was treated with moist exposed burn ointment (MEBO) combined with Jinhuang powder, while the control group was treated with MEBO only. Results After one week of treatment, the effective rate in the treatment group was 100%, and the effective rate in the control group was only 76%. The difference between the two groups was statistically significant (P < 0.05). The wound pain score was 2.40 ± 1.38 in the treatment group and 3.76 ± 1.85 in the control group. The difference was statistically significant (P < 0.01). After one month of treatment, the effective rate of wound healing was 92.0% in the treatment group and 68% in the control group. The difference between the two groups was statistically significant (P < 0.05). Conclusion MEBO combined with Jinhuang powder is effective in treating diabetic foot with infection wound.
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25
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Sloan G, Selvarajah D, Tesfaye S. Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy. Nat Rev Endocrinol 2021; 17:400-420. [PMID: 34050323 DOI: 10.1038/s41574-021-00496-z] [Citation(s) in RCA: 158] [Impact Index Per Article: 52.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
Diabetic sensorimotor peripheral neuropathy (DSPN) is a serious complication of diabetes mellitus and is associated with increased mortality, lower-limb amputations and distressing painful neuropathic symptoms (painful DSPN). Our understanding of the pathophysiology of the disease has largely been derived from animal models, which have identified key potential mechanisms. However, effective therapies in preclinical models have not translated into clinical trials and we have no universally accepted disease-modifying treatments. Moreover, the condition is generally diagnosed late when irreversible nerve damage has already taken place. Innovative point-of-care devices have great potential to enable the early diagnosis of DSPN when the condition might be more amenable to treatment. The management of painful DSPN remains less than optimal; however, studies suggest that a mechanism-based approach might offer an enhanced benefit in certain pain phenotypes. The management of patients with DSPN involves the control of individualized cardiometabolic targets, a multidisciplinary approach aimed at the prevention and management of foot complications, and the timely diagnosis and management of neuropathic pain. Here, we discuss the latest advances in the mechanisms of DSPN and painful DSPN, originating both from the periphery and the central nervous system, as well as the emerging diagnostics and treatments.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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26
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Russell DA. Modernizing vascular services to meet the demands of a changing disease burden. Br J Surg 2021; 108:593-594. [PMID: 33748849 PMCID: PMC10364869 DOI: 10.1093/bjs/znab080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 02/08/2021] [Indexed: 11/12/2022]
Affiliation(s)
- David A Russell
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds, UK
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27
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Guest JF, Atkin L, Aitkins C. Potential cost-effectiveness of using adjunctive dehydrated human amnion/chorion membrane allograft in the management of non-healing diabetic foot ulcers in the United Kingdom. Int Wound J 2021; 18:889-901. [PMID: 33827144 PMCID: PMC8613389 DOI: 10.1111/iwj.13591] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 01/26/2023] Open
Abstract
The aim of this study was to estimate the cost‐effectiveness of using dehydrated human amnion/chorion membrane (dHACM) allografts (Epifix) as an adjunct to standard care, compared with standard care alone, to manage non‐healing diabetic foot ulcers (DFUs) in secondary care in the United Kingdom, from the perspective of the National Health Service (NHS). A Markov model was constructed to simulate the management of diabetic lower extremity ulcers over a period of 1 year. The model was used to estimate the cost‐effectiveness of using adjunctive dHACM, compared with standard care alone, to treat non‐healing DFUs in the United Kingdom, in terms of the incremental cost per quality‐adjusted life year (QALY) gained at 2019/2020 prices. The study estimated that at 12 months after the start of treatment, use of adjunctive dHACM instead of standard care alone is expected to lead to a 90% increase in the probability of healing, a 34% reduction in the probability of wound infection, a 57% reduction in the probability of wound recurrence, a 6% increase in the probability of avoiding an amputation, and 8% improvement in the number of QALYs. Additionally, if £4062 is spent on dHACM allografts per ulcer, then adjunctive use of dHACM instead of standard care alone is expected to lead to an incremental cost per QALY gain of £20 000. However, if the amount spent on dHACM allografts was ≤£3250 per ulcer, the 12‐month cost of managing an ulcer treated with adjunctive dHACM would break‐even with that of DFUs treated with standard care, and it would have a 0.95 probability of being cost‐effective at the £20 000 per QALY threshold. In conclusion, within the study's limitations, and within a certain price range, adjunctive dHACM allografts afford the NHS a cost‐effective intervention for the treatment of non‐healing DFUs within secondary care among adult patients with type 1 or 2 diabetes mellitus in the United Kingdom.
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Affiliation(s)
- Julian F Guest
- Health Economics and Outcomes Research, Catalyst Consultants, Poole, UK
| | - Leanne Atkin
- Vascular Surgery, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK.,University of Huddersfield, Huddersfield, UK
| | - Christopher Aitkins
- Diabetes Care Centre, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
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28
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Monteiro-Soares M, Vale-Lima J, Martiniano J, Pinheiro-Torres S, Dias V, Boyko EJ. A systematic review with meta-analysis of the impact of access and quality of diabetic foot care delivery in preventing lower extremity amputation. J Diabetes Complications 2021; 35:107837. [PMID: 33423910 DOI: 10.1016/j.jdiacomp.2020.107837] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 11/30/2020] [Accepted: 11/30/2020] [Indexed: 11/24/2022]
Abstract
AIMS To assess the impact of diabetic foot care delivery in preventing lower extremity amputation (LEA). METHODS We systematically searched the MEDLINE database for research evaluating the association between any aspect of diabetic foot care delivery and risk of LEA. Meta-analysis was conducted by calculating a pooled odds ratio through a random effects model. RESULTS Our search retrieved 5093 articles. In total, 58 articles were included: 9 addressing healthcare access, 4 educating health professionals, 2 implementing guidelines, 6 receiving chiropody/podiatry care services and 37 implementing structured diabetic foot care services (SDFC). All of these aspects of diabetic foot care seemed to have a positive impact on preventing LEA. Only SDFC literature met criteria for performing a meta-analysis. For SDFC impact on preventing overall and major LEA but not for minor LEA compelling evidence was observed [aggregated odds ratio (OR) of 0.45 (95% CI 0.37-0.57), 0.40 (95% CI 0.32-0.51), and 0.87 (95% CI 0.67-1.14), respectively]. However, high heterogeneity (superior to 60%) was observed for all outcomes. CONCLUSIONS Results support a reduction in diabetic LEA frequency in association with structured diabetic foot care, and, in particular, major LEA. Less evidence is available for the remaining aspects of diabetic foot care delivery.
