Lower extremity amputations in persons with and without diabetes in Italy: 2001-2010

Using nephropathy as an outcome to determine the HbA1c diagnostic threshold for type 2 diabetes

OBJECTIVE

The hemoglobin A1c (HbA1c) diagnostic threshold for type 2 diabetes (T2D) of 6.5 % (48 mmol/mol) was based on the prevalence of retinopathy found in populations not known to have T2D. It is unclear if nephropathy has a similar HbA1c threshold, partly because it is a rarer complication of early diabetes. This cohort study investigated a very high diabetes prevalence population to determine if a better diagnostic HbA1c value can be established for predicting nephropathy rather than retinopathy in subjects without T2D.

METHODS

The urine albumin:creatinine ratios (UACRs) of 2920 healthy individuals from the Qatar Biobank who had an HbA1c ≥ 5.6 %. were studied. Nephropathy was defined as a UACR≥30 mg/g and its prediction by HbA1c was assessed using cut-points ranging from 5.7 to 7.0 % to dichotomize high from low HbA1c.

RESULTS

Although there was a significant trend for an increased prevalence of abnormal UACR as the HbA1c threshold increased (p < 0.01), significance was due mostly to subjects with HbA1c ≥ 7.0 % (53 mmol/mol). The odds ratios for abnormal UACR were similar over the 5.7-6.9 % HbA1c threshold range, with a narrow odds ratio range of 1.2-1.6. Utilizing area-under-receiver-operating characteristic curves, no HbA1c threshold <7.0 % was identified as the best predictor of nephropathy.

CONCLUSION

Even in a population with a high prevalence of known and unknown diabetes, no HbA1c threshold <7.0 % could be found predicting an increased prevalence of nephropathy. This means there is not a requirement to change the existing retinopathy-based HbA1c threshold of 6.5 % to also accommodate diabetes nephropathy risk.

Predicting the onset of diabetes-related complications after a diabetes diagnosis with machine learning algorithms

AIMS

Using machine learning algorithms and administrative data, we aimed to predict the risk of being diagnosed with several diabetes-related complications after one-, two- and three-year post-diabetes diagnosis.

METHODS

We used longitudinal data from administrative registers of 610,019 individuals in Catalonia with a diagnosis of diabetes and checked the presence of several complications after diabetes onset from 2013 to 2017: hypertension, renal failure, myocardial infarction, cardiovascular disease, retinopathy, congestive heart failure, cerebrovascular disease, peripheral vascular disease and stroke. Four different machine learning (ML) algorithms (logistic regression (LR), Decision tree (DT), Random Forest (RF), and Extreme Gradient Boosting (XGB)) will be used to assess their prediction performance and to evaluate the prediction accuracy of complications changes over the period considered.

RESULTS

610,019 people with diabetes were included. After three years since diabetes diagnosis, the area under the curve values ranged from 60% (retinopathy) to 69% (congestive heart failure), whereas accuracy rates varied between 60% (retinopathy) to 75% (hypertension). RF was the most relevant technique for hypertension, myocardial and retinopathy, and LR for the rest of the comorbidities. The Shapley additive explanations values showed that age was associated with an elevated risk for all diabetes-related complications except retinopathy. Gender, other comorbidities, co-payment levels and age were the most relevant factors for comorbidity diagnosis prediction.

CONCLUSIONS

Our ML models allow for the identification of individuals newly diagnosed with diabetes who are at increased risk of developing diabetes-related complications. The prediction performance varied across complications but within acceptable ranges as prediction tools.

Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot

BACKGROUND

One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital.

METHODS

We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared.

RESULTS

A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001).

CONCLUSIONS

The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

The Elephant in the Room

Despite its increasing prevalence, severity, and mortality, Diabetic foot syndrome (DFS) still remains an unaddressed critical issue. The management of DFS is adequately performed only in few centers, and clinical outcomes vary, depending on the possibility of patients to access optimal standards of care. To focus on the critical aspects of the management of DFS in Italy with the purpose of suggesting arguments that might have a more general audience, to improve the quality of therapy and accessibility to optimal care, we have written this article.

Effect of Early Rehabilitation on Walking Independence and Health-Related Quality of Life in Patients With Chronic Foot Wounds: A Multicenter Randomized Clinical Trial

Rehabilitation is usually provided to patients with chronic foot wounds (CFWs) after surgery. This study aimed to assess whether early postoperative rehabilitation could maintain walking independence in hospitalized patients with CFWs. This single-blind, randomized clinical trial was performed between September 10, 2018 and March 2019, involving 60 patients who underwent both surgical procedures and rehabilitation. Participants were randomly allocated into the early rehabilitation (EG, n = 30) or the control (CG, n = 30) groups. EG received early rehabilitation immediately after surgery, while CG received late rehabilitation after wound closure. Both groups received rehabilitation sessions 5 times per week until discharge. The primary outcome was walking independence, measured via Functional Independence Measure (FIM)-gait scores. Secondary outcomes included health-related quality of life (HRQoL) using EuroQol 5 dimensions 5-level (EQ-5D-5L) and the presence of rehabilitation-related adverse events, including dehiscence of wounds and falls. Differences in intervention timing effects were analyzed using nonparametric split-plot factorial design analysis, including Fisher's exact test, Mann-Whitney U test, and Wilcoxon signed-rank test (P < .05). Out of the 60 participants, 53 patients completed the discharge follow up. Three participants (10.0%) from the EG and 4 (13.3%) from the CG dropped out due to postoperative complications unrelated to rehabilitation intervention. No rehabilitation-related adverse events were found. Participants in the EG maintained greater FIM-gait scores during hospitalization than the CG (difference, -1; P = .0001), with a difference of 0 (P = .109) at discharge. EQ-5D-5L significantly improved in both groups (EG: difference, 0.13 [P = .014], CG: difference, 0.17 [P = .0074]). The EG intervention was associated more with maintaining walking independence at discharge than CG intervention. Postoperative rehabilitation improved HRQoL without adverse events, indicating that clinicians should recommend early rehabilitation for patients with CFW to enhance walking independence.

DIONYSIUS trial: "Does increasing oxygen nurture your symptomatic ischaemic ulcer sufficiently?" Study protocol for an international multicentre randomised trial

INTRODUCTION

Diabetic foot ulcers (DFUs) are a major complication of diabetes and often associated with peripheral arterial occlusive disease. Current available evidence shows hyperbaric oxygen therapy (HBOT) can reduce the risk of major amputation, but clinicians remain sceptical about the (cost-)effectiveness and feasibility of HBOT for ischaemic DFUs in clinical practice. Therefore, vascular surgeons and HBOT physicians worldwide feel a strong need for a sufficiently powered clinical trial to determine whether and how many HBOT sessions may be a (cost-)effective adjunctive treatment to ischaemic DFUs.

METHODS

An international, multicentre, multi-arm multi-stage design is chosen to conduct an efficient randomised clinical trial. Patients will be randomised to receive standard care (wound treatment and surgical interventions following international guidelines) with either 0, 20, 30 or at least 40 sessions of HBOT. These sessions will comprise 90-120 min of HBOT at a pressure of 2.2-2.5 atmospheres absolute according to international standards. Based on a planned interim analysis, the best performing study arm(s) will continue. Primary end point is major amputation (ie, above ankle) rate after 12 months. Secondary end points are amputation-free survival, wound healing, health-related quality of life and cost-effectiveness.

ETHICS AND DISSEMINATION

All patients enrolled in this trial will receive maximum vascular, endovascular or conservative treatment and local wound care according to best practice and (inter)national guidelines. HBOT therapy is added to the standard treatment and is regarded as a low-risk to moderate-risk therapy. The study is approved by the medical ethics committee of the Amsterdam University Medical Centers, location University of Amsterdam.

TRIAL REGISTRATION NUMBER

2020-000449-15, NL9152, NCT05804097.

Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature

Lower limb amputation (LLA) is a major surgical procedure with a significant impact on quality of life and mortality rates as well. Previous studies have shown that mortality rates following LLA can range from 9-17% within 30 days in the UK. This study systematically evaluates and reviews the published literature on life expectancy, mortality, and survival rates following lower extremity amputation (LEA). We have conducted a comprehensive search on Medline, CINAHL, and Cochrane Central databases resulting in 87 full-text articles. After a thorough review, only 45 (52.9%) articles met the minimum inclusion criteria for the study. Our analysis indicated 30-day mortality rates following LEA ranged from 7.1% to 51.4%, with an average mortality rate of 16.45% (SD 14.35) per study. Furthermore, 30-day mortality rates following below-knee amputation (BKA) and above-knee amputation (AKA) were found to be between 6.2% to 51.4%, X= 17.16% ± 19.46 SD and 12.7 to 21.7%, X= 16.15% ± 4.17 SD, respectively. Our review provides a comprehensive insight into the life expectancy, mortality, and survival rates following LEA. These findings highlight the importance of considering various factors, including patient age, presence of comorbidities such as diabetes, heart failure, and renal failure, and lifestyle factors such as smoking, in determining prognosis following LLA. Further research is necessary to determine strategies for improving outcomes and reducing mortality in this patient population.

Longitudinal Gait Analysis of a Transfemoral Amputee Patient: Single-Case Report from Socket-Type to Osseointegrated Prosthesis

The aim of the present case report was to provide a longitudinal functional assessment of a patient with transfemoral amputation from the preoperative status with socket-type prosthesis to one year after the osseointegration surgery. A 44 years-old male patient was scheduled for osseointegration surgery 17 years after transfemoral amputation. Gait analysis was performed through 15 wearable inertial sensors (MTw Awinda, Xsens) before surgery (patient wearing his standard socket-type prosthesis) and at 3-, 6-, and 12-month follow-ups after osseointegration. ANOVA in Statistical Parametric Mapping was used to assess the changes in amputee and sound limb hip and pelvis kinematics. The gait symmetry index progressively improved from the pre-op with socket-type (1.14) to the last follow-up (1.04). Step width after osseointegration surgery was half of the pre-op. Hip flexion-extension range significantly improved at follow-ups while frontal and transverse plane rotations decreased (p < 0.001). Pelvis anteversion, obliquity, and rotation also decreased over time (p < 0.001). Spatiotemporal and gait kinematics improved after osseointegration surgery. One year after surgery, symmetry indices were close to non-pathological gait and gait compensation was sensibly decreased. From a functional point of view, osseointegration surgery could be a valid solution in patients with transfemoral amputation facing issues with traditional socket-type prosthesis.

Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Wearable High Voltage Compliant Current Stimulator for Restoring Sensory Feedback

Transcutaneous Electrical Nerve Stimulation (TENS) is a promising technique for eliciting referred tactile sensations in patients with limb amputation. Although several studies show the validity of this technique, its application in daily life and away from laboratories is limited by the need for more portable instrumentation that guarantees the necessary voltage and current requirements for proper sensory stimulation. This study proposes a low-cost, wearable high-voltage compliant current stimulator with four independent channels based on Components-Off-The-Shelf (COTS). This microcontroller-based system implements a voltage-current converter controllable through a digital-to-analog converter that delivers up to 25 mA to load up to 3.6 kΩ. The high-voltage compliance enables the system to adapt to variations in electrode-skin impedance, allowing it to stimulate loads over 10 kΩ with currents of 5 mA. The system was realized on a four-layer PCB (115.9 mm × 61 mm, 52 g). The functionality of the device was tested on resistive loads and on an equivalent skin-like RC circuit. Moreover, the possibility of implementing an amplitude modulation was demonstrated.

Impact of Sex and Gender on Clinical Management of Patients with Advanced Chronic Liver Disease and Type 2 Diabetes

Gender differences in the epidemiology, pathophysiological mechanisms and clinical features in chronic liver diseases that may be associated with type 2 diabetes (T2D) have been increasingly reported in recent years. This sexual dimorphism is due to a complex interaction between sex- and gender-related factors, including biological, hormonal, psychological and socio-cultural variables. However, the impact of sex and gender on the management of T2D subjects with liver disease is still unclear. In this regard, sex-related differences deserve careful consideration in pharmacology, aimed at improving drug safety and optimising medical therapy, both in men and women with T2D; moreover, low adherence to and persistence of long-term drug treatment is more common among women. A better understanding of sex- and gender-related differences in this field would provide an opportunity for a tailored diagnostic and therapeutic approach to the management of T2D subjects with chronic liver disease. In this narrative review, we summarized available data on sex- and gender-related differences in chronic liver disease, including metabolic, autoimmune, alcoholic and virus-related forms and their potential evolution towards cirrhosis and/or hepatocarcinoma in T2D subjects, to support their appropriate and personalized clinical management.

Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: a review of national rates in the 21st century

AIMS/HYPOTHESIS

Diabetic foot disease (DFD) is a leading cause of hospital admissions and amputations. Global trends in diabetes-related amputations have been previously reviewed, but trends in hospital admissions for multiple other DFD conditions have not. This review analysed the published incidence of hospital admissions for DFD conditions (ulceration, infection, peripheral artery disease [PAD], neuropathy) and diabetes-related amputations (minor and major) in nationally representative populations.

METHODS

PubMed and Embase were searched for peer-reviewed publications between 1 January 2001 and 5 May 2022 using the terms 'diabetes', 'DFD', 'amputation', 'incidence' and 'nation'. Search results were screened and publications reporting the incidence of hospital admissions for a DFD condition or a diabetes-related amputation among a population representative of a country were included. Key data were extracted from included publications and initial rates, end rates and relative trends over time summarised using medians (ranges).

RESULTS

Of 2527 publications identified, 71 met the eligibility criteria, reporting admission rates for 27 countries (93% high-income countries). Of the included publications, 14 reported on DFD and 66 reported on amputation (nine reported both). The median (range) incidence of admissions per 1000 person-years with diabetes was 16.3 (8.4-36.6) for DFD conditions (5.1 [1.3-7.6] for ulceration; 5.6 [3.8-9.0] for infection; 2.5 [0.9-3.1] for PAD) and 3.1 (1.4-10.3) for amputations (1.2 [0.2-4.2] for major; 1.6 [0.3-4.3] for minor). The proportions of the reported populations with decreasing, stable and increasing admission trends were 80%, 20% and 0% for DFD conditions (50%, 0% and 50% for ulceration; 50%, 17% and 33% for infection; 67%, 0% and 33% for PAD) and 80%, 7% and 13% for amputations (80%, 17% and 3% for major; 52%, 15% and 33% for minor), respectively.

CONCLUSIONS/INTERPRETATION

These findings suggest that hospital admission rates for all DFD conditions are considerably higher than those for amputations alone and, thus, the more common practice of reporting admission rates only for amputations may substantially underestimate the burden of DFD. While major amputation rates appear to be largely decreasing, this is not the case for hospital admissions for DFD conditions or minor amputation in many populations. However, true global conclusions are limited because of a lack of consistent definitions used to identify admission rates for DFD conditions and amputations, alongside a lack of data from low- and middle-income countries. We recommend that these areas are addressed in future studies.

REGISTRATION

This review was registered in the Open Science Framework database ( https://doi.org/10.17605/OSF.IO/4TZFJ ).

Demographics and Etiology for Lower Extremity Amputations-Experiences of an University Orthopaedic Center in Germany

Background and Objectives: Currently, the worldwide incidence of major amputations in the general population is decreasing whereas the incidence of minor amputations is increasing. The purpose of our study was to analyze whether this trend is reflected among orthopaedic patients treated with lower extremity amputation in our orthopaedic university institution. Materials and Methods: We conducted a single-center retrospective study and included patients referred to our orthopaedic department for lower extremity amputation (LEA) between January 2007 and December 2019. Acquired data were the year of amputation, age, sex, level of amputation and cause of amputation. T test and Chi² test were performed to compare age and amputation rates between males and females; significance was defined as p < 0.05. Linear regression and multivariate logistic regression models were used to test time trends and to calculate probabilities for LEA. Results: A total of 114 amputations of the lower extremity were performed, of which 60.5% were major amputations. The number of major amputations increased over time with a rate of 0.6 amputation/year. Men were significantly more often affected by LEA than women. Age of LEA for men was significantly below the age of LEA for women (men: 54.8 ± 2.8 years, women: 64.9 ± 3.2 years, p = 0.021). Main causes leading to LEA were tumors (28.9%) and implant-associated complications (25.4%). Implant-associated complications and age raised the probability for major amputation, whereas malformation, angiopathies and infections were more likely to cause a minor amputation. Conclusions: Among patients in our orthopaedic institution, etiology of amputations of the lower extremity is multifactorial and differs from other surgical specialties. The number of major amputations has increased continuously over the past years. Age and sex, as well as diagnosis, influence the type and level of amputation.

