Mortality and hospitalization in patients after amputation: a comparison between patients with and without diabetes

Association of remoteness and ethnicity with major amputation following minor amputation to treat diabetes-related foot disease

INTRODUCTION

Minor amputation is commonly needed to treat diabetes-related foot disease (DFD). Remoteness of residence is known to limit access to healthcare and has previously been associated with poor outcomes. The primary aim of this study was to examine the associations between ethnicity and remoteness of residency with the risk of major amputation and death following initial treatment of DFD by minor amputation. A secondary aim was to identify risk factors for major amputation and death following minor amputation to treat DFD.

RESEARCH DESIGN AND METHODS

This was a retrospective analysis of data from patients who required a minor amputation to treat DFD between 2000 and 2019 at a regional tertiary hospital in Queensland, Australia. Baseline characteristics were collected together with remoteness of residence and ethnicity. Remoteness was classified according to the 2019 Modified Monash Model (MMM) system. Ethnicity was based on self-identification as an Aboriginal and Torres Strait Islander or non-Indigenous person. The outcomes of major amputation, repeat minor amputation and death were examined using Cox-proportional hazard analyses.

RESULTS

A total of 534 participants were included, with 306 (57.3%) residing in metropolitan or regional centres, 228 (42.7%) in rural and remote communities and 144 (27.0%) were Aboriginal or Torres Strait Islander people. During a median (inter quartile range) follow-up of 4.0 (2.1-7.6) years, 103 participants (19.3%) had major amputation, 230 (43.1%) had repeat minor amputation and 250 (46.8%) died. The risks (hazard ratio [95% CI]) of major amputation and death were not significantly higher in participants residing in rural and remote areas (0.97, 0.67-1.47; and 0.98, 0.76-1.26) or in Aboriginal or Torres Strait Islander people (HR 1.44, 95% CI 0.96, 2.16 and HR 0.89, 95% CI 0.67, 1.18). Ischemic heart disease (IHD), peripheral artery disease (PAD), osteomyelitis and foot ulceration (p<0.001 in all instances) were independent risk factors for major amputation.

CONCLUSION

Major amputation and death are common following minor amputation to treat DFD and people with IHD, PAD and osteomyelitis have an increased risk of major amputation. Aboriginal and Torres Strait Islander People and residents of remote areas were not at excess risk of major amputation.

Prevalence and Risk Factors of Pressure Ulcers in Bedbound Diabetic vs. Non-diabetic Patients in a Lower-Middle-Income Country

Introduction Pressure ulcers, also known as bedsores, are a significant concern for bedridden individuals, presenting both physical and socioeconomic challenges. Factors such as prolonged immobility, chronic medical conditions, and poor nutrition contribute to their development. Despite extensive research in some regions, studies comparing diabetic and non-diabetic populations remain limited, particularly in low-income settings. This study aimed to investigate the risk factors and frequency of pressure ulcers among bedridden patients, addressing this gap in understanding and guiding targeted interventions. Materials and methods A cross-sectional study was conducted across four government hospitals in Peshawar, Pakistan. A total of 388 bedridden patients with pressure ulcers were included, and data were collected through a questionnaire. The questionnaire covered demographics, comorbidities, duration of bedbound status, BMI, and caregivers' awareness of pressure ulcer care. Data analysis was performed using SPSS version 22.0 (Armonk, NY: IBM Corp.), with qualitative data presented as frequencies and percentages and quantitative data as mean and standard deviation. Chi-square tests were utilized for significance, with p<0.05 considered significant. Results Of the 388 patients analyzed, 230 (59.3%) were diabetic, highlighting the prevalence of diabetes among pressure ulcer cases. The majority of diabetic patients with ulcers were over 41 years old, and 293 (75.5%) had comorbidities. Surgical intervention was the primary cause of ulcers in 213 (54.8%) cases, followed by stroke in 77 (19.8%) cases. Notably, 252 (65%) of caregivers exhibited inadequate knowledge regarding ulcer care. Stage II ulcers were prevalent in both diabetic and non-diabetic cohorts. Conclusions Pressure ulcers are poorly controlled complications observed in bedridden individuals, highlighting a critical need for comprehensive preventive measures and caregiver education to alleviate the burden of pressure ulcers, especially in diabetic patients. Factors such as prolonged immobility, surgical interventions, and insufficient caregiver knowledge contribute to the development of pressure ulcers. Understanding these complexities is essential for implementing effective care approaches and mitigating the impact of pressure ulcers.