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Affiliation(s)
- Matilde Monteiro-Soares
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine, University of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Jorge Vale-Lima
- Unidade de Saúde Familiar Nova Salus, Agrupamento de Centros de Saúde Grande Porto VII, Vila Nova de Gaia, Portugal
| | - João Martiniano
- Escola Superior de Saúde da Cruz Vermelha Portuguesa de Lisboa, Portugal
| | - Sofia Pinheiro-Torres
- Unidade de Saúde Familiar Aldoar, Agrupamento de Centros de Saúde Porto Ocidental, Porto, Portugal
| | - Vanessa Dias
- Unidade de Saúde Familiar St André de Canidelo, Agrupamento de Centros de Saúde Grande Porto VII, Vila Nova de Gaia, Portugal; Centro de Investigação Interdisciplinar em Saúde(CIIS)- UCP- ICS Porto, Portugal
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs, Puget Sound Health Care System and the University of Washington, Seattle, WA, USA
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Gunn LH, Vamos EP, Majeed A, Normahani P, Jaffer U, Molina G, Valabhji J, McKay AJ. Associations between attainment of incentivized primary care indicators and incident lower limb amputation among those with type 2 diabetes: a population-based historical cohort study. BMJ Open Diabetes Res Care 2021; 9:9/1/e002069. [PMID: 33903115 PMCID: PMC8076942 DOI: 10.1136/bmjdrc-2020-002069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/18/2021] [Accepted: 04/03/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION England has invested considerably in diabetes care through such programs as the Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA). Associations between program indicators and clinical endpoints, such as amputation, remain unclear. We examined associations between primary care indicators and incident lower limb amputation. RESEARCH DESIGN AND METHODS This population-based retrospective cohort study, spanning 2010-2017, was comprised of adults in England with type 2 diabetes and no history of lower limb amputation. Exposures at baseline (2010-2011) were attainment of QOF glycated hemoglobin (HbA1c), blood pressure and total cholesterol indicators, and number of NDA processes completed. Propensity score matching was performed and multivariable Cox proportional hazards models, adjusting for disease-related, comorbidity, lifestyle, and sociodemographic factors, were fitted using matched samples for each exposure. RESULTS 83 688 individuals from 330 English primary care practices were included. Mean follow-up was 3.9 (SD 2.0) years, and 521 (0.6%) minor or major amputations were observed (1.62 per 1000 person-years). HbA1c and cholesterol indicator attainment were associated with considerably lower risks of minor or major amputation (adjusted HRs; 95% CIs) 0.61 (0.49 to 0.74; p<0.0001) and 0.67 (0.53 to 0.86; p=0.0017), respectively). No evidence of association between blood pressure indicator attainment and amputation was observed (adjusted HR 0.88 (0.73 to 1.06; p=0.1891)). Substantially lower amputation rates were observed among those completing a greater number of NDA care processes (adjusted HRs 0.45 (0.24 to 0.83; p=0.0106), 0.67 (0.47 to 0.97; p=0.0319), and 0.38 (0.20 to 0.70; p=0.0022) for comparisons of 4-6 vs 0-3, 7-9 vs 0-3, and 7-9 vs 4-6 processes, respectively). Results for major-only amputations were similar for HbA1c and blood pressure, though cholesterol indicator attainment was non-significant. CONCLUSIONS Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.
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Affiliation(s)
- Laura H Gunn
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
- School of Data Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Eszter P Vamos
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Pasha Normahani
- Imperial Vascular Unit, Imperial College London NHS Healthcare Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Usman Jaffer
- Imperial Vascular Unit, Imperial College London NHS Healthcare Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - German Molina
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jonathan Valabhji
- Division of Metabolism, Digestion & Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- NHS England and NHS Improvement, London, UK
| | - Ailsa J McKay
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation. Arch Phys Med Rehabil 2021; 102:1191-1197. [PMID: 33412108 DOI: 10.1016/j.apmr.2020.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/05/2020] [Accepted: 11/08/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG). DATA SOURCES Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018). STUDY SELECTION Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the "Appraisal of Guidelines for Research and Evaluation." DATA EXTRACTION Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation. DATA SYNTHESIS We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses. CONCLUSIONS The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.
