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Mohamed AA, Elmotaleb Hussein MA, Nabil Hanna I, Japer Nashwan AJ, Saleh M, Abdel Wahed WY, Mohamed Mansour AM, Ezz Al Arab MR, Fawzy N, Sakr Y, Shalby H, AlHussain E, Kamal Darwish M, El-Osaily H, Naguib M, Mohamed AA, Farouk Mohamed W, Hafez W. The potential impact and diagnostic value of inflammatory markers on diabetic foot progression in type II diabetes mellitus: A case-control study. Med Clin (Barc) 2024; 162:e33-e39. [PMID: 38458959 DOI: 10.1016/j.medcli.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 11/19/2023] [Accepted: 01/25/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND The wound-healing process in diabetic foot is affected by pro and anti-inflammatory markers, and any disruption in the inflammatory reaction interferes with tissue homeostasis, leading to chronic non-wound healing. AIM This study aimed to determine the diagnostic value and effect of CRP, IL-6, TNF, and HbA1c on initiation the and progression of diabetic foot ulcers. METHOD ELISA was used to quantify IL-6, TNF, CRP, and HbA1c in 205 patients with diabetes, and 105 were diabetic foot free. The prevalence and progression of diabetic foot were also evaluated. The area under the curve (AUC) was calculated using the receiver operating characteristic (ROC) curve to analyze the predictive values. Forward stepwise logistic regression analysis was used to compute the odds ratio (OR) and the corresponding 95% confidence intervals (CIs). RESULTS CRP, IL-6, and FBS were found to be significant predictors of diabetic foot (OR=1.717, 95% CI=1.250-2.358, P=0.001; OR=1.434, 95% CI=1.142-1.802, P=0.002; and OR=1.040, 95% CI=1.002-1.080, P=0.037), respectively. The AUCs for CRP, IL-6, and HbA1c in predicting diabetic foot were 0.839, 0.728, and 0.834, respectively, demonstrating a good predictive value for each diagnostic marker. CONCLUSION The current study demonstrated that IL-6, CRP, and HbA1c may be useful biomarkers to indicate diabetic foot progression. Furthermore, our findings showed a substantial relationship between CRP and HbA1c in individuals with diabetic foot conditions.
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Affiliation(s)
- Amal Ahmed Mohamed
- Biochemistry Department, National Hepatology and Tropical Medicine Research Institute, Gothi, Egypt
| | | | - Ihab Nabil Hanna
- Surgical Department, National Institute of Diabetes and Endocrinology, Egypt
| | | | - Mohamed Saleh
- Gastroentrology Department, National Hepatology and Tropical Medicine Research Institute, Egypt
| | | | | | | | - Naglaa Fawzy
- Clinical and Chemical Pathology Department, National Institute of Diabetes and Endocrinology, Egypt
| | - Yasser Sakr
- Clinical and Chemical Pathology Department, National Institute of Diabetes and Endocrinology, Egypt
| | - Hassan Shalby
- Internal Medicine Department, Faculty of Medicine, Misr University for Science and Technology, Egypt
| | - Eman AlHussain
- Clinical and Chemical Pathology Department, Faculty of Medicine, Cairo University, Egypt
| | - Marwa Kamal Darwish
- Chemistry Department (Biochemistry Branch), Faculty of Science, Suez University, Suez 43518, Egypt
| | - Heba El-Osaily
- Biochemistry Department, Faculty of Pharmacy, Ahram Canadian University, Egypt
| | - Mervat Naguib
- Internal Medicine Department, Faculty of Medicine, Cairo University, Egypt
| | - Ahmed Ali Mohamed
- Intensive Care Unit, Theodor Bilharz Research Institute, Giza, Egypt
| | | | - Wael Hafez
- Internal Medicine Department, National Research Centre, Elbohoos Street, Dokki, Giza, Egypt
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2
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Li M, Tang F, Lao J, Yang Y, Cao J, Song R, Wu P, Wang Y. Multicomponent prediction of 2-year mortality and amputation in patients with diabetic foot using a random survival forest model: Uric acid, alanine transaminase, urine protein and platelet as important predictors. Int Wound J 2023; 21:e14376. [PMID: 37743574 PMCID: PMC10824700 DOI: 10.1111/iwj.14376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
The current methods for the prediction of mortality and amputation for inpatients with diabetic foot (DF) use only conventional, simple variables, which limits their performance. Here, we used a random survival forest (RSF) model and multicomponent variables to improve the prediction of mortality and amputation for these patients. We performed a retrospective cohort study of 175 inpatients with DF who were recruited between 2014 and 2021. Thirty-one predictors in six categories were considered as potential covariates. Seventy percent (n = 122) of the participants were randomly selected to constitute a training set, and 30% (n = 53) were assigned to a testing set. The RSF model was used to screen appropriate variables for their value as predictors of 2-year all-cause mortality and amputation, and a multicomponent prediction model was established. Model performance was evaluated using the area under the curve (AUC) and the Hosmer-Lemeshow test. The AUCs were compared using the Delong test. Seventeen variables were selected to predict mortality and 23 were selected to predict amputation. Uric acid and alanine transaminase were the top two most useful variables for the prediction of mortality, whereas urine protein and platelet were the top variables for the prediction of amputation. The AUCs were 0.913 and 0.851 for the prediction of mortality for the training and testing sets, respectively; and the equivalent AUCs were 0.963 and 0.893 for the prediction of amputation. There were no significant differences between the AUCs for the training and testing sets for both the mortality and amputation models. These models showed a good degree of fit. Thus, the RSF model can predict mortality and amputation in inpatients with DF. This multicomponent prediction model could help clinicians consider predictors of different dimensions to effectively prevent DF from clinical outcomes .
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Affiliation(s)
- Mingzhuo Li
- Department of Plastic SurgeryThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Center for Big Data Research in Health and MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Jinan Clinical Research Center for Tissue Engineering Skin Regeneration and Wound RepairJinanChina
- Shandong Data Open Innovative Application LaboratoryJinanChina
| | - Fang Tang
- Center for Big Data Research in Health and MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Shandong Data Open Innovative Application LaboratoryJinanChina
| | - Jiahui Lao
- Center for Big Data Research in Health and MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Shandong Data Open Innovative Application LaboratoryJinanChina
| | - Yang Yang
- Center for Big Data Research in Health and MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Shandong Data Open Innovative Application LaboratoryJinanChina
| | - Jia Cao
- Center for Big Data Research in Health and MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Shandong Data Open Innovative Application LaboratoryJinanChina
| | - Ru Song
- Department of Plastic SurgeryThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Jinan Clinical Research Center for Tissue Engineering Skin Regeneration and Wound RepairJinanChina
| | - Peng Wu
- Department of Plastic SurgeryThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Jinan Clinical Research Center for Tissue Engineering Skin Regeneration and Wound RepairJinanChina
| | - Yibing Wang
- Department of Plastic SurgeryThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Center for Big Data Research in Health and MedicineThe First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan HospitalJinanChina
- Jinan Clinical Research Center for Tissue Engineering Skin Regeneration and Wound RepairJinanChina
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3
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Lo ZJ, Tan E, Chandrasekar S, Ooi D, Liew H, Ang G, Yong E, Hong Q, Chew T, Muhammad Farhan MF, Zhu X, Ang P, Law C, Raman N, Park D, Tavintharan S, Hoi WH, Lin J, Koo HY, Choo J, Low KQ, Low R, Venkataraman K, Car J, Chew DEK. Diabetic foot in primary and tertiary (
DEFINITE
) Care: A health services innovation in coordination of diabetic foot ulcer (
DFU
) Care within a healthcare cluster ‐ 18‐month results from an observational population health cohort study. Int Wound J 2022; 20:1609-1621. [PMID: 36372913 PMCID: PMC10088846 DOI: 10.1111/iwj.14016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013-2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013-2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.