Trends in the incidence rates of lower limb amputation due to nondiabetic peripheral artery disease in a large industrial city in Western Siberia, Russia: A review from 1996 to 2019

BACKGROUND

lower limb amputation (LLA) is a growing problem in the population with and without diabetes mellitus. Monitoring the incidence rates of LLA is important for health care planning and has implications for the future problems of medical and social care.

OBJECTIVE

This study aimed to determine the trends in incidence rates of LLA due to nondiabetic peripheral artery disease in Novokuznetsk, Western Siberia, Russia.

STUDY DESIGN

An observational study.

METHODS

Data on all transtibial and transfemoral amputations performed in inpatient facilities in Novokuznetsk from 1996 to 2019 were derived from the regional Register of patients with limb amputations. The rates were calculated per 100,000 population.

RESULTS

A total of 2448 persons with amputations due to nondiabetic peripheral artery disease were included in this study (3191 amputations). The overall incidence rate of LLA in Novokuznetsk increased from 14.6 in 1996 to 30.4 in 2019. The proportion of persons older than 60 years increased from 15.5% in 1996 to 20.3% in 2019.

CONCLUSION

The expected aging of the population and increasing incidence of LLA are relevant issues in Russia. These findings can contribute to improving healthcare services and the development of prevention programs to reverse the alarming trend.

Low Back Pain in People With Lower Limb Amputation: A Cross-Sectional Study

STUDY DESIGN

A cross-sectional study based on an online questionnaire.

OBJECTIVE

The aim was to investigate the prevalence and intensity of low back pain (LBP) in people with lower limb amputation (LLA) and to analyze the association factors that can influence the genesis of LBP.

SUMMARY OF BACKGROUND DATA

It is still unclear whether LBP is more prevalent in the amputated population than in its nonamputated counterpart. Given the multifactorial nature of LBP, it is necessary to explore possible factors that can influence its presence and intensity, to build a solid background to define a better rehabilitation pathway for the management of these people.

METHODS

The online questionnaire included six sections: informed consent of the study, demographic information, comorbid conditions, history of LLA, history of LBP, and acceptance of the amputation.

RESULTS

Between March and June 2021, 239 participants [mean age (SD): 49.2 (11.5); female 11%] completed the survey (response rate: 32%). From the results of this study, LBP in LLA showed a prevalence of 82% postamputation and 70% in the last year. A logistic regression with a backward method showed that participants who had problems in the not affected leg presented 1.58 (95% confidence interval: 0.70; 2.45) times higher odds to have LBP after the amputation.

CONCLUSION

This study shows that the prevalence of LBP in lower limb amputees appears to be higher than in the general population, with similar levels of pain intensity and frequency. The highest percentage of people with a sedentary lifestyle not practicing any kind of sports emphasizes the importance of educating this population on the importance of physical activity. New strategies to invest in the education of this population in terms of physical activity are needed.

LEVEL OF EVIDENCE

Level 4.

Sex- and gender-differences in chronic long-term complications of type 1 and type 2 diabetes mellitus in Italy

AIMS

This review summarizes the contribution of Italian diabetologists devoted to a better understanding of the complex relationship linking sex/gender and long-term complications of type 1 (T1DM) and type 2 diabetes (T2DM) over the last fifteen years.

DATA SYNTHESIS

Microvascular and macrovascular complications of diabetes show sex- and gender-related differences, involving pathophysiological mechanisms, epidemiological features and clinical presentation, due to the interaction between biological and psychosocial factors. These differences greatly impact on the progression of diabetes and its long-term complications, especially in the cardiovascular, renal and liver districts.

CONCLUSION

A better knowledge of such sex- and gender-related characteristics is required for a more precise patient phenotypization, and for the choice of a personalized antihyperglycemic treatment. Despite such mounting evidence, current diabetes clinical guidelines do not as yet adequately consider sex/gender differences.

Diabetic Foot Management: Education of Vascular Surgeons Remains a Priority

Diabetic foot ulcers remain difficult to heal, especially in the setting of peripheral arterial disease (PAD). Vascular surgeons are very important members of the multidisciplinary foot care team. To make the most of their potential, adequate education of vascular trainees on diabetic PAD remains a priority. This should include not only endovascular therapies but also open surgical approaches. Evaluation of trainees' skills, as well as of the educational program itself, is also desirable. Finally, simulation-based training may prove a useful educational tool.

Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

OBJECTIVE

This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes.

METHODS

This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex.

RESULTS

The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations.

CONCLUSION

The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.

Preventive foot self-care practice and associated factors among diabetic patients attending the university of Gondar comprehensive specialized referral hospital, Northwest Ethiopia, 2021

BACKGROUND

Diabetes mellitus is emerging as a major worldwide health problem that has a social, financial, and developmental impact on developing countries. Foot complications are among the most serious and costly complications of diabetes which lead to lower extremity amputation due to diabetic foot ulcers. Poor diabetic foot self-care practice is identified by different studies as a major contributing factor to diabetic foot ulcers. Therefore, this study was intended to assess foot self-care practice and associated factors among diabetic patients attending the University of Gondar comprehensive specialized referral hospital.

METHODS

A hospital-based cross-sectional study was conducted from July 1 to August 30, 2021, at the University of Gondar comprehensive specialized referral hospital. A systematic random sampling technique was employed to select 384 diabetic patients. A structured pretested interviewer-administered questionnaire was used to collect data. The data was entered in epi-info version 7, analyzed using SPSS version 21, and presented using frequencies, percentages, tables, and graphs. Bivariable and multivariable analyses were investigated using a binary logistic regression model. P-value < 0.05 and an odds ratio with a 95% confidence interval were used to determine the significance and strength of the association.

RESULTS

Of the 384 diabetic patients, 46.4% (95% CI (41.1%-51.6%)) of them had poor foot self-care practice. Being male [AOR = 0.54, 95% CI (0.32, 0.89)], couldn't read and write and completed primary education [AOR = 2.35, 95% CI (1.01, 5.43)] & [AOR = 2.92, 95% CI (1.39, 6.12)], living in rural area [AOR = 3.84, 95% CI (1.91, 7.75)], having diabetic complications [AOR = 2.19, 95% CI (1.07, 4.46)], taking both injection and pills [AOR = 0.33, 95% CI (0.12, 0.88)], having previous information about foot care [AOR = 0.12, 95% CI (0.06, 0.24)], and family support [AOR = 0.57, 95% CI (0.34, 0.94)] were determinants of poor foot self-care practice.

CONCLUSION

The adherence of diabetic patients toward foot self-care practice was poor. Being male, having low educational status, living in a rural area, having diabetic-related complications, taking both injections and pills, not having previous information about foot care, and having poor family support increases the odds of having poor foot self-care practice. Giving health education to patients and their caregivers about the basic principles of diabetes foot care, like regular inspection of feet and appropriate footwear at their regular follow-up time, should be emphasized.

Mortality Risk Associated with Diabetic Foot Complications in People with or without History of Diabetic Foot Hospitalizations

The aim of this study was to evaluate the risk of death after hospitalizations for diabetic foot (DF) complications, comparing two different cohorts of people with or without a prior history of DF hospitalizations across the years 2011 to 2018 in Tuscany, Italy. The DF complications were categorized by administrative source datasets such as: amputations (both major and minor), gangrene, ulcers, infections, Charcot and revascularizations. A further aim was to present the trend over time of the first ever incidents of diabetic foot hospitalizations in Tuscany. The eight-year-mortality rate was higher in the cohort with prior hospitalizations (n = 6633; 59%) compared with the cohort with first incident DF hospitalizations (n = 5028; 44%). Amputations (especially major ones) and ulcers had the worst effect on survival in people without basal history of DF hospitalizations and respectively in those with a history of prior DF hospitalizations. In both cohorts, revascularization procedures, when compared to ulcers, were associated with a significantly reduced risk of mortality. The prevalence rate of minor amputations showed a slightly rising trend over time. This result agrees with the national trend. Conversely, the progressive increase over time of revascularizations, associated with the fractional decrease in the rate of gangrene, suggests a trend for more proactive behavior by DF care teams in Tuscany.