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Watt A, Beacham A, Palmer-Mann L, Williams A, White J, Brown R, Williams E, Richards G, White L, Budge P, Darvall K, Bond E, Paisey R. Service user and community clinician design of a partially virtual diabetic service improves access to care and education and reduces amputation incidence. BMJ Open Diabetes Res Care 2021; 9:9/1/e001657. [PMID: 33431598 PMCID: PMC7802684 DOI: 10.1136/bmjdrc-2020-001657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/12/2020] [Accepted: 11/25/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Design of an integrated diabetes service based on needs of service users (persons living with diabetes) and community clinicians in a semirural low-income health district of the UK. RESEARCH DESIGN AND METHODS One hundred and eighty-five service users engaged through public meetings, questionnaires and focus groups. General practice staff contributed views through workshops and questionnaires. Analysis of feedback indicated service user needs for better access to education, dietary advice and foot care. General practice staff endorsed these views and requested regular access to secondary care in the community. Seven hundred persons registered with diabetes attended eight well-being events in the community. From 2017 virtual practice multidisciplinary patient reviews, virtual referral of foot cases and non-face-to-face helplines were developed. A National Health Service (NHS) approved 'App' and web-based personalized education support for those recently diagnosed with diabetes was introduced. RESULTS Engagement in education for those recently diagnosed with diabetes increased from 5% to 71%. Weight and hemoglobin A1c (HbA1c) levels before and 6 months after starting the program were 99.4±25 and 95.5±24.2 kg and 59.3±16 and 54.8±12.9 mmol/mol, respectively, p=0.00003 and 0.003. Of those engaging at well-being events, 44 had missed regular follow-up. One hundred and seventy-five cases were reviewed virtually with practice staff by the secondary care team avoiding referral to the hospital diabetic clinic. One hundred and seventy-six referrals were made to the virtual multidisciplinary diabetic foot team clinic. Major amputation incidence declined from 13 to 3 major procedures/10 000 per annum and minor amputation from 26 to 18/10 000. Percentage bed day occupancy by persons with diabetes fell significantly in the district general hospital. CONCLUSIONS Integrated community-based diabetes care delivery has been achieved with partially virtual reviews. Patient education, secondary care in the community, access to dietetic advice and foot care outcomes have all improved.
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Affiliation(s)
- Alastair Watt
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Andrea Beacham
- Department of Integrated Care, Northern Devon Healthcare NHS Trust, Barnstaple, UK
| | - Lynne Palmer-Mann
- Department of Integrated Care, Northern Devon Healthcare NHS Trust, Barnstaple, UK
| | - Amy Williams
- Department of Integrated Care, Northern Devon Healthcare NHS Trust, Barnstaple, UK
| | - Jacqueline White
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Rebecca Brown
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Ellena Williams
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Gayle Richards
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Lyndon White
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Pauline Budge
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Katy Darvall
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
| | - Ed Bond
- Integrated Diabetes Care, Bideford Medical Centre, North Devon, Barnstaple, UK
| | - Richard Paisey
- Integrated Diabetes Care, Northern Devon Healthcare NHS Trust, Barnstaple, Devon, UK
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Mullan L, Wynter K, Driscoll A, Rasmussen B. Implementation strategies to overcome barriers to diabetes-related footcare delivery in primary care: a qualitative study. Aust J Prim Health 2021; 27:328-337. [PMID: 34229831 DOI: 10.1071/py20241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 03/05/2021] [Indexed: 11/23/2022]
Abstract
The aim of this study is to identify, from the perspectives of key health policy decision-makers, strategies that address barriers to diabetes-related footcare delivery in primary care, and outline key elements required to support implementation into clinical practice. The study utilised a qualitative design with inductive analysis approach. Seven key health policy decisions-makers within Australia were interviewed. Practical strategies identified to support provision and delivery of foot care in primary care were: (a) building on current incentivisation structures through quality improvement projects; (b) enhancing education and community awareness; (c) greater utilisation and provision of resources and support systems; and (d) development of collaborative models of care and referral pathways. Key elements reported to support effective implementation of footcare strategies included developing and implementing strategies based on co-design, consultation, collaboration, consolidation and co-commissioning. To the authors' knowledge, this is the first Australian study to obtain information from key health policy decision-makers, identifying strategies to support footcare delivery in primary care. Implementation of preventative diabetes-related footcare strategies into 'routine' primary care clinical practice requires multiparty co-design, consultation, consolidation, collaboration and co-commissioning. The basis of strategy development will influence implementation success and thus improve outcomes for people living with diabetes.
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Affiliation(s)
- Leanne Mullan
- Deakin University School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, Vic. 3220, Australia; and Corresponding author.