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Affiliation(s)
- Zhiwen Joseph Lo
- Vascular Surgery Service, Department of Surgery Woodlands Health Singapore Singapore
- Centre for Population Health Sciences. Lee Kong Chian School of Medicine Nanyang Technological University Singapore Singapore
| | - Elaine Tan
- Toa Payoh Polyclinic National Healthcare Group Polyclinics Singapore Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery Tan Tock Seng Hospital Singapore Singapore
| | - Desmond Ooi
- Vascular Surgery Service, Department of General Surgery Khoo Teck Puat Hospital Singapore Singapore
| | - Huiling Liew
- Department of Endocrinology Tan Tock Seng Hospital Singapore Singapore
| | - Gary Ang
- Health Services and Outcomes Research National Healthcare Group Singapore Singapore
| | - Enming Yong
- Vascular Surgery Service, Department of General Surgery Tan Tock Seng Hospital Singapore Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery Tan Tock Seng Hospital Singapore Singapore
| | - Tiffany Chew
- Department of Podiatry Tan Tock Seng Hospital Singapore Singapore
| | | | - Xiaoli Zhu
- Nursing Service National Healthcare Group Polyclinics Singapore Singapore
| | - Pauline Ang
- Podiatry Service National Healthcare Group Polyclinics Singapore Singapore
| | - Chelsea Law
- Department of Podiatry Khoo Teck Puat Hospital Singapore Singapore
| | - Nadiah Raman
- Department of Podiatry Khoo Teck Puat Hospital Singapore Singapore
| | - Derek Park
- Department of Orthopaedics Khoo Teck Puat Hospital Singapore Singapore
| | | | - Wai Han Hoi
- Department of Endocrinology Woodlands Health Singapore Singapore
| | - Jaime Lin
- Department of Endocrinology Woodlands Health Singapore Singapore
| | - Hui Yan Koo
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Julia Choo
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Kai Qiang Low
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Rose Low
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Kavita Venkataraman
- Saw Swee Hock School of Public Health National University of Singapore Singapore Singapore
| | - Josip Car
- Centre for Population Health Sciences. Lee Kong Chian School of Medicine Nanyang Technological University Singapore Singapore
- School of Public Health Imperial College London London UK
| | - Daniel EK Chew
- Department of Endocrinology Tan Tock Seng Hospital Singapore Singapore
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4
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Dai W, Li Y, Huang Z, Lin C, Zhang XX, Xia W. Predictive factors and nomogram to evaluate the risk of below-ankle re-amputation in patients with diabetic foot. Curr Med Res Opin 2022; 38:1823-1829. [PMID: 36107826 DOI: 10.1080/03007995.2022.2125257] [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] [Indexed: 11/03/2022]
Abstract
BACKGROUND Diabetes mellitus, as the most common metabolic disease, is common worldwide and represents a crucial global health concern. The purpose of this research was to investigate the related risk factors and to develop a re-amputation risk nomogram in diabetic patients who have undergone an amputation. METHODS A observational analysis was performed on 459 patients who have underwent amputation for diabetic foot from January 2014 through December 2019 at the First Affiliated Hospital of Wenzhou Medical University. The least absolute shrinkage and selection operator regression and stepwise regression methods were implemented to determine risk selection for the re-amputation risk model, and the predictive nomogram was established with these features. Calibration curve, receiver operating characteristic curve, and decision curve analysis of this re-amputation nomogram were assessed. RESULTS Predictors contained in this predictive model included smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI) and C-reactive protein (CRP). Good discrimination with a C-index of 0.725 (95% CI, 0.6624-0.7876) and good calibration were displayed with this predictive model. The decision curve analysis showed that this re-amputation nomogram predicting risk adds more benefit than none strategy if the threshold probability of a patient was >6% and <59%. CONCLUSIONS This novel re-amputation nomogram incorporating smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI), C-reactive protein (CRP), and smoking could be easily used to predict individual re-amputation risk prediction in diabetic foot patients who have undergone an amputation. In the future, further analysis and external testing will be needed as much as possible to reconfirm that this new Nomogram can accurately predict the risk of toe re-amputation.
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Affiliation(s)
- Wentong Dai
- Burn and Wound Healing Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yuan Li
- Burn and Wound Healing Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zexin Huang
- Department of Endocrinology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Cai Lin
- Burn and Wound Healing Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xing-Xing Zhang
- Department of Endocrinology, The First Affiliated Hospital, Wenzhou Medical University, Wenzhou, China
| | - Weidong Xia
- Burn and Wound Healing Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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5
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Hicks CW, Wang D, Matsushita K, McEvoy JW, Christenson R, Selvin E. Glycated albumin and HbA1c as markers of lower extremity disease inUS adults with and without diabetes. Diabetes Res Clin Pract 2022; 184:109212. [PMID: 35066057 PMCID: PMC8917067 DOI: 10.1016/j.diabres.2022.109212] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 01/12/2022] [Accepted: 01/18/2022] [Indexed: 02/03/2023]
Abstract
AIM We evaluated the associations of two biomarkers of hyperglycemia-hemoglobin A1c(HbA1c) and glycated albumin-with lower extremity disease in US adultsoverall and by diabetes status. METHODS We conducted a cross-sectional study of adult participants aged ≥ 40 years who attended the National Health and Nutrition Examination Survey (NHANES) 1999-2004 (unweighted N = 5,785). We used logistic regression to evaluate the associations of HbA1c and glycated albumin with lower extremity disease: peripheral neuropathy (assessed by monofilament test), peripheral artery disease (assessed by ankle-brachial index), history of foot ulcer, or amputation. All analyses were weighted and accounted for the complex NHANES sample survey design. RESULTS The prevalence of lower extremity disease was 17.4% (15.9% in adults without diabetes and 33.2% in adults with diabetes). HbA1c and glycated albumin were not significantly associated with lower extremity disease in adults without diabetes. However, we observed significant associations of both HbA1c (OR 1.19 per 1-% point increase, 95 %CI 1.06-1.34) and glycated albumin (OR 1.06 per 1-% point increase, 95 %CI 1.02-1.10) with lower extremity disease in adults with diabetes after adjustment. The patterns of association were similar for HbA1c and glycated albumin (P-for-seemingly-unrelated-regression = 0.60), with strong linear associations observed at high (diabetic) levels of both biomarkers. CONCLUSIONS Our study suggests the importance of diabetes prevention and glycemic control in adults with diabetes to reduce the burden of lower extremity disease.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore MD, United States
| | - Dan Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, United States
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, United States
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland, Galway, Ireland
| | - Robert Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore MD, United States
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, United States.
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6
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Almohammadi AA, Alnashri MM, Abdulrahman T Harun R, Alsamiri SM, Alkhatieb MT. Pattern and type of amputation and mortality rate associated with diabetic foot in Jeddah, Saudi Arabia: A retrospective Cohort Study. Ann Med Surg (Lond) 2022; 73:103174. [PMID: 34976392 PMCID: PMC8689050 DOI: 10.1016/j.amsu.2021.103174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/06/2021] [Accepted: 12/06/2021] [Indexed: 01/13/2023] Open
Abstract
Background Diabetic foot complications constitute a major public health problem worldwide, especially in Jeddah, Saudi Arabia, where the prevalence of diabetes is high. Our study was designed to determine the pattern and type of amputations performed on patients with diabetic foot admitted to a tertiary center in Jeddah, Saudi Arabia; we also aimed to determine the 7-year mortality rate of patients with diabetic foot at the same institution. Materials and methods This retrospective study was conducted between January 2013 and September 2020 at a tertiary center in Jeddah, Saudi Arabia. It included all patients previously diagnosed with diabetes mellitus who presented to the hospital with either diabetic foot ulcers or foot gangrene (dry/wet/gas). The medical records of 358 patients were reviewed to acquire information regarding demographics, admission history regarding diabetes and its outcome, medical and surgical history, the level of amputation, and the presence of infection. Results Among the participants, 84.9% underwent amputation, 38.2% underwent minor amputations, 40.1% underwent major amputations, and 21.7% underwent both types of amputation. The most common cause of amputation was infection (50.3%). There were 75 deaths and a 7-year mortality rate of 20%. Low mean hemoglobin and high mean creatinine levels were significantly associated with mortality (p < 0.05). Conclusion Efforts to decrease the risk of amputation and mortality among patients with diabetic foot complications are required. Early detection of the risk factors and intervention in specialist centers with a multidisciplinary approach is essential. Diabetic foot complications are a serious health problem, especially in our society. The risk for lower limb amputation increased significantly with a high hemoglobin A1c. Once infection occurs, the risk of diabetic foot–related amputation significantly increases. Premature death was identified among patients underwent amputation.