Geographic and Ethnic Inequalities in Diabetes-Related Amputations

Individuals with diabetes mellitus are at increasing risk for major lower-extremity amputations (LEAs). Poor quality of life and remarkable disabilities are associated with LEAs, determining a high economic burden for the healthcare systems. Reducing LEAs is therefore a primary marker of quality of care of the diabetic foot. At global level, between-countries comparisons of LEAs rates are basically hampered by differences in criteria used for data collection and analysis among studies. Significant variability in amputation rates exists between geographic areas, and also within specific regions of a country. Overall 5-year mortality rate after major amputations is reported to vary substantially across countries, from 50 to 80%. The odds of LEAs are substantially higher for Black, Native American and Hispanic ethnicities compared with White groups, with similar figures observed in the economically disadvantaged areas compared to more developed ones. Such discrepancies may reflect differences in diabetes prevalence as well as in financial resources, health-care system organization and management strategies of patients with diabetic foot ulcers. Looking at the experience of countries with lower rates of hospitalization and LEAs worldwide, a number of initiatives should be introduced to overcome these barriers. These include education and prevention programs for the early detection of diabetic foot at primary care levels, and the multidisciplinary team approach with established expertise in the treatment of the more advanced stage of disease. Such a coordinated system of support for both patients and physicians is highly required to reduce inequalities in the odd of diabetes-related amputations worldwide.

Trends of Non-Traumatic Lower-Extremity Amputation and Type 2 Diabetes: Spain, 2001-2019

(1) Background: To examine trends in the incidence (2001–2019), clinical characteristics and in-hospital outcomes following major and minor non-traumatic lower-extremity amputations (LEAs) among people with type 2 diabetes mellitus (T2DM) in Spain, assessing possible sex differences. (2) Methods: Retrospective cohort study using data from the Spanish National Hospital Discharge Database. Joinpoint regression was used to estimate incidence trends, and multivariable logistic regression to estimate factors associated with in-hospital mortality (IHM). (3) Results: LEA was coded in 129,059 patients with T2DM (27.16% in women). Minor LEAs accounted for 59.72% of amputations, and major LEAs comprised 40.28%. The adjusted incidences of minor and major LEAs were higher in men than in women (IRR 3.51; 95%CI 3.46–3.57 and IRR 1.98; 95%CI 1.94–2.01, respectively). In women, joinpoint regression showed that age-adjusted incidence of minor LEAs remained stable over time, and for major LEAs, it decreased from 2006 to 2019. In men, incidences of minor and major LEAs decreased significantly from 2004 to 2019. In-hospital mortality (IHM) increased with age and the presence of comorbidity, such as heart failure (OR 5.11; 95%CI 4.61–5.68, for minor LEAs and OR 2.91; 95%CI 2.71–3.13 for major LEAs). Being a woman was associated with higher IHM after minor and major LEA (OR 1.3; 95%CI 1.17–1.44 and OR 1.18; 95%CI 1.11–1.26, respectively). (4) Conclusions: Our data showed major sex differences indicating decreasing and increasing LEA trends among men and women, respectively; furthermore, women presented significantly higher IHM after minor and major LEA procedures than men.

Lower Limb Amputation Rates in Germany

Background and Objectives: The current epidemiology of lower limb amputations is unknown. Therefore, the purpose of this study was to determine (1) lower extremity amputation rates as a function of age, gender, and amputation level between 2015 and 2019, (2) main diagnoses indicating amputation, (3) revision rates after lower extremity amputation. Materials and Methods: Lower extremity amputation rates were quantified based on annual Operation and Procedure Classification System (OPS) and International Classifications of Disease (ICD)-10 codes from all German medical institutions between 2015 through 2019, provided by the Federal Statistical Office of Germany (Destatis). Results: In 2019, 62,016 performed amputations were registered in Germany. Out of these 16,452 procedures (26.5%) were major amputations and 45,564 patients (73.5%) underwent minor amputations. Compared to 2015, the incidence of major amputations decreased by 7.3% to 24.2/100,000 inhabitants, whereas the incidence of minor amputation increased by 11.8% to 67.1/100,000 inhabitants. Highest incidence was found for male patients aged 80-89 years. Patients were mainly diagnosed with peripheral arterial disease (50.7% for major and 35.7% for minor amputations) and diabetes mellitus (18.5% for major and 44.2% for minor amputations). Conclusions: Lower limb amputations remain a serious problem. Further efforts in terms of multidisciplinary team approaches and patient optimization strategies are required to reduce lower limb amputation rates.

Gender Differences in the Risk of Adverse Outcomes After Incident Diabetic Foot Hospitalization: A Population Cohort Study

BACKGROUND

Diabetic Foot Disease (DFD) is more prevalent among males and is associated with an excess risk of cardiovascular events or mortality.

AIMS

This study aimed at exploring the risk of cardiovascular events, renal failure, and all-cause mortality after incident DFD hospitalizations, separately in males and females, to detect any gender difference in a cohort of 322,140 people with diabetes retrospectively followed up through administrative data sources in Tuscany, Italy, over the years 2011-2018.

METHODS

The Hazard Ratio (HR) for incident adverse outcomes after first hospitalizations for DFD, categorized as major/minor amputations (No.=449;3.89%), lower limbs' revascularizations (LLR: No.=2854;24.75%), and lower-extremity-arterial-disease (LEAD) with no procedures (LEAD-no proc: No.=6282;54.49%), was compared to the risk of patients having a background of DFD (ulcers, infections, Charcot-neuroarthropathy: No.=1,944;16.86%).

RESULTS

DFD incidence rate was higher among males compared to females (1.57(95% CI:1.54-1.61) vs. 0.97(0.94-1.00)/100,000p-years]. After DFD, the overall risk of coronary artery disease was significantly associated with the male gender and of stroke with the female gender. LEAD-no proc and LLR were associated with the risk of stroke only in females, whereas they were found to be associated with the risk of coronary artery disease among females to a significantly greater extent compared to males. The incident of renal failure was not associated with any DFD category. Amputations and LEAD-no proc significantly predicted high mortality risk only in females, while LLR showed reduced risk in both genders. Moreover, females had a greater risk of composite outcomes (death or cardiovascular events). Compared to the background of DFD, the risk was found to be 34% higher after amputations (HR: 1.34(1.04-1.72)) and 10% higher after LEAD-no proc (HR:1.10(1.03-1.18)), confirming that after incident DFD associated with vascular pathogenesis, females are at an increased risk of adverse events.

CONCLUSION

After incident DFD hospitalizations, females with DFD associated with amputations or arterial disease are at a greater risk of subsequent adverse cardiovascular events than those with a DFD background.

National Rates of Lower Extremity Amputation in People With and Without Diabetes in a Multi-Ethnic Asian Population: a Ten Year Study in Singapore

OBJECTIVE

Population level data from Asia on amputation rates in people with and without diabetes are extremely limited. Hence it is unclear how the rising diabetes prevalence in Asia has affected the amputation burden. The present study examined national amputation rates in people with and without diabetes in Singapore from 2008 to 2017 in the context of increasing diabetes prevalence and health system changes.

METHODS

This was a retrospective observational study using national population data for ages 16 - 100 years obtained from the Ministry of Health Singapore administrative datasets. Age sex standardised major and toe/ray amputation rates per 100 000 people with diabetes and per 100 000 people without diabetes were calculated. Rates were calculated overall and in each ethnic group (Chinese, Malay, Indian, Others), with trends over time calculated using joinpoint trend analysis. In addition, age specific rates, relative risk (RR) of amputation in diabetics compared with non-diabetics and proportion of amputations in the population attributable to diabetes were also calculated.

RESULTS

Between 2008 and 2017, the database included 3.6 million unique individuals, of whom 75% were Chinese, 8.6% Malay, 7.9% Indian, and 8.4% Others. Of those, 413 486 (11%) had diabetes. Major amputation rates in people with diabetes remained stable (2008: 99.5/100 000; 2017: 95.0/100 000 people with diabetes, p = .91) as did toe/ray amputation rates. Rates in people without diabetes were substantially lower, with major amputation rates decreasing significantly (2008: 3.0/100 000; 2017: 2.1/100 000 people without diabetes, 3% annual reduction, p = .048). Diabetes related amputation rates were highest in Malays and lowest in Chinese. Diabetes related major amputation rates declined significantly among Chinese (3.1% annual reduction, p < .038). While the RR for amputations in diabetes remained stable, the proportion of major amputations attributable to diabetes increased from 63.6% in 2008 to 81.7% in 2017 (3% annual increase, p = .003).