| | - Karen Wynter
- Deakin University School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, Vic. 3220, Australia; and Centre for Quality and Patient Safety, Deakin University, 1 Gheringhap Street, Geelong, Vic. 3220, Australia; and Western Health Partnership, 176 Furlong Road, St Albans, Vic. 3021, Australia
| | - Andrea Driscoll
- Deakin University School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, Vic. 3220, Australia; and Centre for Quality and Patient Safety, Deakin University, 1 Gheringhap Street, Geelong, Vic. 3220, Australia
| | - Bodil Rasmussen
- Deakin University School of Nursing and Midwifery, 1 Gheringhap Street, Geelong, Vic. 3220, Australia; and Centre for Quality and Patient Safety, Deakin University, 1 Gheringhap Street, Geelong, Vic. 3220, Australia; and Western Health Partnership, 176 Furlong Road, St Albans, Vic. 3021, Australia; and Faculty of Health and Medical Sciences, Blegdamsvej 3B, 2200 Copenhagen, Denmark; and Faculty of Health Sciences, University of Southern Denmark and Steno Diabetes Center, Campusvej 55, DK-5230 Odense M, Denmark
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Awasthi A, Singh SK, Kumar B, Gulati M, Kumar R, Wadhwa S, Khursheed R, Corrie L, Kr A, Kumar R, Patni P, Kaur J, Vishwas S, Yadav A. Treatment Strategies Against Diabetic Foot Ulcer: Success so Far and the Road Ahead. Curr Diabetes Rev 2021; 17:421-436. [PMID: 33143613 DOI: 10.2174/1573399816999201102125537] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 10/15/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diabetic foot ulcer (DFU) is one of the leading complications of type-2 diabetes mellitus. It is associated with neuropathy and peripheral arterial disease of the lower limb in patients with diabetes. There are four stages of wound healing, namely hemostasis phase, inflammatory phase, proliferative phase and maturation phase. In the case of DFU, all these stages are disturbed which lead to delay in healing and consequently to lower limb amputation. Conventional dosage forms like tablets, creams, ointments, gels and capsules have been used for the treatment of diabetic foot ulcer for many years. INTRODUCTION In this review, the global prevalence as well as etiopathogenesis related to diabetic foot ulcer have been discussed. The potential role of various synthetic and herbal drugs, as well as their conventional dosage forms in the effective management of DFU have been discussed in detail. METHODS Structured search of bibliographic databases from previously published peer-reviewed research papers was explored and data has been represented in terms of various approaches that are used for the treatment of DFU. RESULTS About 148 papers, including both research and review articles, were included in this review to produce a comprehensive as well as a readily understandable article. A series of herbal and synthetic drugs have been discussed along with their current status of treatment in terms of dose and mechanism of action. CONCLUSION DFU has become one of the most common complications in patients having diabetes for more than ten years. Hence, understanding the root cause and its successful treatment is a big challenge because it depends upon multiple factors such as the judicious selection of drugs as well as proper control of blood sugar level. Most of the drugs that have been used so far either belong to the category of antibiotics, antihyperglycaemic or they have been repositioned. In clinical practice, much focus has been given to dressings that have been used to cover the ulcer. The complete treatment of DFU is still a farfetched dream to be achieved and it is expected that combination therapy of herbal and synthetic drugs with multiple treatment pathways could be able to offer better management of DFU.
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Affiliation(s)
- Ankit Awasthi
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Sachin Kumar Singh
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Bimlesh Kumar
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Monica Gulati
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Rajesh Kumar
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Sheetu Wadhwa
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Rubiya Khursheed
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Leander Corrie
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Arya Kr
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Rajan Kumar
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Pooja Patni
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Jaskiran Kaur
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Sukriti Vishwas
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
| | - Ankit Yadav
- School of Pharmaceutical Sciences, Lovely Professional University Phagwara, 144411, Punjab, India
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Gandhi SK, Waschbusch M, Michael M, Zhang M, Li X, Juhaeri J, Wu C. Age- and sex-specific incidence of non-traumatic lower limb amputation in patients with type 2 diabetes mellitus in a U.S. claims database. Diabetes Res Clin Pract 2020; 169:108452. [PMID: 32949656 DOI: 10.1016/j.diabres.2020.108452] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 07/22/2020] [Accepted: 09/14/2020] [Indexed: 02/08/2023]
Abstract
AIM To estimate age- and sex-specific incidence rates (IRs) of non-traumatic lower limb amputations (LLA) in patients with type 2 diabetes mellitus (T2DM) using a claims database from the United States (US). METHODS Patients with T2DM 18 years and older were identified using the Truven Health MarketScan database from January 1, 2007 to September 30, 2018. The overall and age- and sex-specific IRs of all non-traumatic LLA, minor LLA (amputation at or below the ankle), and major LLA (amputation above ankle) were calculated. RESULTS Among the 6,117,981 patients with T2DM, 14,627 LLA events occurred (minor LLA; 72.8%; major LLA: 27.2%). The IRs (95% CI) of all LLA, minor LLA, and major LLA per 1000 person-years or PY were 0.86 (0.85, 0.88), 0.63 (0.62, 0.64), and 0.23 (0.23, 0.24), respectively. The IR (95% CI) of all LLA per 1000 PY in males was higher compared to females [1.24 (1.22, 1.26) vs. 0.46 (0.45, 0.48)]. The incidence of all LLA increased with an increasing age (highest IR in age-group of ≥80 years). CONCLUSIONS This study identified males and older patients with T2DM at higher risk of developing LLA in the US, warranting further exploration of risk factors of LLA in these subgroups.
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Affiliation(s)
- Sampada K Gandhi
- Epidemiology and Benefit Risk, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA.
| | - Max Waschbusch
- Global Pharmacovigilance, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Madlen Michael
- Global Pharmacovigilance, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Meng Zhang
- Global Pharmacovigilance, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Xinyu Li
- Epidemiology and Benefit Risk, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Juhaeri Juhaeri
- Epidemiology and Benefit Risk, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA
| | - Chuntao Wu
- Epidemiology and Benefit Risk, Sanofi U.S., 55 Corporate Drive, Bridgewater, NJ 08807, USA
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Harding JL, Andes LJ, Rolka DB, Imperatore G, Gregg EW, Li Y, Albright A. National and State-Level Trends in Nontraumatic Lower-Extremity Amputation Among U.S. Medicare Beneficiaries With Diabetes, 2000-2017. Diabetes Care 2020; 43:2453-2459. [PMID: 32723844 PMCID: PMC10982954 DOI: 10.2337/dc20-0586] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/07/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes is a leading cause of nontraumatic lower-extremity amputation (NLEA) in the U.S. After a period of decline, some national U.S. data have shown that diabetes-related NLEAs have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear. RESEARCH DESIGN AND METHODS To examine NLEA trends among older adults with diabetes (≥67 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as fee for service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age-group, sex, race/ethnicity, NLEA level (toe, foot, below-the-knee amputation [BKA], or above-the-knee amputation [AKA]), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported. RESULTS NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC -7.9, P < 0.001). However, from 2009 onward, NLEA rates increased to 4.8 (APC 1.2, P < 0.01). Trends were similar across most age, sex, and race/ethnic groups, but absolute rates were highest in the oldest age-groups, Blacks, and men. By NLEA type, overall increases were driven by increases in rates of toe and foot NLEAs, while BKA and AKA continued to decline. The majority of U.S. states showed recent increases in NLEA, similar to national estimates. CONCLUSIONS This study of the U.S. Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (<65 years) in the general population. Preventive foot care has been shown to reduce rates of NLEA among adults with diabetes, and the findings of the study suggest that those with diabetes-across the age spectrum-could benefit from increased attention to this strategy.