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Affiliation(s)
| | | | | | | | - Maram Taha Alkhatieb
- Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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7
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Hallström S, Svensson AM, Pivodic A, Ólafsdóttir AF, Löndahl M, Wedel H, Lind M. Risk factors and incidence over time for lower extremity amputations in people with type 1 diabetes: an observational cohort study of 46,088 patients from the Swedish National Diabetes Registry. Diabetologia 2021; 64:2751-2761. [PMID: 34494137 PMCID: PMC8563633 DOI: 10.1007/s00125-021-05550-z] [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: 02/06/2021] [Accepted: 06/14/2021] [Indexed: 01/30/2023]
Abstract
AIMS/HYPOTHESIS The aim of this work was to study the incidence over time of lower extremity amputations and determine variables associated with increased risk of amputations in people with type 1 diabetes. METHODS Individuals with type 1 diabetes registered in the Swedish National Diabetes Registry with no previous amputation from 1 January 1998 and followed to 2 October 2019 were included. Time-updated Cox regression and gradient of risk per SD were used to evaluate the impact of risk factors on the incidence of amputation. Age- and sex-adjusted incidences were estimated over time. RESULTS Of 46,088 people with type 1 diabetes with no previous amputation (mean age 32.5 years [SD 14.5], 25,354 [55%] male sex), 1519 (3.3%) underwent amputation. Median follow-up was 12.4 years. The standardised incidence for any amputation in 1998-2001 was 2.84 (95% CI 2.32, 3.36) per 1000 person-years and decreased to 1.64 (95% CI 1.38, 1.90) per 1000 person-years in 2017-2019. The incidence for minor and major amputations showed a similar pattern. Hyperglycaemia and renal dysfunction were the strongest risk factors for amputation, followed by older age, male sex, cardiovascular comorbidities, smoking and hypertension. Glycaemic control and age- and sex-adjusted renal function improved during the corresponding time period as amputations decreased. CONCLUSIONS/INTERPRETATION The incidence of amputation and of the most prominent risk factors for amputation, including renal dysfunction and hyperglycaemia, has improved considerably during recent years for people with type 1 diabetes. This finding has important implications for quality of life, health economics and prognosis regarding CVD, indicating a trend shift in the treatment of type 1 diabetes.
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Affiliation(s)
- Sara Hallström
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden.
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Center of Registers in Region Västra Götaland, Gothenburg, Sweden
| | - Aldina Pivodic
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Statistiska Konsultgruppen, Gothenburg, Sweden
| | - Arndís F Ólafsdóttir
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU-Hospital Group, Uddevalla, Sweden
| | - Magnus Löndahl
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Endocrinology, Skane University Hospital, Lund, Sweden
| | - Hans Wedel
- Department of Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Marcus Lind
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, NU-Hospital Group, Uddevalla, Sweden
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8
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Cicek SC, Demir S, Yilmaz D, Yildiz S. Effect of reflexology on ankle brachial index, diabetic peripheral neuropathy, and glycemic control in older adults with diabetes: A randomized controlled trial. Complement Ther Clin Pract 2021; 44:101437. [PMID: 34237668 DOI: 10.1016/j.ctcp.2021.101437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/30/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The purpose of this study was to determine the effect of foot reflexology on ankle brachial index, diabetic peripheral neuropathy and glycemic control in older adults with diabetes. METHODS A randomized controlled, parallel-group trial study was conducted at the outpatient elderly health center in Bolu, Turkey. 48 adults aged 65 and over enrolled in the elderly health center were randomized into two groups in a ratio of 1:1 (experimental, n = 24; control, n = 24). Foot reflexology was performed for 12-week in the experimental group, whereas the control group continued their routine treatment and follow-up. The outcome measures included: (1) ankle brachial index, (2) diabetic peripheral neuropathy measured by a comprehensive foot exam, and (3) glycemic control by a glycated hemoglobin A blood test at baseline and after 12 weeks. RESULTS Post-test diabetic peripheral neuropathy scores (p < 0.001) and glycated hemoglobin A levels (p = 0.002) decreased in the experimental group and increased in the control group. There was no significant between-group difference regarding post-test ankle brachial index scores (p = 0.726). Foot reflexology had a medium effect size on diabetic peripheral neuropathy (95% confidence interval 0.003-2.24; d = 0.51; p < 0.001) and glycated hemoglobin A (95% confidence interval 0.72-1.22; d = 0.52; p = 0.002). CONCLUSIONS A foot reflexology practice can be a useful for improving the glycemic control and diabetic peripheral neuropathy in the older adults with diabetes. TRIAL REGISTRATION NUMBER NCT04416503.
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Affiliation(s)
- Saadet Can Cicek
- Bolu Abant Izzet Baysal University, Faculty of Health Sciences, Nursing Department, Internal Medicine Nursing, Bolu, Turkey.
| | - Seyma Demir
- Bolu Abant Izzet Baysal University, Faculty of Health Sciences, Nursing Department, Internal Medicine Nursing, Bolu, Turkey
| | - Dilek Yilmaz
- Bolu Abant Izzet Baysal University, Izzet Baysal Training and Research Hospital, Department of Neurology, Bolu, Turkey
| | - Sedat Yildiz
- Private Physical Therapy and Rehabilitation Clinic, Isparta, Turkey
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9
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Taloyan M, Momtaz S, Steiner K, Östenson CG, Salminen H. Burning sensation in the feet and glycosylated haemoglobin levels in Swedish- and non-Swedish-born primary healthcare patients. Prim Care Diabetes 2021; 15:522-527. [PMID: 33339766 DOI: 10.1016/j.pcd.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/24/2020] [Accepted: 11/29/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND A painful burning sensation in the feet is a common problem. The most common cause is small fibre neuropathy, a type of peripheral neuropathy that is often a consequence of diabetes and prediabetes. AIM To examine the association between a self-reported burning sensation in the feet and HbA1c levels in primary healthcare patients. METHODS This study used data from patients in the 4D diabetes project in Swedish primary healthcare. The study population included 824 patients. Logistic regression was performed to study the association between the outcome and explanatory variables. RESULTS A total of 24% of patients reported a burning sensation in the feet. This sensation was not associated with HbA1c levels. However, the probability of reporting a burning sensation was two times higher in non-Swedish-born than Swedish-born patients (OR, 2.31; 95% CI, 1.55-3.44) and higher in smokers than those who had never smoked, regardless of region of birth (OR, 1.69; 95% CI, 1.07-2.65). CONCLUSIONS Our results do not support the hypothesis that a self-reported burning sensation in the feet is associated with HbA1c levels. Rather, they indicate a strong relationship between a burning sensation and region of birth, as well as between a burning sensation and smoking.