CONCLUSION

Diabetes related major and toe/ray amputation rates have remained stable but relatively high in Singapore compared with other countries, and the proportion of amputations attributable to diabetes has increased over time. More research is needed to understand the aetiopathological, sociocultural, and health system factors that may underlie the continued high rates of diabetes related amputations in this population.

Understanding variations in reported epidemiology of major lower extremity amputation in the UK: a systematic review

OBJECTIVE

Estimate the prevalence/incidence/number of major lower extremity amputations (MLEAs) in the UK; identify sources of routinely collected electronic health data used; assess time trends and regional variation; and identify reasons for variation in reported incidence/prevalence of MLEA.

DESIGN

Systematic review and narrative synthesis.

DATA SOURCES

Medline, Embase, EMcare, CINAHL, The Cochrane Library, AMED, Scopus and grey literature sources searched from 1 January 2009 to 1 August 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Reports that provided population-based statistics, used routinely collected electronic health data, gave a measure of MLEA in adults in the general population or those with diabetes in the UK or constituent countries were included.

DATA EXTRACTION AND SYNTHESIS

Data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Instruments were performed by two reviewers independently. Due to considerable differences in study populations and methodology, data pooling was not possible; data were tabulated and narratively synthesised, and study differences were discussed.

RESULTS

Twenty-seven reports were included. Incidence proportion for the general population ranged from 8.2 to 51.1 per 100 000 and from 70 to 291 per 100 000 for the population with diabetes. Evidence for trends over time was mixed, but there was no evidence of increasing incidence. Reports consistently found regional variation in England with incidence higher in the north. No studies reported prevalence. Differences in database use, MLEA definition, calculation methods and multiple procedure inclusion which, together with identified inaccuracies, may account for the variation in incidence.

CONCLUSIONS

UK incidence and trends in MLEA remain unclear; estimates vary widely due to differences in methodology and inaccuracies. Reasons for regional variation also remain unexplained and prevalence uninvestigated. International consensus on the definition of MLEA and medical code list is needed. Future research should recommend standards for the reporting of such outcomes and investigate further the potential to use primary care data in MLEA epidemiology.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020165592.

Incidence of lower limb amputation in people with and without diabetes: a nationwide 5-year cohort study in Japan

INTRODUCTION

This study was conducted to investigate the incidence and time trend of lower limb amputation (LLA) among people with and without diabetes.

RESEARCH DESIGN AND METHODS

This retrospective population-based cohort study was based on the national claims data in Japan, comprising a total population of 150 million. Data of all individuals who had LLA from April 2013 to March 2018 were obtained. We analysed the sex-adjusted and age-adjusted annual LLA rate (every fiscal year) in people with and without diabetes for major and minor amputation. To test for time trend, Poisson regression models were fitted.

RESULTS

In the 5-year period, 30 187 major and 29 299 minor LLAs were performed in Japan. The sex-adjusted and age-adjusted incidence of major and minor LLAs was 9.5 (people with diabetes, 21.8 vs people without diabetes, 2.3, per 100 000 person-years) and 14.9 (people with diabetes, 28.4 vs people without diabetes, 1.9, per 100 000 person-years) times higher, respectively, in people with diabetes compared with those without. A significant decline in the annual major amputation rate was observed (p<0.05) and the annual minor amputation rate remained stable (p=0.63) when sex, age and people with and without diabetes were included as dependent variables.

CONCLUSIONS

This is the first report of the national statistics of LLAs in Japan. The incidence of major and minor LLAs was 10 and 15 times higher, respectively, in people with diabetes compared with those without. A significant decline in the major amputation rate was observed, and the annual minor amputation rate remained stable during the observation period. This information can help to create an effective national healthcare strategy for preventing limb amputations, which affect the quality of life of patients with diabetes and add to the national healthcare expenditure.

The Burden of Diabetes-Related Preventable Hospitalization: 11-Year Trend and Associated Factors in a Region of Southern Italy

(1) Introduction: Diabetes care is complex and delivered by different care providers in different settings across the healthcare system. Better coordination through all levels of care can lead to better outcomes and fewer hospitalizations. Prevention quality indicators (PQIs) for diabetes allow us to monitor diabetes-related avoidable admissions. The aim of this research is to assess the trend of diabetes-related preventable hospitalizations and associated risk factors in a southern Italian region. (2) Methods: The study considered all hospital admissions performed from 2008 to 2018 in the Abruzzo region, Southern Italy. Data were collected from hospital discharge records. Four different indicators were evaluated as follows: short-term complications (PQI-01), long-term complications (PQI-03), uncontrolled diabetes (PQI-14) and lower-extremity amputations (PQI-16). Joinpoint models were used to evaluate the time trends of standardized rates and the average annual percent change (AAPC). (3) Results: During study period, 8660 DRPH were performed: 1298 among PQI-01, 3217 among PQI-03, 1975 among PQI-14 and 2170 among PQI-16. During the study period, PQI-01and PQI-04 showed decreasing trends. An increasing trend was showed by PQI-16. (4) Conclusions: During an 11-year period, admissions for short-term diabetes complications and for uncontrolled diabetes significantly decreased. The use of standardized tools as PQIs can help the evaluation of healthcare providers in developing preventive strategy.

Economic Impact of COVID-19 Lockdown on Italian NHS: Focus on Diabetes Mellitus

Background

In Italy, the adoption of a total lockdown has generated almost total suspension of outpatient visits except for emergencies. Even after lockdown, the pandemic fear created additional barriers to access the health services. The aim of our study is to evaluate the economic impact of the lockdown for COVID-19 on public health in Italy, focusing on its effects on diabetic population.

Materials and Methods

We analyzed the impact of the lockdown on excess mortality and morbidity in the Italian diabetic population during 2020. The analysis was divided into several steps: a quantification of specialist visit reduction, the calculation of excess mortality in the diabetic population, the economic evaluation of the slowdown in the use of innovative diabetic therapies. Furthermore, the impact of the lockdown on the reduction of procedures and follow-up visits in diabetic population was evaluated. The overall impact of the pandemic and lockdown effects on costs and quality of life was then calculated.

Results

During 2020, a drop of 28% in patient access has been observed. Diabetic patients recorded a twice higher mortality value compared to general population (20.4% vs 10.2%). The analysis of market data revealed a slowdown in consumption of new antidiabetic therapies (−14%, 27% vs 41%). We estimated an expense of €26.6 million for NHS and a loss of 257 utilities in diabetic population due to the missed benefits related to slowdown in innovative antidiabetic drugs use and non-optimal follow-up and control of diabetes complications. In simulation scenarios, we also estimated an overall expenditure ranging from €38.7 to 94.0 million and a loss of 294–836 utilities.

Conclusion

Diabetic population paid a high tribute to pandemic and lockdown, both in terms of number of deaths and burden of diabetic complications, together with an overall deterioration of quality of life.

Sex differences in the association of prediabetes and type 2 diabetes with microvascular complications and function: The Maastricht Study

BACKGROUND

Women with type 2 diabetes are disproportionally affected by macrovascular complications; we here investigated whether this is also the case for microvascular complications and retinal microvascular measures.

METHODS

In a population-based cohort study of individuals aged 40-75 years (n = 3410; 49% women, 29% type 2 diabetes (oversampled by design)), we estimated sex-specific associations, and differences therein, of (pre)diabetes (reference: normal glucose metabolism), and of continuous measures of glycemia with microvascular complications and retinal measures (nephropathy, sensory neuropathy, and retinal arteriolar and venular diameters and dilatation). Sex differences were analyzed using regression models with interaction terms (i.e. sex-by- (pre)diabetes and sex-by-glycemia) and were adjusted for potential confounders.

RESULTS

Men with type 2 diabetes (but not those with prediabetes) compared to men with normal glucose metabolism, (and men with higher levels of glycemia), had significantly higher prevalences of nephropathy (odds ratio: 1.58 95% CI (1.01;2.46)) and sensory neuropathy (odds ratio: 2.46 (1.67;3.63)), larger retinal arteriolar diameters (difference: 4.29 µm (1.22;7.36)) and less retinal arteriolar dilatation (difference: - 0.74% (- 1.22; - 0.25)). In women, these associations were numerically in the same direction, but generally not statistically significant (odds ratios: 1.71 (0.90;3.25) and 1.22 (0.75;1.98); differences: 0.29 µm (- 3.50;4.07) and: - 0.52% (- 1.11;0.08), respectively). Interaction analyses revealed no consistent pattern of sex differences in the associations of either prediabetes or type 2 diabetes or glycemia with microvascular complications or retinal measures. The prevalence of advanced-stage complications was too low for evaluation.