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Affiliation(s)
- Jessica L Harding
- Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Linda J Andes
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Deborah B Rolka
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Giuseppina Imperatore
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
| | - Edward W Gregg
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, U.K
| | - Yanfeng Li
- Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA
| | - Ann Albright
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA
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Missed Opportunities for Timely Recognition of Chronic Limb Threatening Ischaemia in Patients Undergoing a Major Amputation: A Population Based Cohort Study Using the UK's Clinical Practice Research Datalink. Eur J Vasc Endovasc Surg 2020; 60:703-710. [PMID: 32718828 DOI: 10.1016/j.ejvs.2020.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 04/09/2020] [Accepted: 05/05/2020] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care. METHODS This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days). RESULTS In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p = .003), with higher systolic (p = .008) and diastolic (p = .001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p = .003) and ethnicity (p = .006). CONCLUSION Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.
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Abstract
Bei der virtuellen Veranstaltung Diabetes Update 2020 wurden zahlreiche neue Erkenntnisse und Empfehlungen zu Diagnostik, Therapie und Management des Diabetes und benachbarter Themen vorgestellt, von denen die Bereiche Typ-2-Diabetes, Diabetes und Herz, Diabetes und Schwangerschaft sowie Impfungen im aktuellen Heft von Der Diabetologe in separaten Beiträgen ausführlich beschrieben werden. Im Folgenden sollen die aus Sicht des Autors wichtigsten und für die Praxis relevantesten Neuigkeiten aus den anderen referierten diabetesbezogenen Themengebieten in aller Kürze wiedergegeben werden.
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Affiliation(s)
- Werner A. Scherbaum
- Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Deutschland
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38
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Araki E, Goto A, Kondo T, Noda M, Noto H, Origasa H, Osawa H, Taguchi A, Tanizawa Y, Tobe K, Yoshioka N. Japanese Clinical Practice Guideline for Diabetes 2019. Diabetol Int 2020; 11:165-223. [PMID: 32802702 PMCID: PMC7387396 DOI: 10.1007/s13340-020-00439-5] [Citation(s) in RCA: 235] [Impact Index Per Article: 58.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Eiichi Araki
- Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Atsushi Goto
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama, Japan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and Endocrinology, Kumamoto University Hospital, Kumamoto, Japan
| | - Mitsuhiko Noda
- Department of Diabetes, Metabolism and Endocrinology, Ichikawa Hospital, International University of Health and Welfare, Ichikawa, Japan
| | - Hiroshi Noto
- Division of Endocrinology and Metabolism, St. Luke’s International Hospital, Tokyo, Japan
| | - Hideki Origasa
- Department of Biostatistics and Clinical Epidemiology, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular Genetics, Ehime University Graduate School of Medicine, Toon, Japan
| | - Akihiko Taguchi
- Department of Endocrinology, Metabolism, Hematological Science and Therapeutics, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Yukio Tanizawa
- Department of Endocrinology, Metabolism, Hematological Science and Therapeutics, Graduate School of Medicine, Yamaguchi University, Ube, Japan
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, Toyama, Japan
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Araki E, Goto A, Kondo T, Noda M, Noto H, Origasa H, Osawa H, Taguchi A, Tanizawa Y, Tobe K, Yoshioka N. Japanese Clinical Practice Guideline for Diabetes 2019. J Diabetes Investig 2020; 11:1020-1076. [PMID: 33021749 PMCID: PMC7378414 DOI: 10.1111/jdi.13306] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 05/24/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Eiichi Araki
- Department of Metabolic MedicineFaculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Atsushi Goto
- Department of Health Data ScienceGraduate School of Data ScienceYokohama City UniversityYokohamaJapan
| | - Tatsuya Kondo
- Department of Diabetes, Metabolism and EndocrinologyKumamoto University HospitalKumamotoJapan
| | - Mitsuhiko Noda
- Department of Diabetes, Metabolism and EndocrinologyIchikawa HospitalInternational University of Health and WelfareIchikawaJapan
| | - Hiroshi Noto
- Division of Endocrinology and MetabolismSt. Luke's International HospitalTokyoJapan
| | - Hideki Origasa
- Department of Biostatistics and Clinical EpidemiologyGraduate School of Medicine and Pharmaceutical SciencesUniversity of ToyamaToyamaJapan
| | - Haruhiko Osawa
- Department of Diabetes and Molecular GeneticsEhime University Graduate School of MedicineToonJapan
| | - Akihiko Taguchi
- Department of Endocrinology, Metabolism, Hematological Science and TherapeuticsGraduate School of MedicineYamaguchi UniversityUbeJapan
| | - Yukio Tanizawa
- Department of Endocrinology, Metabolism, Hematological Science and TherapeuticsGraduate School of MedicineYamaguchi UniversityUbeJapan
| | - Kazuyuki Tobe
- First Department of Internal MedicineGraduate School of Medicine and Pharmaceutical SciencesUniversity of ToyamaToyamaJapan
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Musuuza J, Sutherland BL, Kurter S, Balasubramanian P, Bartels CM, Brennan MB. A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. J Vasc Surg 2020; 71:1433-1446.e3. [PMID: 31676181 PMCID: PMC7096268 DOI: 10.1016/j.jvs.2019.08.244] [Citation(s) in RCA: 128] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/20/2019] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams. METHODS We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915). RESULTS We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team. CONCLUSIONS Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.