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Affiliation(s)
- Marina Taloyan
- Division of Family Medicine and Primary Care, Department of Neurobiology, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, S-141 83 Huddinge, Sweden; Academic Primary Health Care Centre, Region Stockholm, Box 45436, 104 31 Stockholm, Sweden.
| | - Shakila Momtaz
- Study Programme in Medicine, Karolinska Institutet, Sweden
| | - Kristin Steiner
- Academic Primary Health Care Centre, Region Stockholm, Box 45436, 104 31 Stockholm, Sweden
| | - Claes-Göran Östenson
- Karolinska Institutet, Department of Molecular Medicine and Surgery, Endocrine and Diabetes Unit, Sweden
| | - Helena Salminen
- Division of Family Medicine and Primary Care, Department of Neurobiology, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels allé 23, S-141 83 Huddinge, Sweden; Academic Primary Health Care Centre, Region Stockholm, Box 45436, 104 31 Stockholm, Sweden
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10
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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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11
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Shatnawi NJ, Al-Zoubi NA, Hawamdeh HM, Khader YS, Heis M, Al Omari M, Bataineh B. The relation of anatomical distribution of symptomatic peripheral arterial disease (PAD) with HbA1c level in patients with type 2 diabetes mellitus. Ther Adv Endocrinol Metab 2021; 12:20420188211000504. [PMID: 33767809 PMCID: PMC7953225 DOI: 10.1177/20420188211000504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 02/12/2021] [Indexed: 11/24/2022] Open
Abstract
AIMS Increased level of glycated hemoglobin (HbA1c) is associated with an increased prevalence of peripheral arterial disease (PAD). This study aimed to assess the relationship between the anatomical distribution of symptomatic PAD lesions in patients with type 2 diabetes and HbA1c levels at the time of PAD diagnosis. PATIENTS AND METHODS A retrospective study was conducted at King Abdullah University Hospital during the period August 2011 to December 2015. Consecutive patients with type 2 diabetes presented with symptomatic PAD confirmed by computed tomography-angiography (CTA) were included in this study. CTA images were reviewed. Relevant information including demographic data, PAD symptoms, comorbidities, HbA1c level, lipid profile, C-reactive protein and the mean platelets volume were retrieved from medical records. RESULTS A total of 332 patients with type 2 diabetes (255 males and 77 females) were included in this study. The mean HbA1c at the time of PAD diagnosis was 8.68% (±2.06%). The prevalence of hemodynamic relevant atherosclerotic lesions of the superficial femoral artery, popliteal artery, leg vessels, femoro-popliteal, and crural segments was significantly higher in patients with HbA1c >7.5% compared with patients with HbA1c ⩽7.5%. CONCLUSION The anatomical distribution of symptomatic PAD in patients with type 2 diabetes mellitus differed significantly according to HbA1c level at the time of PAD diagnosis.
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Affiliation(s)
- Nawaf J. Shatnawi
- Department of Surgery, Jordan University of Science and Technology, University Street, P.O. Box 3030, Irbid 22110, Jordan
| | - Nabil A. Al-Zoubi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Hassan M. Hawamdeh
- Department of Basic Medical Science, Faculty of Medicine, Hashemite University, Zarqua, Jordan
| | - Yousef S. Khader
- Department of Community Medicine, Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mowafeq Heis
- Department of Radiology, Jordan University of Science and Technology, Irbid, Jordan
| | - Mamoon Al Omari
- Department of Radiology, Jordan University of Science and Technology, Irbid, Jordan
| | - Bassem Bataineh
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
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12
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Lo ZJ, Surendra NK, Saxena A, Car J. Clinical and economic burden of diabetic foot ulcers: A 5-year longitudinal multi-ethnic cohort study from the tropics. Int Wound J 2021; 18:375-386. [PMID: 33497545 PMCID: PMC8244009 DOI: 10.1111/iwj.13540] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/29/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot ulcers (DFUs) present a substantial clinical and economic burden to healthcare systems around the world, with significant reductions in quality of life for those affected. We aimed to analyse the clinical and economic burden of DFU via a 5-year longitudinal multi-ethnic cohort study. A longitudinal analysis of inpatient and outpatient DFUs data over 5 years from a university tertiary hospital in Singapore was performed. Data included baseline characteristics, clinical outcomes, hospitalisation, and outpatient details. Descriptive statistics, Kaplan-Meier survival analyses, and Cox proportional hazard models were performed. Patients treated for DFUs (n = 1729, mean patient age of 63·4 years) were assessed. The cohort consists of Chinese (61.4%), Malay (13.5%), and Indian (18.4%) patients. Common comorbidities included peripheral arterial disease (74.8%), peripheral neuropathy (14.5%), and a median haemoglobin A1c of 9.9%. Patients underwent toe(s) amputation (36.4%), transmetatarsal amputations (16.9%), or major amputations (6·5%). The mean length of inpatient stay for ulcer-only, minor amputation, and major amputation was 13.3, 20.5, and 59.6 days, respectively. Mean cost per patient-year was US $3368 (ulcer-only), US $10468 (minor amputation), and US $30131 (major amputation). Minor amputation-free survival was 80.9% at 1 year and 56.9% at 5 years, while major amputation-free survival was 97.4% at 1 year and 91.0% at 5 years. In conclusion, within our multi-ethnic cohort of patients from the tropics, there was significant clinical and economic burden of DFUs, with a high wound per patient ratio and escalating healthcare costs corresponding to more proximal amputation levels.
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Affiliation(s)
- Zhiwen Joseph Lo
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Naren Kumar Surendra
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Akshar Saxena
- School of Social Sciences, Nanyang Technological University, Singapore, Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.,Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
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13
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Lane KL, Abusamaan MS, Voss BF, Thurber EG, Al-Hajri N, Gopakumar S, Le JT, Gill S, Blanck J, Prichett L, Hicks CW, Sherman RL, Abularrage CJ, Mathioudakis NN. Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies. J Diabetes Complications 2020; 34:107638. [PMID: 32527671 PMCID: PMC7721205 DOI: 10.1016/j.jdiacomp.2020.107638] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/05/2020] [Accepted: 05/16/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS Medline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. Ameta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842). RESULTS Of 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses(n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes. CONCLUSIONS Our findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.
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Affiliation(s)
- Kyrstin L Lane
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Betiel Fesseha Voss
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Emilia G Thurber
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Noora Al-Hajri
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Shraddha Gopakumar
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jimmy T Le
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Sharoon Gill
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Jaime Blanck
- Informationist Services, Welch Medical Library, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Laura Prichett
- Biostatistics, Epidemiology and Data Management Core, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Ronald L Sherman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nestoras N Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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14
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Lee A, Haddad D, Rybin D, Howell C, Ghaderi I, Berman S, Zhou W, Tan TW. The impact of hemoglobin A 1c on outcomes after lower extremity bypass. J Vasc Surg 2020; 73:1332-1339.e5. [PMID: 32730894 DOI: 10.1016/j.jvs.2020.05.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 05/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Diabetes has been shown to be associated with increased risk of postoperative complications after lower extremity bypass (LEB), although it is unclear whether medium-term glucose control affects outcomes. This study aimed to assess the association of perioperative hemoglobin A1c (HbA1c) level on perioperative outcomes after LEB. METHODS We examined consecutive infrainguinal LEBs for chronic limb-threatening ischemia (CLTI) using the Vascular Quality Initiative database (2007-2018). Perioperative HbA1c levels were stratified into <5.7%, 5.7% to 6.5%, and >6.5%. Propensity score matching on demographics, medical history, and procedural characteristics was used to select comparable patients across HbA1c groups. The primary outcome was postoperative wound infection. Multivariable analyses were performed for matched and unmatched groups using Cox proportional hazards models for survival outcomes and logistic regression for binary outcomes with association expressed by adjusted hazard ratio (aHR) or adjusted odds ratio (aOR) and corresponding 95% confidence intervals (CIs). RESULTS The CLTI cohort included 8171 infrainguinal LEBs: 631 (7.7%) had HbA1c <5.7%; 1691 (20.6%), 5.7% to 6.5%; and 5849 (71.6%), >6.5%. There was no difference in rates of wound infection in the CLTI cohort (HbA1c ≤5.7%, 3.8%; HbA1c 5.7%-6.5%, 3.7%; HbA1c >6.5%, 3.2%; P = .53) or matched cohort (4.3%, 4.5%, 3.4%; P = .62). There were no differences in perioperative mortality in the CLTI cohort (2.5%, 1.7%, 1.5%; P = .16) or the matched cohort (2.7%, 2.3%, 2.2%; P = .84). In multivariable analysis, there was no significant association between HbA1c and wound infection in the CLTI cohort (HbA1c 5.7%-6.5% vs <5.7%: aOR, 0.91 [95% CI, 0.56-1.50; P = .72]; HbA1c >6.5% vs <5.7%: aOR, 0.81 [95% CI, 0.52-1.26; P = .35]). There was, however, a significant association between decreased HbA1c and mortality (HbA1c 5.7%-6.5% vs <5.7%: aHR, 0.77 [95% CI, 0.61-0.97; P = .03]; HbA1c >6.5% vs <5.7%: aHR, 0.75 [95% CI, 0.61-0.93; P = .01]). CONCLUSIONS Our study suggests no significant association of increased HbA1c level and perioperative complications. Additional investigation is required to further evaluate the impact of short-term glycemic control and long-term outcomes of patients undergoing LEB.