CONCLUSIONS

Our findings show that women with type 2 diabetes are not disproportionately affected by early microvascular complications.

Hospitalization for Short-Term Diabetes-Related Complications: Focus on Patients Aged over 85 Years

(1) Background: The prevalence of diabetes in elderly people is frequently high. When occurring in the elderly, diabetes is often accompanied by complications and comorbidities, at least one in 60% and four or more in 40% of older people with diabetes. As far as short-term complications among the elderly are concerned, hypoglycemia and hyperglycemic crises prove to be frequent. The aim of this study was to investigate the difference in hospitalization for short-term diabetes complications in patients below and over 85 years of age. (2) Methods: Data were collected from hospital discharge records (HDRs) of all hospital admissions that occurred in Abruzzo Region, Italy, from 2006 to 2015. Only diabetic patients aged over 65 years were included. Outcomes included were diabetic ketoacidosis, hyperosmolar coma, hypoglycemic shock, iatrogenic hypoglycemic coma, and other diabetic comas. (3) Results: During the study period, 144,376 admissions were collected, 116,305 (80.56%) of which referred to patients below 85 years. Those aged over 85 years were significantly associated to all short-term diabetes-related complications with the exception of ketoacidosis. (4) Conclusions: In older diabetic patients, the avoidance of short-term diabetes complications are a greater concern than in younger patients. Diabetes management among very elderly patients should be tailored accordingly to patient characteristics.

Twenty-Four-Month Outcomes of Drug-Coated Balloon in Diabetic Patients in the BIOLUX P-III Registry: A Subgroup Analysis

OBJECTIVES

This study aims to assess the use of drug-coated balloon (DCB) in a large patient population under real-world conditions and, specifically, analyse the impact of diabetes mellitus on long term outcomes following DCB utilisation.

METHODS

BIOLUX P-III is a prospective, international, multicentre, registry that was conducted at 41 centres. The present study is a 24-month subgroup analysis of patients with diabetes mellitus having infrainguinal lesions treated with the Passeo-18 Lux DCB. The primary endpoints were freedom from major adverse events (MAEs) within 6 months of intervention and freedom from clinically driven target lesion revascularisation (CD-TLR) within 12 months of intervention.

RESULTS

Of the 882 patients in the registry, 418 had diabetes (516 lesions). Most diabetics had concomitant hypertension (88.8%) and hyperlipidaemia (70.3%). Insulin dependence was observed in 48.8% of diabetics. Moreover, smoking (62.2%) and chronic renal insufficiency (41.9%) were also found to be common in this cohort. Chronic limb threatening ischemia (Rutherford class ≥4) was present in 53.1% of all patients. 22.9% of lesions were infrapopliteal, while 22.5% of lesions were treated for in-stent restenosis. The mean target lesion length was 85.6 ± 73.2 mm, and 79.4% of lesions were calcified (of which 17.9% were heavily calcified). Overall, device success was 99.7%. Freedom from MAEs was 90.5% (95% confidence interval (95% CI): 87.2-93.0) at 6 months, 85.4% (95% CI: 81.5-88.6) at 12 months and 80% (95% CI: 75.5-83.8) at 24 months. Freedom from CD-TLR was 95.9% (95% CI: 93.8-97.4), 91.6% (95% CI: 88.7-93.8), and 87.1% (95% CI: 83.5-89.9) at 6, 12, and 24 months, respectively. All-cause mortality at 24 months in diabetics was 16.0% (95% CI: 12.6-20.2), and major target limb amputation was 6.1% (95% CI: 4.1-8.9), which was significantly higher than in non-diabetics (8.4% (95% CI: 6.0-11.6), P = 0.0005 and 1.2% (95% CI: 0.5-2.9), P <0.0001, respectively). At 24 months, 82.0% of patients had improved by ≥1 Rutherford class.

CONCLUSION

Treatment of a real-world diabetic patient population with the Passeo-18 Lux DCB resulted in high efficacy and low complication rates, despite the fact that diabetic patients usually suffer from a multitude of concomitant comorbidities.

CLINICAL TRIAL REGISTRATION

NCT02276313.

How patients interpret early signs of foot problems and reasons for delays in care: Findings from interviews with patients who have undergone toe amputations

Aims

To describe how patients respond to early signs of foot problems and the factors that result in delays in care.

Methods

Semi-structured interviews were conducted with a large sample of Veterans from across the United States with diabetes mellitus who had undergone a toe amputation. Data were analyzed using inductive content analysis.

Results

We interviewed 61 male patients. Mean age was 66 years, 41% were married, and 37% had a high school education or less. The patient-level factors related to delayed care included: 1) not knowing something was wrong, 2) misinterpreting symptoms, 3) “sudden” and “unexpected” illness progression, and 4) competing priorities getting in the way of care-seeking. The system-level factors included: 5) asking patients to watch it, 6) difficulty getting the right type of care when needed, and 7) distance to care and other transportation barriers.

Conclusion

A confluence of patient factors (e.g., not examining their feet regularly or thoroughly and/or not acting quickly when they noticed something was wrong) and system factors (e.g., absence of a mechanism to support patient’s appraisal of symptoms, lack of access to timely and convenient-located appointments) delayed care. Identifying patient- and system-level interventions that can shorten or eliminate care delays could help reduce rates of limb loss.

The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis

AIM

To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM).

METHODS

In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively.

RESULTS

The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14).

CONCLUSIONS

Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.

Modern multidisciplinary team approach is crucial in treatment for critical limb threatening ischemia

The aim of this study was to provide a brief overview of the history the multidisciplinary team approach, highlighting the benefit to the patient with critical limb threatening ischemia in relation to health care economics. Furthermore, we provided a description of the requisites and key components, showing how to build a multidisciplinary team.

The impact of gender on diabetes-related lower extremity amputations: An Italian regional analysis on trends and predictors

BACKGROUND

Diabetes-related lower extremity amputations (LEAs) are a major public health issue. The aim of the study was to evaluate trends by gender and predictors of LEAs in an Italian region.

METHODS

Data were collected from hospital discharge records between 2006 and 2015. Gender- and age-adjusted standardised hospitalisation rates for major and minor amputations were calculated. Poisson regression model was performed to estimate trends in LEAs.

RESULTS

Hospitalisation rates decreased for minor amputations both among males (-30.0%) and females (-5.3%), while the major amputation rates decreased only for males (-44.7%). Males were at higher risk of undergoing major (IRR 1.41, 95%CI 1.19-1.67) and minor (IRR 1.62, 95%CI 1.45-1.82) amputations. Peripheral vascular disease was the leading predictor of major and minor amputations.

CONCLUSION

A significant reduction of LEAs was observed only for males. Identifying their predictable factors may help caregivers to provide higher standards of diabetes care.

Gender Difference in the Risk of Adverse Outcomes After Diabetic Foot Disease: A Mini-Review

Diabetic foot disease (DFD) is a complication of diabetes mellitus, characterized by multiple pathogenetic factors, bearing a very high burden of disability as well as of direct and indirect costs for individuals or healthcare systems. A further characteristic of DFD is that it is associated with a marked risk of subsequent hospitalizations for incident cardiovascular events, chronic renal failure or of allcause mortality. Additionally, DFD is strongly linked to the male sex, being much more prevalent among men. However, even if DFD mainly affects males, several past reports suggest that females are disadvantaged as regards the risk of subsequent adverse outcomes. This review aims to clarify this point, attempting to provide an explanation for this apparent oddity: being DFD a typically male complication of diabetes but, seemingly, with a greater load of subsequent consequences for females.

Epidemiology of major lower extremity amputations in individuals with diabetes in Austria, 2014-2017: A retrospective analysis of health insurance database

AIMS

To describe the incidence, mortality, and trend of major lower extremity amputations (LEA) and to assess risk factors of all-cause mortality after major LEA in individuals with diabetes.