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Affiliation(s)
- Jackson Musuuza
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisc; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, Wisc
| | - Bryn L Sutherland
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisc
| | - Suleyman Kurter
- Department of Podiatry, William S. Middleton Memorial Veterans Hospital, Madison, Wisc
| | | | | | - Meghan B Brennan
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisc; Department of Medicine, William S. Middleton Memorial Veterans Hospital, Madison, Wisc.
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Pourkazemi A, Ghanbari A, Khojamli M, Balo H, Hemmati H, Jafaryparvar Z, Motamed B. Diabetic foot care: knowledge and practice. BMC Endocr Disord 2020; 20:40. [PMID: 32192488 PMCID: PMC7083045 DOI: 10.1186/s12902-020-0512-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 02/25/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) are common problems in diabetes. One of the most important factors affecting the quality of diabetes care is knowledge and practice. The current study aimed at determining the knowledge and practice of patients with diabetes regarding the prevention and care of DFUs. METHODS The current analytical, cross sectional study was conducted in Guilan Province (north of Iran) on 375 patients registered in the medical records as type 2 diabetes mellitus. Demographic characteristics, knowledge, and practice of participants were recorded in a questionnaire during face-to-face interviews conducted by the researcher. Descriptive and inferential statistics were performed using SPSS version18. RESULTS The mean score of knowledge was 8.63 ± 2.5 out of 15, indicating that the majority of participants had a poor knowledge (84.8%). The mean practice score was 7.6 ± 2.5 out of 15, indicating that a half of them had poor performance (49.6%). There was a significant and direct correlation between knowledge and practice. Knowledge level, place of residence, marital status, and history of admission due to diabetic foot were predictors of practice score. CONCLUSIONS According to the low level of knowledge and practice in patients with diabetes regarding the prevention and care of DFUs, and considering the significant relationship of some demographics of patients with knowledge and practice scores, a targeted educational program is needed to promote knowledge of patients with diabetes.
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Affiliation(s)
- Aydin Pourkazemi
- Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran
| | - Atefeh Ghanbari
- Social Determinants of Health Research center, nursing and midwifery school, Guilan University of medical sciences, Rasht, Iran
| | - Monireh Khojamli
- Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran
| | - Heydarali Balo
- Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran
| | - Hossein Hemmati
- Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran
| | - Zakiyeh Jafaryparvar
- Razi Clinical Research Development unit, Guilan university of medical sciences, Rasht, Iran
| | - Behrang Motamed
- Department of internal medicine , Razi Hospital ,School of Medicine, Guilan university of Medical Sciences, Rasht, Iran
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Jiang X, Meng W, Li L, Meng Z, Wang D. Adjuvant Therapy With Mushroom Polysaccharides for Diabetic Complications. Front Pharmacol 2020; 11:168. [PMID: 32180724 PMCID: PMC7059129 DOI: 10.3389/fphar.2020.00168] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 02/07/2020] [Indexed: 12/11/2022] Open
Abstract
Background Diabetic complications seriously endanger the health of most diabetic patients around the world. Most chemical hypoglycemic agents have adverse effects and are unable to improve the progression of diabetic complications. In recent years, a number of medicinal herbs have become increasingly popular for the treatment of diabetic complications due to their relative safety. Polysaccharides extracted from medicinal herbs with multiple pharmacological activities and low toxicity have been reported to be useful in the treatment of diabetic complications. Methods Primary studies with keywords including polysaccharide and diabetic complications were retrieved from the Web of Science and NCBI databases and were read and analyzed. Results Mushroom polysaccharides were proven to have positive effects on diabetic complications. Conclusions We studied the effects of mushroom polysaccharides on hyperglycemia and as adjuvant therapies for diabetic complications and summarized the applications and limitations of mushroom polysaccharides to better understand their application for the treatment of diabetic complications.
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Affiliation(s)
- Xue Jiang
- Department of Translational Medicine Research Institute, First Hospital, Jilin University, Changchun, China.,School of Life Sciences, Jilin University, Changchun, China
| | - Weiqi Meng
- School of Life Sciences, Jilin University, Changchun, China
| | - Lanzhou Li
- School of Life Sciences, Jilin University, Changchun, China
| | - Zhaoli Meng
- Department of Translational Medicine Research Institute, First Hospital, Jilin University, Changchun, China
| | - Di Wang
- School of Life Sciences, Jilin University, Changchun, China
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Price BL, Morley R, Bowling FL, Lovering AM, Dobson CB. Susceptibility of monomicrobial or polymicrobial biofilms derived from infected diabetic foot ulcers to topical or systemic antibiotics in vitro. PLoS One 2020; 15:e0228704. [PMID: 32069293 PMCID: PMC7028275 DOI: 10.1371/journal.pone.0228704] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 01/22/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetic foot ulcers can become chronic and non-healing despite systemic antibiotic treatment. The penetration of systematically-administered antibiotics to the site of infection is uncertain, as is the effectiveness of such levels against polymicrobial biofilms. We have developed an in vitro model to study the effectiveness of different treatments for infected diabetic foot ulcers in a wound-like environment and compared the activity of systemic levels of antibiotics with that for topically applied antibiotics released from calcium sulfate beads. This is the first study that has harvested bacteria from diabetic foot infections and recreated similar polymicrobial biofilms to those present in vivo for individual subjects. After treatment with levels of gentamicin attained in serum after systemic administration (higher than corresponding tissues concentrations) we measured a 0-2 log reduction in bacterial viability of P. aeruginosa, S. aureus or a polymicrobial biofilm. Conversely, addition of gentamicin loaded calcium sulfate beads resulted in 5-9 log reductions in P. aeruginosa, S aureus and polymicrobial biofilms derived from three subjects. We conclude that systemically administered antibiotics are likely to be inadequate for successfully treating these infections, especially given the vastly increased concentrations required to inhibit cells in a biofilm, and that topical antibiotics provide a more effective alternative.