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Affiliation(s)
- Ashton Lee
- Division of Vascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - David Haddad
- Division of Vascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Denis Rybin
- Boston University School of Public Health, Boston, Mass
| | - Caronae Howell
- Division of Vascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Iman Ghaderi
- Division of Vascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | | | - Wei Zhou
- Division of Vascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz
| | - Tze-Woei Tan
- Division of Vascular Surgery, Department of Surgery, University of Arizona College of Medicine, Tucson, Ariz.
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15
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Al-Thani H, El-Matbouly M, Al-Sulaiti M, Al-Thani N, Asim M, El-Menyar A. Does Perioperative Hemoglobin A1c Level Affect the Incidence, Pattern and Mortality of Lower Extremity Amputation? Curr Vasc Pharmacol 2020; 17:354-364. [PMID: 29359671 DOI: 10.2174/1570161116666180123112529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Revised: 05/14/2018] [Accepted: 06/14/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND We hypothesized that perioperative HbA1c influenced the pattern and outcomes of Lower Extremity Amputation (LEA). METHODS A retrospective analysis was conducted for all patients who underwent LEA between 2000 and 2013. Patients were categorized into 5 groups according to their perioperative HbA1c values [Group 1 (<6.5%), Group 2 (6.5-7.4%), Group 3 (7.5-8.4%), Group 4 (8.5-9.4%) and Group 5 (≥9.5%)]. We identified 848 patients with LEA; perioperative HbA1c levels were available in 547 cases (Group 1: 18.8%, Group 2: 17.7%, Group 3: 15.0%, Group 4: 13.5% and Group 5: 34.9%). Major amputation was performed in 35%, 32%, 22%, 10.8% and 13.6%, respectively. RESULTS The overall mortality was 36.5%; of that one quarter occurred during the index hospitalization. Mortality was higher in Group 1 (57.4%) compared with Groups 2-5 (46.9%, 38.3%, 36.1% and 31.2%, respectively, p=0.001). Cox regression analysis showed that poor glycemic control (Group 4 and 5) had lower risk of mortality post-LEA [hazard ratio 0.57 (95% CI 0.35-0.93) and hazard ratio 0.46 (95% CI 0.31-0.69)]; this mortality risk persisted even after adjustment for age and sex but was statistically insignificant. The rate of LEA was greater among poor glycemic control patients; however, the mortality was higher among patients with tight control. CONCLUSION The effects of HbA1c on the immediate and long-term LEA outcomes and its therapeutic implications need further investigation.
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Affiliation(s)
- Hassan Al-Thani
- Department of Surgery, Vascular and Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | | | | | - Noora Al-Thani
- Department of Internal Medicine, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Vascular and Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
| | - Ayman El-Menyar
- Vascular and Trauma Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar.,Department of Clinical Medicine, Weill Cornell Medical College, Doha, Qatar
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16
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Sung JA, Gurung S, Lam T, Yusaf S, Vicaretti M, Begg L, Cheung NW, Padmanabhan S, Girgis CM. A ‘Speed-Dating’ Model of Wound Care? Rapid,
High-Volume Assessment of Patients With Diabetes in a Multidisciplinary Foot
Wound Clinic. Exp Clin Endocrinol Diabetes 2020; 129:837-841. [DOI: 10.1055/a-1151-4731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Abstract
Background Diabetes is a major risk factor for foot ulceration and leg
amputation, but the effect of intensive glycaemic control on wound healing is
unknown. While an interdisciplinary approach has been shown to be important in
the management of diabetic foot ulcer (DFU), there is no standardised definition
of such an interdisciplinary team.
Objective To investigate the role of an opportunistic, rapid-access,
inter-disciplinary model of diabetes care at a foot wound clinic.
Methods A retrospective case-control study of patients with DFUs
attending a diabetes foot wound clinic over a 6-month period. Outcomes in
patients who were seen by a rapid-access interdisciplinary team (RAIT)
consisting of an endocrinologist, diabetes educator and dietician during the
standard wound care those who were not seen by this team were compared.
Results Fifty-five patients were seen by the RAIT and 64 control patients
were not seen by this team during their attendance of a diabetes foot wound
clinic. Patients in the intervention group had non-significantly higher baseline
HbA1c and a significantly larger proportion were active cigarette smokers. Both
groups achieved comparable reduction in the total number of DFUs per patient
(p=0.971). Patients in the intervention group had a 60.1%
reduction in wound size compared to 52.4% reduction in control group
(p=0.526).
Conclusion Our study shows that the use of a rapid-access
interdisciplinary team to assess and manage patients’ diabetes in a foot
wound clinic is feasible. Patients with higher-risk diabetes foot wounds exposed
to RAIT had comparable wound healing outcomes to lower risk patients.
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Affiliation(s)
- Jasper A. Sung
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
| | - Seema Gurung
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
| | - Teresa Lam
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
| | - Shehzi Yusaf
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
| | - Mauro Vicaretti
- Department of Vascular Surgery, Westmead Hospital, Sydney,
Australia
| | - Lindy Begg
- Foot Wound Clinic, Westmead Hospital, Sydney, Australia
| | - N. Wah Cheung
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
- The University of Sydney, Sydney, Australia
| | - Suja Padmanabhan
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
- The University of Sydney, Sydney, Australia
| | - Christian M. Girgis
- Department of Endocrinology and Metabolism, Westmead Hospital, Sydney,
Australia
- The University of Sydney, Sydney, Australia
- Department of Diabetes and Endocrinology, Royal North Shore Hospital,
Sydney, Australia
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17
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Lower Limb Amputations and Revascularisation Procedures in the Hungarian Population: A 14 Year Retrospective Cohort Study. Eur J Vasc Endovasc Surg 2020; 59:447-456. [DOI: 10.1016/j.ejvs.2019.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 10/13/2019] [Accepted: 10/31/2019] [Indexed: 12/13/2022]
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18
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Li CI, Cheng HM, Liu CS, Lin CH, Lin WY, Wang MC, Yang SY, Li TC, Lin CC. Association between glucose variation and lower extremity amputation incidence in individuals with type 2 diabetes: a nationwide retrospective cohort study. Diabetologia 2020; 63:194-205. [PMID: 31686118 DOI: 10.1007/s00125-019-05012-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/23/2019] [Indexed: 01/21/2023]
Abstract
AIMS/HYPOTHESIS Elevated glucose level is one of the risk factors for lower extremity amputation (LEA), but whether glycaemic variability confers independent risks of LEA remains to be elucidated. This study aimed to investigate the association between visit-to-visit glycaemic variability and minor and major LEA risks during 8 years of follow-up in type 2 diabetic individuals aged 50 years and older. METHODS This retrospective cohort study included 27,574 ethnic Chinese type 2 diabetic individuals aged ≥50 years from the National Diabetes Care Management Program in Taiwan. Glycaemic variability measures were presented as the CVs of fasting plasma glucose (FPG-CV) and of HbA1c (A1c-CV). The effect of glycaemic variability on the incidence of LEA events was analysed using Cox proportional hazards models. RESULTS After a median follow-up of 8.9 years, 541 incident cases of LEA with a crude incidence density rate of 2.4 per 1000 person-years were observed. After multivariate adjustment, FPG-CV and A1c-CV were found to be significantly associated with minor LEA, with corresponding HRs of 1.53 (95% CI 1.15, 2.04) and 1.34 (95% CI 1.02, 1.77) for the third tertiles of FPG-CV and A1c-CV, respectively. In addition, these associations were stronger amongst older adults with longer diabetes duration (≥3 years) than amongst those with shorter duration (<3 years) (pinteraction < 0.01). CONCLUSIONS/INTERPRETATION Our study suggests that visit-to-visit variations in HbA1c and FPG are important predictors of minor LEA amongst older adults with type 2 diabetes, particularly for those with more than 3 years of diabetes duration.