METHODS

Procedure codes of major LEA were extracted from the Austrian Health Insurance database (N = 507,180) during 2014-2017 to estimate crude and age-standardized rates per 100,000 population. Short- (30-day, 90-day) and long-term (1-year, 5-year) all-cause mortality after major LEA was estimated from the date of amputation till the date of death.

RESULTS

The age-standardized rate of major LEA was 6.44 with an insignificant annual change of 3% (p = 0.825) from 2014 to 2017. Cumulative 30-day mortality was 13.5%, 90-day 22.0%, 1-year 34.4%, and 5-year 66.7%. Age, male sex, above-knee amputation, Charlson index, and heart failure were significantly associated with both short- and long-term mortality. Cancer, dementia, heart failure, peripheral vascular disease, and renal disease were associated with long-term mortality.

CONCLUSIONS

The rate of major LEA in individuals with diabetes remained stable during 2014-2017 in Austria. Short- and long-term mortality rates were considerably high after major LEA. Old age, male sex, above-knee amputations, and Charlson Index were significant predictors of both short- and long-term mortality and comorbidities were significant predictors of long-term mortality only.

Age- and sex-specific incidence of non-traumatic lower limb amputation in patients with type 2 diabetes mellitus in a U.S. claims database

AIM

To estimate age- and sex-specific incidence rates (IRs) of non-traumatic lower limb amputations (LLA) in patients with type 2 diabetes mellitus (T2DM) using a claims database from the United States (US).

METHODS

Patients with T2DM 18 years and older were identified using the Truven Health MarketScan database from January 1, 2007 to September 30, 2018. The overall and age- and sex-specific IRs of all non-traumatic LLA, minor LLA (amputation at or below the ankle), and major LLA (amputation above ankle) were calculated.

RESULTS

Among the 6,117,981 patients with T2DM, 14,627 LLA events occurred (minor LLA; 72.8%; major LLA: 27.2%). The IRs (95% CI) of all LLA, minor LLA, and major LLA per 1000 person-years or PY were 0.86 (0.85, 0.88), 0.63 (0.62, 0.64), and 0.23 (0.23, 0.24), respectively. The IR (95% CI) of all LLA per 1000 PY in males was higher compared to females [1.24 (1.22, 1.26) vs. 0.46 (0.45, 0.48)]. The incidence of all LLA increased with an increasing age (highest IR in age-group of ≥80 years).

CONCLUSIONS

This study identified males and older patients with T2DM at higher risk of developing LLA in the US, warranting further exploration of risk factors of LLA in these subgroups.

Analysis of Diabetes Mellitus-Related Amputations in the State of Espírito Santo, Brazil

Background and objectives: Diabetes mellitus (DM) stands out among the most important public health problems worldwide since it represents a high burden on health systems and is associated with higher hospitalization rates, and a higher incidence of cardiovascular diseases. Amputations are among the most common complications, leading to disability and increasing care costs. This research aims to analyze the prevalence of DM-related amputations, comorbidities and associated risk factors in the diabetic population residing in the State of Espírito Santo, Brazil. Materials and Methods: This is a quantitative, exploratory, cross-sectional study with a time series design and the use of secondary data registered and followed by the system of Registration and Monitoring of Hypertension and Diabetes-SisHiperdia. Results: The sample consisted of 64,196 diabetic patients, out of them, 3.9% had type 1 DM, 10.9% with type 2 DM, and 85.2% with DM coexisting with hypertension. Most were female (66.6%), aged 40 to 59 years (45.6%), and 60 years and older (45.2%). The prevalence of DM-related amputations in the analyzed sample was 1.2% in type 1 DM, 1.5% in type 2 DM, and 2.2% in concomitant DM and hypertension. Higher amputation rates were observed in males in the age group above 60 years in type 1 DM and type 2 DM and were slightly higher in the age groups up to 29 years in DM with hypertension. A higher prevalence of amputation was related to smoking, physical inactivity, acute myocardial infarction (AMI), stroke, chronic kidney disease (CKD), and diabetic foot (DF) in all types of DM. Conclusions: The present study showed a significant prevalence of DM-related amputations. An increased prevalence was evidenced when correlated with smoking, physical inactivity, AMI, stroke, CKD, and DF with significant statistical associations, except for a sedentary lifestyle in type 1 DM.

Risk of Ipsilateral Reamputation Following an Incident Toe Amputation Among U.S. Military Veterans With Diabetes, 2005-2016

OBJECTIVE

To assess whether the risk of subsequent lower-limb amputations and death following an initial toe amputation among individuals with diabetes has changed over time and varies by demographic characteristics and geographic region.

RESEARCH DESIGN AND METHODS

Using Veterans Health Administration (VHA) electronic medical records from 1 October 2004 to 30 September 2016, we determined risk of subsequent ipsilateral minor and major amputation within 1 year after an initial toe/ray amputation among veterans with diabetes. To assess changes in the annual rate of subsequent amputation over time, we estimated age-adjusted incidence of minor and major subsequent ipsilateral amputation for each year, separately for African Americans (AAs) and whites. Geographic variation was assessed across VHA markets (n = 89) using log-linear Poisson regression models adjusting for age and ethnoracial category.

RESULTS

Among 17,786 individuals who had an initial toe amputation, 34% had another amputation on the same limb within 1 year, including 10% who had a major ipsilateral amputation. Median time to subsequent ipsilateral amputation (minor or major) was 36 days. One-year risk of subsequent major amputation decreased over time, but risk of subsequent minor amputation did not. Risk of subsequent major ipsilateral amputation was higher in AAs than whites. After adjusting for age and ethnoracial category, 1-year risk of major subsequent amputation varied fivefold across VHA markets.

CONCLUSIONS

Nearly one-third of individuals require reamputation following an initial toe amputation, although risks of subsequent major ipsilateral amputation have decreased over time. Nevertheless, risks remain particularly high for AAs and vary substantially geographically.

An in-depth assessment of diabetes-related lower extremity amputation rates 2000-2013 delivered by twenty-one countries for the data collection 2015 of the Organization for Economic Cooperation and Development (OECD)

BACKGROUND

International comparisons of diabetes-related lower extremity amputation rates are still hampered by different criteria used for data collection and analysis. We aimed to evaluate trends and variation of major/minor amputations, using agreed definitions adopted by the Organization for Economic Cooperation and Development in 2015.

METHODS

Direct age-sex standardized rates were calculated per 100,000 subjects per year between 2000 and 2013, using major/minor amputations with diabetes diagnosis as numerators and the total population or number of people with diabetes as denominators. Longitudinal trends were investigated using generalized estimating equations.

RESULTS

Twenty-one countries reported major amputations referred to the general population, showing a mean reduction from 10.8 to 7.5 per 100,000 (- 30.6%). Eleven countries also reported major amputations among people with diabetes, showing a mean reduction from 182.9 to 128.3 per 100,000 (- 29.8%). Minor amputations remained stable over the study period. Longitudinal trends showed a significant average annual decrease of - 0.19 per 100,000 in the general population (95% CI - 0.36 to - 0.02; p = .03) and - 4.52 per 100,000 among subjects with diabetes (95% CI - 6.09 to - 2.94; p < .001). The coefficient of variation of major amputation rates between countries was fairly high (64%-in the total population, 67% among people with diabetes).

CONCLUSIONS

The study highlighted a clinically significant reduction of major amputations, in both the general population and among people with diabetes. The use of standardized definitions, while increasing the comparability of multinational data, highlighted remarkable differences between countries. These results can help identifying and sharing best practices effectively on a global scale.

Cross-cultural adaptation and measurement properties of the French version of the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R)

BACKGROUND

The Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) is a self-administered questionnaire to measure multidimensional adjustment to a prosthetic limb. Our aim was to assess the validity and reliability of the French version of the TAPES-R (TAPES-R-F).

MATERIALS AND METHODS

The cross-cultural adaptation was performed according to the recommendations. Factor analysis and Rasch analysis were also performed to allow comparison with the original English version. Construct validity was assessed by measuring the correlations between TAPES-R-F subscores and quality of life, pain, body image satisfaction, anxiety and depression. Internal consistency was measured with Cronbach's α. The standard error of measurement, smallest detectable change, Bland and Altman limits of agreement, and intraclass correlation were the measures of agreement and reliability.