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Affiliation(s)
- Bianca L. Price
- Division of Pharmacy and Optometry, Lydia Becker Institute of Immunology and Inflammation, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Robert Morley
- Podiatric Surgery Dept, Buxton Hospital, Derbyshire Community Health Services NHS Foundation Trust, Bakewell, United Kingdom
| | - Frank L. Bowling
- Division of Diabetes, Endocrinology & Gastroenterology, Faculty of Biology Medicine and Health, University of Manchester, Manchester, United Kingdom
| | - Andrew M. Lovering
- Microbiology Department, Antimicrobial Reference Laboratory, Bristol, United Kingdom
| | - Curtis B. Dobson
- Medical Device Biology Group, Division of Pharmacy and Optometry, Faculty of Biology Medicine and Health (FBMH), University of Manchester, Manchester, United Kingdom
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44
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Mullan L, Wynter K, Driscoll A, Rasmussen B. Preventative and early intervention diabetes-related foot care practices in primary care. Aust J Prim Health 2020; 26:161-172. [DOI: 10.1071/py19183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/01/2019] [Indexed: 01/11/2023]
Abstract
The aim of this study was to identify current preventative and early intervention diabetes-related foot care practices among Australian primary care healthcare professionals. A survey was developed to obtain information about preventative and early intervention foot care actions, priorities of care, access and referral to expert multidisciplinary foot care teams and adherence to best-practice diabetes-related foot care recommendations. The survey was distributed to GPs and Credentialled Diabetes Educators (CDEs). Surveys were completed by 10 GPs and 84 CDEs. Only 45% of all respondents reported removing the shoes and socks of their patients with diabetes at a consultation. Eighty-one percent of participants reported having access to specialist multidisciplinary foot care teams. Those in urban settings were significantly more likely to report access than those in rural areas (P=0.04). Median scores indicated that participants did not often utilise specialist teams to refer patients with diabetes-related foot ulceration and Charcot’s neuroarthropathy. Only 16% of participants reported having access to specialist foot care telehealth services; patients with diabetes-related foot ulceration and Charcot’s neuroarthropathy were rarely referred to these services. This study is the first Australian study to elicit information about preventative and early intervention diabetes-related foot care practices by GPs and CDEs working in Australian primary care. In the presence of acute diabetes-related foot complications, primary healthcare practitioners are not always adhering to best practice foot care recommendations. Further studies are required to understand the reasons for this and ensure evidence-based best practice foot care delivery to people with diabetes.
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Selvarajah D, Kar D, Khunti K, Davies MJ, Scott AR, Walker J, Tesfaye S. Diabetic peripheral neuropathy: advances in diagnosis and strategies for screening and early intervention. Lancet Diabetes Endocrinol 2019; 7:938-948. [PMID: 31624024 DOI: 10.1016/s2213-8587(19)30081-6] [Citation(s) in RCA: 226] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/02/2019] [Accepted: 01/03/2019] [Indexed: 12/13/2022]
Abstract
Diabetic peripheral neuropathy (DPN) is a common complication of both type 1 and 2 diabetes. It is a leading cause of lower-limb amputation and disabling neuropathic pain. Amputations in patients with diabetes have a devastating effect on quality of life and are associated with an alarmingly low life expectancy (on average only 2 years from the amputation). Amputation also places a substantial financial burden on health-care systems and society in general. With the introduction of national diabetes eye screening programmes, the prevalence of blindness in working-age adults is falling. This is not the case, however, with diabetes related amputations. In this Review, we appraise innovative point-of-care devices that enable the early diagnosis of DPN and assess the evidence for early risk factor-based management strategies to reduce the incidence and slow the progression of DPN. We also propose a framework for screening and early multifactorial interventions as the best prospect for preventing or halting DPN and its devastating sequelae.
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Affiliation(s)
- Dinesh Selvarajah
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
| | - Debasish Kar
- Derbyshire Community Health Services NHS Foundation Trust, Bakewell, UK; Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Melanie J Davies
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Adrian R Scott
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jeremy Walker
- Department of Podiatry Services, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Solomon Tesfaye
- Academic Unit of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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46
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Aljarrah Q, Allouh MZ, Bakkar S, Aleshawi A, Obeidat H, Hijazi E, Al-Zoubi N, Alalem H, Mazahreh T. Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community. BMC Surg 2019; 19:170. [PMID: 31722699 PMCID: PMC6852935 DOI: 10.1186/s12893-019-0637-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 10/31/2019] [Indexed: 12/30/2022] Open
Abstract
Background We aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan. Methods Clinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon’s specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated. Results The study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA. Conclusions In developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.