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Affiliation(s)
- Chia-Ing Li
- School of Medicine, College of Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Hui-Man Cheng
- School of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung, Taiwan
- Department of Integration of Traditional Chinese and Western Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chiu-Shong Liu
- School of Medicine, College of Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Chih-Hsueh Lin
- School of Medicine, College of Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Wen-Yuan Lin
- School of Medicine, College of Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Mu-Cyun Wang
- School of Medicine, College of Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Shing-Yu Yang
- Department of Public Health, College of Public Health, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan
| | - Tsai-Chung Li
- Department of Public Health, College of Public Health, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan.
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan.
| | - Cheng-Chieh Lin
- School of Medicine, College of Medicine, China Medical University, 91 Hsueh-Shih Road, Taichung, 40402, Taiwan.
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan.
- Department of Family Medicine, China Medical University Hospital, Taichung, Taiwan.
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Lin CW, Hung SY, Huang CH, Yeh JT, Huang YY. Diabetic Foot Infection Presenting Systemic Inflammatory Response Syndrome: A Unique Disorder of Systemic Reaction from Infection of the Most Distal Body. J Clin Med 2019; 8:jcm8101538. [PMID: 31557854 PMCID: PMC6832445 DOI: 10.3390/jcm8101538] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/21/2019] [Accepted: 09/23/2019] [Indexed: 12/23/2022] Open
Abstract
Diabetic foot infection (DFI) is a major complication of diabetic foot that lead to nontraumatic lower-extremity amputation (LEA). Such distal infection of the body having systemic inflammatory response syndrome (SIRS) is rarely reported. Consecutive patients treated for limb-threatening DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 to 2017. Clinical factors, laboratory data, perfusion, extent, depth, infection and sensation (PEDIS) wound score in 519 subjects with grade 3 DFI and 203 presenting SIRS (28.1%) were compared. Major LEA and in-hospital mortality were defined as poor prognosis. Patients presenting SIRS had poor prognosis compared with those with grade 3 DFI (14.3% versus 6.6% for major LEA and 6.4% versus 3.5% for in-hospital mortality). Age, wound size, and HbA1c were independent risk factors favoring SIRS presentation. Perfusion grade 3 (odds ratio 3.37, p = 0.044) and history of major adverse cardiac events (OR 2.41, p = 0.036) were the independent factors for poor prognosis in treating patients with DFI presenting SIRS. SIRS when presented in patients with DFI is not only limb- but life-threatening as well. Clinicians should be aware of the clinical factors that are prone to develop and those affecting the prognosis in treating patients with limb-threatening foot infections.
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Affiliation(s)
- Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Jiun-Ting Yeh
- Department of Plastic surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Chang Gung Memorial Hospital at Linkou, Taoyuan 33305, Taiwan.
- College of Medicine, Chang Gung University, Taoyuan 33305, Taiwan.
- Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan.
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20
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Guo Z, Yue C, Qian Q, He H, Mo Z. Factors associated with lower-extremity amputation in patients with diabetic foot ulcers in a Chinese tertiary care hospital. Int Wound J 2019; 16:1304-1313. [PMID: 31448507 DOI: 10.1111/iwj.13190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022] Open
Abstract
Providing a better understanding of the risk factors for amputation in this particular region, Hunan province, in China might help patients with diabetic foot ulcers receive timely and appropriate medical care and help prevent amputation. Diabetic foot ulcer patients referred to the Third Xiangya Hospital during the period between December 2014 and September 2018 were enrolled. Participants who underwent amputations and received conservative treatments were compared using univariate and multivariate analyses to identify the independent predictors of amputation. Those who required amputation presented significantly higher levels of white blood cell counts, platelet counts, erythrocyte sedimentation rate, C-reactive protein, and glycated haemoglobin (HbA1c) levels. However, levels of haemoglobin, postprandial plasma C-peptide, triglyceride, high-density lipoprotein cholesterol, albumin, and uric acid were decreased in patients with amputations. Patients with more advanced Wagner grades had much higher rates of amputation. Multivariable-adjusted odds ratios in stepwise logistic regression model was 1.317 for HbA1c (95% CI: 1.015-1.709), 0.255 for triglyceride (95% CI: 0.067-0.975), and 20.947 for Wagner grades (95% CI: 4.216-104.080). Independent risk factors for amputation in these Chinese diabetic foot ulcer patients included an elevated HbA1c level, lower triglyceride level, and higher Wagner grades.
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Affiliation(s)
- Zi Guo
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chun Yue
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qiang Qian
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Honghui He
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhaohui Mo
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
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21
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Monteiro-Soares M, Ribeiro-Vaz I, Boyko EJ. Canagliflozin should be prescribed with caution to individuals with type 2 diabetes and high risk of amputation. Diabetologia 2019; 62:900-904. [PMID: 30941448 DOI: 10.1007/s00125-019-4861-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 03/08/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Matilde Monteiro-Soares
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Ribeiro-Vaz
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, Portugal
- Porto Pharmacovigilance Center, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Edward J Boyko
- Veterans Affairs Puget Sound Health Care System (S-123-PCC), 1660 S. Columbian Way, Seattle, WA, 98108, USA.
- University of Washington School of Medicine, Seattle, WA, USA.
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22
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Sørensen MLB, Jansen RB, Wilbek Fabricius T, Jørgensen B, Svendsen OL. Healing of Diabetic Foot Ulcers in Patients Treated at the Copenhagen Wound Healing Center in 1999/2000 and in 2011/2012. J Diabetes Res 2019; 2019:6429575. [PMID: 31583251 PMCID: PMC6754878 DOI: 10.1155/2019/6429575] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/28/2019] [Accepted: 07/02/2019] [Indexed: 12/15/2022] Open
Abstract
AIM To describe differences in healing time of diabetic foot ulcers for patients treated at the Copenhagen Wound Healing Center, Bispebjerg Hospital, between the years 1999/2000 and 2011/2012. The Center is highly specialized and receives diabetes patients with hard-to-heal foot ulcers. A further aim is to attempt to find predictors of healing time of diabetic foot ulcers. METHODS A retrospective descriptive study of records from patients with diabetic foot ulcer treated at the Copenhagen Wound Healing Center in 1999, 2000, 2011, or 2012. Follow-up data was collected until the 3rd of August 2018. RESULTS Median time (range) to healing was 6 (61.3) months in 1999/2000 and 6.6 (67.8) in 2011/2012 (p = 0.2). About 33% of ulcers were healed, 17% were minor or major amputated, and 1.5% were dead within one year in 1999/2000, whereas 30% of ulcers were healed (p = 0.6), 14% were amputated (p = 0.2), and 12.8% were dead within one year in 2011/2012 (p < 0.001). The single factor found significantly associated with longer ulcer duration was infection. Related to shorter ulcer duration were toe localization of the ulcer and good glycemic control. CONCLUSION The median time to healing of a diabetic foot ulcer was long, around 6 months and with a high recurrence rate in 1999/2000 as well as in 2011/2012. Some factors were found to be significantly related to healing time, and intervention addressing these may improve the time to heal, although such interpretations must be taken with precaution from the present study and should be proven in randomized prospective intervention trials.
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Affiliation(s)
- Marie Louise Buhl Sørensen
- Department of Endocrinology I, Copenhagen Diabetes Foot Center, Bispebjerg Hospital, University of Copenhagen, DK-2400 Copenhagen, Denmark
| | - Rasmus Bo Jansen
- Department of Endocrinology I, Bispebjerg Hospital, DK-2400 Copenhagen, Denmark
| | | | - Bo Jørgensen
- Copenhagen Diabetes Foot Center, Bispebjerg Hospital, DK-2400 Copenhagen, Denmark
| | - Ole Lander Svendsen
- Department of Endocrinology I, Bispebjerg Hospital, DK-2400 Copenhagen, Denmark
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23
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Olivieri B, Yates TE, Vianna S, Adenikinju O, Beasley RE, Houseworth J. On the Cutting Edge: Wound Care for the Endovascular Specialist. Semin Intervent Radiol 2018; 35:406-426. [PMID: 30728657 PMCID: PMC6363558 DOI: 10.1055/s-0038-1676342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Clinical outcomes in patients with critical limb ischemia (CLI) depend not only on endovascular restoration of macrovascular blood flow but also on aggressive periprocedural wound care. Education about this area of CLI therapy is essential not only to maximize the benefits of endovascular therapy but also to facilitate participation in the multidisciplinary care crucial to attaining limb salvage. In this article, we review the advances in wound care products and therapies that have granted the wound care specialist the ability to heal previously nonhealing wounds. We provide a primer on the basic science behind wound healing and the pathogenesis of ischemic wounds, familiarize the reader with methods of tissue viability assessment, and provide an overview of wound debridement techniques, dressings, hyperbaric therapy, and tissue offloading devices. Lastly, we explore emerging technology on the horizons of wound care.