RESULTS

No major difficulties were encountered throughout the trans-cultural adaptation process. The final version of the TAPES-R-F was well accepted and understood by the patients. According to the factor analysis, the satisfaction scale should be treated as a one-dimensional construct when used by French-speaking people and should not be separated into two separate subscales, functional and aesthetic, as is the case in the original English version. Our study confirmed that there is a strong relationship between biopsychosocial factors and adjustment to amputation. Cronbach's α > 0.8 for all the subscales. Reliability was good to excellent for all the subscales (ICCs between 0.61 and 0.89). The smallest detectable changes were 0.7, 0.8, 1.3, 0.4, and 1.8 (general adjustment, social adjustment, adjustment to limitation, activity restriction, and global satisfaction with the prosthesis).

CONCLUSIONS

The TAPES-R-F is a valid and reliable instrument to assess multidimensional adjustment of French-speaking lower limb amputees. This questionnaire can be used for both clinical assessment and research purposes.

Physician experts in diabetes are natural team leaders for managing diabetic patients with foot complications. A position statement from the Italian diabetic foot study group

Diabetic foot syndrome (DFS) is a complex disease. The best outcomes are reported with the multi-disciplinary team (MDT) approach, where each member works collaboratively according to his/her expertise. However, which health provider should act as the team leader (TL) has not been determined. The TL should be familiar with the management of diabetes, related complications and comorbidities. He/she should be able to diagnose and manage foot infections, including prompt surgical treatment of local lesions, such as abscesses or phlegmons, in an emergent way in the first meeting with the patient. According to the Organization for Economic Co-operation and Development (OECD) reports, Italy is one of countries with a low amputation rate in diabetic patients. Many factors might have contributed to this result, including 1)the special attention directed to diabetes by the public health system, which has defined diabetes as a "protected disease", and accordingly, offers diabetic patients, at no charge, the best specialist care, including specific devices, and 2)the presence of a network of diabetic foot (DF) clinics managed by diabetologists with medical and surgical expertise. The health care providers all share a "patient centred model" of care, for which they use their internal medicine background and skills in podiatric surgery to manage acute or chronic needs in a timely manner. Therefore, according to Italian experiences, which are fully reported in this document, we believe that only a skilled diabetologist/endocrinologist should act as a TL. Courses and university master's degree programmes focused on DF should guarantee specific training for physicians to become a TL.

Analysis of the Peri-Operative Cost of Non-Traumatic Major Lower Extremity Amputation in Jordan

Purpose

Non-traumatic major lower extremity amputation (NMLEA) is a commonly performed procedure that presents a substantial cost burden. Patients who undergo NMLEA are usually considered as a high-risk group with significant comorbidities, which translates into a protracted peri-operative course and increased health-care costs. The primary aim of this study was therefore to perform a contemporary peri-operative cost analysis of NMLEA performed in our center. We are a major tertiary referral hospital that provides vascular surgery services to the entire northern counties in Jordan. We also aimed to assess the various factors that influence the cost of NMLEA in less economically developed countries.

Methods

Records of all patients who underwent NMLEA at King Abdullah University Hospital between January 2012 and December 2017 were retrieved. Total inpatient cost was calculated and analyzed against different patients' variables.

Results

A total of 140 patients underwent NMLEA between 2012 and 2017 in our facility. Below-knee amputations accounted for 110 cases, while above-knee amputations included 30 patients. Approximately two-thirds of the cases (61.4%) were males, with average age of the patients being approximately 62.9 years. The commonest comorbidities were diabetes mellitus and hypertension, which were recorded in 89.3% and 80.3% of the patients, respectively. The average operative time was 133.0 ± 10.8 mins, and the average length of stay (LOS) was 6.7±0.4 days. The mean cost for amputations was 4904.7± 429.3 United States dollars. Multiple linear regression analysis demonstrated that LOS and admission-to-operation time were the independent predictors of cost.

Conclusion

Delayed amputations and prolonged LOS remain the most important determinants for the peri-operative cost of NMLEA. When amputation is deemed inevitable, an expedited multidisciplinary approach may possibly reduce undue delays and result in cost-effective delivery of this age-old remedy.

The current state of bionic limbs from the surgeon's viewpoint

Amputations have a devastating impact on patients' health with consequent psychological distress, economic loss, difficult reintegration into society, and often low embodiment of standard prosthetic replacement.The main characteristic of bionic limbs is that they establish an interface between the biological residuum and an electronic device, providing not only motor control of prosthesis but also sensitive feedback.Bionic limbs can be classified into three main groups, according to the type of the tissue interfaced: nerve-transferred muscle interfacing (targeted muscular reinnervation), direct muscle interfacing and direct nerve interfacing.Targeted muscular reinnervation (TMR) involves the transfer of the remaining nerves of the amputated stump to the available muscles.With direct muscle interfacing, direct intramuscular implants record muscular contractions which are then wirelessly captured through a coil integrated in the socket to actuate prosthesis movement.The third group is the direct interfacing of the residual nerves using implantable electrodes that enable reception of electric signals from the prosthetic sensors. This can improve sensation in the phantom limb.The surgical procedure for electrode implantation consists of targeting the proximal nerve area, competently introducing, placing, and fixing the electrodes and cables, while retaining movement of the arm/leg and nerve, and avoiding excessive neural damage.Advantages of bionic limbs are: the improvement of sensation, improved reintegration/embodiment of the artificial limb, and better controllability. Cite this article: EFORT Open Rev 2020;5:65-72. DOI: 10.1302/2058-5241.5.180038.

Incidence of hospitalization and mortality in patients with diabetic foot regardless of amputation: a population study

AIMS

The aim of our study was to estimate the overall rate of first hospitalizations for diabetic foot (DF) regardless of the outcome in amputations, as well as the mortality rate with their determinants in the period 2012-2016 in Piedmont Region in Italy.

METHODS

The study included all the subjects registered in the Regional Diabetes Registry and alive as at January 1, 2012. DF cases were identified by record linkage with the regional hospital discharge database. Incident cases of diabetic foot were followed up for mortality.

RESULTS

The 5-year rates were 1762, 324, and 343 × 100,000 patients for first hospitalization without amputations, with major amputations, and with minor amputations, respectively. Patients not undergoing amputations were more than 70% of the cohort. Patients with the more severe stages of diabetes and those with low education were at higher risk of each type of hospitalization. The risk of death during a mean follow-up of 2.5 years was about 16, 18, and 30% among patients without amputations, with major amputations, and with minor amputations, respectively. Males, insulin-treated patients, those affected with severe diabetes complications, particularly on dialysis, and those with lower levels of education were at higher risk.

CONCLUSIONS

The heavier burden of DF on hospitalizations is due to cases without amputation, a condition that is seldom considered in the diabetes literature. The severity of diabetes, preexisting complications, and low educational levels are associated with both first hospitalization and subsequent survival at any level of severity of DF.

Major amputations in type 2 diabetes between 2001 and 2015 in Spain: regional differences

Background

To analyze the trend of lower extremity major amputations (MA) among patients with type 2 diabetes mellitus (T2DM) in the Regions of Spain from year 2001 until 2015.

Methods

Descriptive study of 40,392 MA. Data were obtained from the national hospital discharge database in patients with T2DM. The incidence rate was calculated in each Region, in addition to the incidence ratios (IR) between annual incidence and incidence of the year 2001. The length of hospital stay and mortality risks were analyzed using regression models adjusted for sex, age and smoking.

Results

The major amputations incidence rate per 100,000 person-years was 0.48 in Spain; Canary Islands showed the highest incidence (0.81). The trend was a slight decrease or stability of the incidence in all Regions except in the Canary Islands (IR₂₀₁₅ = 2.0 [CI95% = 1.5, 2.6]) and in Madrid (IR₂₀₁₅ = 0.1 [CI95% = 0.1, 0.2]). Mortality after major amputations was 10% in Spain; Cantabria suffered the highest risk of death [1.7 (CI95% = 1.4; 2.1), p < 0.001] and La Rioja the lowest risk (0.5 [CI95% = 0.2; 0.9]; p = 0.026). The longest hospital stay was registered in the Canary Islands [(CI95% = 11.4;13.3], p < 0.001)], and the shortest in the Valencian Community [(CI95% = − 7.3; − 5.8), p < 0.001)].

Conclusion

MA in T2DM followed a growing trend in the Canary Islands, which diverged from the downward trend in Spain. The variability of mortality and hospital stay, suggest to review the clinical management in some Regions. Sudden incidence decrease in Madrid suggests checking the record procedures of hospital discharges.