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Affiliation(s)
- Qusai Aljarrah
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.
| | - Mohammed Z Allouh
- Department of Anatomy, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan.,Department of Anatomy, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, 17666, UAE
| | - Sohail Bakkar
- Department of Surgery, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa, 13133, Jordan
| | - Abdelwahab Aleshawi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Hasan Obeidat
- School of Medicine, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Emad Hijazi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Nabil Al-Zoubi
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
| | - Heba Alalem
- Department of Surgery, Faculty of Medicine, The Hashemite University, P.O. Box 330127, Zarqa, 13133, Jordan
| | - Tagleb Mazahreh
- Department of Surgery, Faculty of Medicine, Jordan University of Science and Technology, P.O. Box 3030, Irbid, 22110, Jordan
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Quach TV, Goldschmidt MH. Evaluating a Program Process Change to Improve Completion of Foot Exams and Amputation Risk Assessments for Veterans with Diabetes. Fed Pract 2019; 36:S10-S15. [PMID: 31892784 PMCID: PMC6913583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
A quality improvement initiative significantly increased the number of veterans receiving thorough foot exams and amputation risk assessments as well as the number of appropriate podiatry referrals.
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Affiliation(s)
- Tiffany V Quach
- At the time this article was written, was a Registered Nurse and was the Health Promotion and Disease Prevention Program Manager, both at Veterans Affairs Portland Healthcare System in Oregon. Tiffany Quach was a doctoral Nurse Practitioner Student at Gonzaga University School of Nursing and Human Physiology in Spokane, Washington
| | - Michele H Goldschmidt
- At the time this article was written, was a Registered Nurse and was the Health Promotion and Disease Prevention Program Manager, both at Veterans Affairs Portland Healthcare System in Oregon. Tiffany Quach was a doctoral Nurse Practitioner Student at Gonzaga University School of Nursing and Human Physiology in Spokane, Washington
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48
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Paisey RB, Abbott A, Paisey CF, Walker D. Diabetic foot ulcer incidence and survival with improved diabetic foot services: an 18-year study. Diabet Med 2019; 36:1424-1430. [PMID: 31150130 PMCID: PMC6852104 DOI: 10.1111/dme.14045] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 02/06/2023]
Abstract
AIMS To ascertain the effects of improvements in diabetic foot services over 18 years on incidence of diabetic foot ulceration. We also compared survival time from first ulcer development with presence of neuropathy, peripheral vascular disease, age and healing. METHODS Persons with new ulceration and those at high risk of ulcer development were referred to community podiatry from 1998. Their details were recorded, with verbal consent, on a central database. The effects of neuropathy, peripheral vascular disease, healing and age on survival were analysed by Cox proportional hazards ratios. RESULTS The incidence of first ulcer presentation decreased from 11.1 to 6.1 per 1000 persons between 2003 to 2017 (P <0.0001). Recurrent ulceration incidence remained stable. Prevalence of chronic and new foot ulceration combined increased from 20.7 to 33.1 per 1000 persons (P <0.0001). Ten-year survival was 85% for persons presenting with first ulcer and aged < 65 years, 50% for those aged 65-74 years and 25% for those aged 75-81 years (P < 0.0001). In those with peripheral vascular disease 5-year survival was 35% (P <0.001). CONCLUSIONS Integrated care for the diabetic foot in one National Health Service (NHS) health service area over 18 years was associated with a reduction in first presentations of diabetic foot ulceration, but failed to reduce recurrent ulceration. Cumulative prevalence of all ulcers continues to increase. Monitoring ulceration incidence can inform audit and planning of diabetic foot care services. Survival is better than reported previously in persons < 65 years and in the absence of peripheral vascular disease.
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Affiliation(s)
- R. B. Paisey
- Torbay and South Devon Integrated Care TrustTorquay
| | - A. Abbott
- Torbay and South Devon Integrated Care TrustTorquay
| | - C. F. Paisey
- West Suffolk District General HospitalBury St EdmundsUK
| | - D. Walker
- Torbay and South Devon Integrated Care TrustTorquay
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López-de-Andrés A, Jiménez-García R, Esteban-Vasallo MD, Hernández-Barrera V, Aragon-Sánchez J, Jiménez-Trujillo I, de Miguel-Diez J, Palomar-Gallego MA, Romero-Maroto M, Perez-Farinos N. Time Trends in the Incidence of Long-Term Mortality in T2DM Patients Who Have Undergone a Lower Extremity Amputation. Results of a Descriptive and Retrospective Cohort Study. J Clin Med 2019; 8:jcm8101597. [PMID: 31581755 PMCID: PMC6832955 DOI: 10.3390/jcm8101597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 01/22/2023] Open
Abstract
(1) Background: The aims of this study were to examine the incidence of lower extremity amputations (LEAs) among patients with type 2 diabetes mellitus (T2DM) and to compare the mortality risk of diabetic individuals who underwent LEA with age and sex-matched diabetic individuals without LEA. (2) Methods: We performed a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients. Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure (HR 1.75; 95% CI 1.65–1.87). Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk.
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Affiliation(s)
- Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain.
| | | | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier Aragon-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, 35005 Las Palmas de Gran Canaria, Spain.
| | - Isabel Jiménez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain.
| | - Maria A Palomar-Gallego
- Basic Science Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Martin Romero-Maroto
- Medical Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Napoleón Perez-Farinos
- Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Malaga, 29071 Malaga, Spain.
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50
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Lazzarini PA, Fitridge R. Regional variations in amputation rates: are regional diabetic foot services the reason? ANZ J Surg 2019; 89:796-797. [DOI: 10.1111/ans.15161] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 02/27/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Peter A. Lazzarini
- School of Public Health and Social WorkQueensland University of Technology Brisbane Queensland Australia
- Allied Health Research CollaborativeMetro North Hospital and Health Service Brisbane Queensland Australia
| | - Robert Fitridge
- Discipline of SurgeryThe University of Adelaide Adelaide South Australia Australia
- Vascular and Endovascular ServiceRoyal Adelaide Hospital Adelaide South Australia Australia
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