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Affiliation(s)
- Brandon Olivieri
- Department of Interventional Radiology, Mount Sinai Medical Center, Miami, Florida
| | - Timothy E. Yates
- Department of Interventional Radiology, Mount Sinai Medical Center, Miami, Florida
| | - Sofia Vianna
- Department of Interventional Radiology, Mount Sinai Medical Center, Miami, Florida
| | | | - Robert E. Beasley
- Department of Interventional Radiology, Mount Sinai Medical Center, Miami, Florida
| | - Jon Houseworth
- School of Podiatric Medicine, Barry University, Miami, Florida
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24
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Álvaro-Afonso FJ, Lázaro-Martínez JL, Papanas N. To Smoke or Not To Smoke: Cigarettes Have a Negative Effect on Wound Healing of Diabetic Foot Ulcers. INT J LOW EXTR WOUND 2018; 17:258-260. [DOI: 10.1177/1534734618808168] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Diabetic foot ulcers (DFUs) have a complex pathophysiology and require an expert multidisciplinary treatment. There are several, both systemic and local, risk factors for DFUs. A recent meta-analysis of 18 studies has now provided robust evidence on the detrimental effect of smoking on healing of DFUs. Indeed, healing rates were consistently lower among smokers than among nonsmokers. Based on this new evidence, it is reasonable to consider the utility of smoking cessation programs. Incorporation of the latter into the holistic therapeutic strategy for DFUs may be anticipated to improve healing rates, but this remains to be shown.
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Affiliation(s)
| | - José Luis Lázaro-Martínez
- Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Nikolaos Papanas
- Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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25
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Fu XL, Ding H, Miao WW, Chen HL. Association Between Cigarette Smoking and Diabetic Foot Healing: A Systematic Review and Meta-Analysis. INT J LOW EXTR WOUND 2018; 17:1534734618809583. [PMID: 30461329 DOI: 10.1177/1534734618809583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The role of smoking for wound healing in patients with diabetic foot has been unclear. This meta-analysis examined the relationship between cigarette smoking and diabetic foot wound healing. Observational studies for the association between smoking and diabetic foot wound healing of patients were systematically searched through PubMed and Wanfang Data, published up to June 2018. Healing rates of wounds were recognized as outcomes. Meta-analysis models were chosen by heterogeneity. A total of 3388 eligible studies were identified, of which 18 met all our inclusion criteria. In the smoking group, healing rate had an average of 62.1%, ranging from 20.0% to 89.6%; in the nonsmoking group, healing rate had an average of 71.5%, ranging from 40.2% to 93.8%. A significant association was found between smoking and the healing of diabetic foot wounds ( z = 3.08; P = .002), with an odds ratio (OR) of 0.70 (95% CI = 0.56-0.88), based on a random-effects model. Meta-regression analyses indicated that the heterogeneity did not come from publication year ( t = -0.50, P = .622) or overall healing rate ( t = 0.16, P = .872). The leave-one-out sensitivity analysis was robust; sensitivity analysis for pooled estimate of adjusted ORs had an OR of 0.20 (95% CI = 0.07-0.56; z = 3.08; P = .002). Subgroup analysis had an OR of 0.62 (95% CI = 0.41-0.95; z = 2.21; P = .027) in retrospective cohort studies and had an OR of 0.75 (95% CI = 0.57-0.99; z = 2.02; P = .043) in prospective cohort studies. Our meta-analysis indicated that smoking had an overall negative effect on the wound healing of diabetic foot individuals. This study provides evidence for the harm of smoking to diabetic foot and may help reduce the medical and economic burden on poor healing of diabetic foot.
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Affiliation(s)
- Xue-Lei Fu
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Hui Ding
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Wei-Wei Miao
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
| | - Hong-Lin Chen
- 1 School of Nursing, Nantong University, Nantong, Jiangsu, People's Republic of China
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26
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Shatnawi NJ, Al-Zoubi NA, Hawamdeh HM, Khader YS, Garaibeh K, Heis HA. Predictors of major lower limb amputation in type 2 diabetic patients referred for hospital care with diabetic foot syndrome. Diabetes Metab Syndr Obes 2018; 11:313-319. [PMID: 29950877 PMCID: PMC6018853 DOI: 10.2147/dmso.s165967] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
PURPOSE This study was conducted to determine the risk factors of major lower extremity amputations in type 2 diabetic patients referred for hospital care with diabetic foot syndrome. PATIENTS AND METHODS This retrospective study involved 225 type 2 diabetic patients referred for management of diabetic foot syndrome at King Abdullah University Hospital in the period between January 2014 and December 2015. A structured customized diabetic foot data collection form with diabetic foot characteristics chart was used for documentation of relevant information, which checks for age, sex, body mass index, smoking, duration of diabetes, diabetic control therapy, associated hypertension, cardiac diseases, stroke, chronic renal impairment, renal replacement therapy (hem-dialysis), and history of diabetes-related complication in both feet prior to the study period. The predictors for major lower limb amputations were compared between groups using chi-square test, and binary logistic regression was used to determine the factors associated with major amputation. RESULTS Twenty-seven limbs underwent major amputations with an overall rate of major amputation of 11.6%. The following predictors were found to be associated with the higher incidence of major lower limb amputations: duration of diabetes ≥15 years, HbA1c ≥8%, patients on insulin, with hypertension, cardiac diseases, chronic renal impairment, stroke, having gangrene, higher number of components, higher Wagner classification, and ischemia. However, the rate did not differ significantly between men and women. CONCLUSION Presentation with gangrenous tissue and poor glycemic control are the important risks and significant predictive factors for type 2 diabetes-related major lower limb amputations.
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Affiliation(s)
- Nawaf J Shatnawi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Nabil A Al-Zoubi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Hassan M Hawamdeh
- Department of Basic Medical Science, Jordan University of Science and Technology, Irbid, Jordan
| | - Yousef S Khader
- Department of Community Medicine, Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Khaled Garaibeh
- Department of Orthopedic Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Hussein A Heis
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
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27
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Yuan Z, DeFalco FJ, Ryan PB, Schuemie MJ, Stang PE, Berlin JA, Desai M, Rosenthal N. Risk of lower extremity amputations in people with type 2 diabetes mellitus treated with sodium-glucose co-transporter-2 inhibitors in the USA: A retrospective cohort study. Diabetes Obes Metab 2018; 20:582-589. [PMID: 28898514 PMCID: PMC5836890 DOI: 10.1111/dom.13115] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/28/2017] [Accepted: 09/01/2017] [Indexed: 01/13/2023]
Abstract
AIMS To examine the incidence of amputation in patients with type 2 diabetes mellitus (T2DM) treated with sodium glucose co-transporter 2 (SGLT2) inhibitors overall, and canagliflozin specifically, compared with non-SGLT2 inhibitor antihyperglycaemic agents (AHAs). MATERIALS AND METHODS Patients with T2DM newly exposed to SGLT2 inhibitors or non-SGLT2 inhibitor AHAs were identified using the Truven MarketScan database. The incidence of below-knee lower extremity (BKLE) amputation was calculated for patients treated with SGLT2 inhibitors, canagliflozin, or non-SGLT2 inhibitor AHAs. Patients newly exposed to canagliflozin and non-SGLT2 inhibitor AHAs were matched 1:1 on propensity scores, and a Cox proportional hazards model was used for comparative analysis. Negative controls (outcomes not believed to be associated with any AHA) were used to calibrate P values. RESULTS Between April 1, 2013 and October 31, 2016, 118 018 new users of SGLT2 inhibitors, including 73 024 of canagliflozin, and 226 623 new users of non-SGLT2 inhibitor AHAs were identified. The crude incidence rates of BKLE amputation were 1.22, 1.26 and 1.87 events per 1000 person-years with SGLT2 inhibitors, canagliflozin and non-SGLT2 inhibitor AHAs, respectively. For the comparative analysis, 63 845 new users of canagliflozin were matched with 63 845 new users of non-SGLT2 inhibitor AHAs, resulting in well-balanced baseline covariates. The incidence rates of BKLE amputation were 1.18 and 1.12 events per 1000 person-years with canagliflozin and non-SGLT2 inhibitor AHAs, respectively; the hazard ratio was 0.98 (95% confidence interval 0.68-1.41; P = .92, calibrated P = .95). CONCLUSIONS This real-world study observed no evidence of increased risk of BKLE amputation for new users of canagliflozin compared with non-SGLT2 inhibitor AHAs in a broad population of patients with T2DM.
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Affiliation(s)
- Zhong Yuan
- Janssen Research & DevelopmentLLCTitusvilleNew Jersey
| | | | | | | | - Paul E. Stang
- Janssen Research & DevelopmentLLCTitusvilleNew Jersey
| | | | - Mehul Desai
- Janssen Research & DevelopmentLLCRaritanNew Jersey
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28
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Gurney JK, Stanley J, York S, Rosenbaum D, Sarfati D. Risk of lower limb amputation in a national prevalent cohort of patients with diabetes. Diabetologia 2018; 61:626-635. [PMID: 29101423 DOI: 10.1007/s00125-017-4488-8] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
AIMS/HYPOTHESIS Lower limb amputation is a serious complication of diabetes mellitus. Understanding how amputation risk differs by population subgroups is crucial in terms of directing preventive strategies. In this study, we describe those factors that impact amputation risk in the entire prevalent diabetic population of New Zealand. METHODS A national prevalent cohort of 217,207 individuals with diabetes in 2010 were followed up until the end of 2013 for lower limb amputations, and 2014 for mortality. Inpatient hospitalisation data were used to define lower limb amputation using ICD-10 codes. Cox proportional hazards models were used to describe relative hazard of amputation over the follow-up period. RESULTS A total of 784 individuals (3.6 cases/1000 individuals) underwent a major (above-ankle) lower limb amputation during follow-up, while 1217 (5.6/1000) underwent a minor (below ankle) amputation. The risk of major and minor amputation was 39% and 77% greater for men than women, respectively (adjusted HR: major amputation 1.39, 95% CI 1.20, 1.61; minor amputation 1.77, 95% CI 1.56, 2.00). Indigenous Māori were at 65% greater risk of above-knee amputation compared with the European/Other diabetic population (HR 1.65, 95% CI 1.37, 1.97). Amputation risk increased with increasing comorbidity burden, and peripheral vascular disease conferred the greatest independent risk of all comorbid conditions. Prior minor amputation increased the risk of subsequent major amputation by tenfold (HR 10.04, 95% CI 7.83, 12.87), and increased the risk of another minor amputation by 20-fold (HR 21.39, 95% CI 17.89, 25.57). Death was common among the total cohort, but particularly among those who underwent amputation, with more than half of those who underwent a major amputation dying within 3 years of their procedure (57%). CONCLUSIONS/INTERPRETATION Using a large, well-defined, national prevalent cohort of people with diabetes, we found that being male, indigenous Māori, living in deprivation, having a high comorbidity burden and/or having a previous amputation were strongly associated with subsequent risk of lower limb amputation. The use of this prevalent cohort strengthens the value of our estimates in terms of applicability to the general population, and highlights the subgroups at greatest risk of lower limb amputation.
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Affiliation(s)
- Jason K Gurney
- Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, 23a Mein St, Newtown, Wellington, New Zealand.
| | - James Stanley
- Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, 23a Mein St, Newtown, Wellington, New Zealand
| | - Steve York
- High Risk Foot Clinic, Northland District Health Board, Whangarei, New Zealand
| | - Dieter Rosenbaum
- Movement Analysis Lab, University Hospital Muenster, Muenster, Germany
| | - Diana Sarfati
- Cancer and Chronic Conditions (C3) Research Group, Department of Public Health, University of Otago, 23a Mein St, Newtown, Wellington, New Zealand
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29
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Shin JY, Roh SG, Lee NH, Yang KM. Influence of Epidemiologic and Patient Behavior–Related Predictors on Amputation Rates in Diabetic Patients. INT J LOW EXTR WOUND 2017; 16:14-22. [DOI: 10.1177/1534734617699318] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Amputation of patients with diabetic foot is a major issue worldwide, particularly from a medical and economic standpoint. This meta-analysis aimed to identify significant risk factors of high amputation rate among epidemiologic and patient behavior–related predictors in diabetic patients. A systematic literature review and meta-analysis were performed using MEDLINE, EMBASE, and Cochrane databases. Seven variables were extracted from the included studies and evaluated based on amputation rate. The Newcastle-Ottawa scale was used to assess the quality of the studies. The search strategy identified 101 publications. After screening, 33 articles were selected for review. Male sex and smoking were identified as significant risk factors of high amputation rate of diabetic foot. Although further investigation of long-term and randomized controlled studies is needed, we identified 2 variables as significant risk factors for high amputation rate in diabetic patients in this meta-analysis.
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Affiliation(s)
- Jin Yong Shin
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Si-Gyun Roh
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Nae-Ho Lee
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
| | - Kyung-Moo Yang
- Medical School of Chonbuk National University, Jeonju, Republic of Korea
- Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea
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30
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İçer M, Durgun HM. Factors Affecting Amputations in Patients with Diabetic Foot Ulcer Referring To the Emergency Units. DICLE MEDICAL JOURNAL 2017. [DOI: 10.5798/dicletip.298615] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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31
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Ang Y, Yap CW, Saxena N, Lin LK, Heng BH. Diabetes-related lower extremity amputations in Singapore. PROCEEDINGS OF SINGAPORE HEALTHCARE 2016. [DOI: 10.1177/2010105816663521] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Lower extremity amputation (LEA) is defined as the complete loss in the transverse anatomical plane of any part of the lower limb. The objective of this study is to look at the trend and mortality trend of LEA performed in diabetes patients from 2008 to 2013. Methods: All patients age 15 and above with diabetes mellitus who had undergone LEAs (both major and minor) in Tan Tock Seng Hospital, Singapore from 1 January 2008 to 31 December 2013 were included. The outcomes of interest were deaths from all causes within 30 days and within 1 year. Results: Major LEA rate has increased from 11.0 per 100,000 population in 2008 to 13.3 per 100,000 population in 2013. The 30-day mortality rate ranges from 6.0% to 11.1% and the 1-year mortality rate ranges from 24.3% to 30.6%. Minor LEA rate has increased from 10.8 per 100,000 population in 2008 to 13.9 per 100,000 population in 2013. The 30-day mortality rate ranges from 1.5% to 3.7% and the 1-year mortality rate ranges from 9.7% to 18.3%. Conclusions: The trends in major and minor LEA are increasing. The 30-day and 1-year mortality for both major and minor LEA are comparable to figures reported worldwide. There is a need to re-look at preventive strategies to reduce LEA in diabetes patients in Singapore.
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Affiliation(s)
- Yee Ang
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Chun Wei Yap
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Nakul Saxena
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Lee-Kai Lin
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Bee Hoon Heng
- Health Services and Outcomes Research, National Healthcare Group, Singapore
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32
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Papanas N, Maltezos E. Glycated Hemoglobin as a Risk Factor for Lower Extremity Amputations in Diabetes: "Success Is Counted Sweetest". INT J LOW EXTR WOUND 2016; 14:106-7. [PMID: 26187323 DOI: 10.1177/1534734615592313] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- N Papanas
- Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - E Maltezos
- Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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