Risk of Heart Disease in Patients With Amputation: A Nationwide Cohort Study in South Korea

BACKGROUND

Amputation confers disabilities upon patients and is linked to substantial morbidity and death attributed to heart disease. While some studies have focused on traumatic amputees in veterans, few studies have focused on traumatic amputees within the general population. Therefore, the present study aimed to assess the risk of heart disease in patients with traumatic amputation with disability within the general population using a large-scale nationwide population-based cohort.

METHODS AND RESULTS

We used data from the Korean National Health Insurance System. A total of 22 950 participants with amputation were selected with 1:3 age, sex-matched controls between 2010 and 2018. We used Cox proportional hazard models to calculate the risk of myocardial infarction, heart failure, and atrial fibrillation among amputees. Participants with amputation had a higher risk of myocardial infarction (adjusted hazard ratio [aHR], 1.30 [95% CI, 1.14-1.47]), heart failure (aHR, 1.27 [95% CI, 1.17-1.38]), and atrial fibrillation (aHR, 1.17 [95% CI, 1.03-1.33]). The risks of myocardial infarction and heart failure were further increased by the presence of disability (aHR, 1.43 [95% CI, 1.04-1.95]; and aHR, 1.38 [95% CI, 1.13-1.67], respectively).

CONCLUSIONS

We demonstrate an increased risk of myocardial infarction, heart failure, and atrial fibrillation among individuals with amputation, and the risk further increased in those with disabilities. Clinicians should pay attention to the increased risk for heart disease in patients with amputation.

A paradigm shift for cardiovascular outcome evaluation in diabetes: Major adverse cardiovascular events (MACE) to major adverse vascular events (MAVE)

BACKGROUND AND AIMS

Drugs for diabetes are required to demonstrate cardiovascular safety through CV outcome trials (CVOT). The pre-defined end-points for cardiovascular outcome studies may not be sufficient to capture all clinically relevant atherosclerotic cardio vascular disease (ASCVD) events particularly peripheral arterial disease (PAD).

METHODS

We planned a scoping review and searched database to identify CVOT conducted in population with diabetes measuring lower limb events due to PAD as the primary outcome measure. We also searched CVOT for reported differential cardiovascular outcomes in population with PAD.

RESULTS

We identified that CV outcomes are measured as 3 point major adverse cardiovascular outcomes (3P-MACE) that includes nonfatal MI and nonfatal stroke or 4P-MACE that included additional unstable angina which is further expanded to 5P-MACE by the inclusion of hospitalization for heart failure (HHF). These CV end points are captured as surrogate for CV mortality based on the biological plausibility of relation between the surrogate and final outcome from pathophysiological studies. We found the prevalence of PAD is no lesser than other CV events in people with diabetes. Moreover, PAD contributes to the significant morbidity associated with diabetes as a surrogate for mortality. However, none of the CVOT with anti-diabetic drugs include PAD events as primary outcome measure despite the inclusion of 6-25 % participants with PAD in major CVOT. PAD outcomes are objectively measurable with tibial arterial waveforms and clinical end-point as lower extremity amputation. PAD outcomes do improve with treatment including intensive glycemic control and novel oral anticoagulants. We suggest the inclusion of PAD to MACE as a pre-specified outcome for a comprehensive capture of major adverse vascular event in future studies for people with diabetes.

CONCLUSIONS

MACE should be expanded to include PAD event as major adverse vascular event in cardiovascular outcome studies since PAD is clinically relevant and objectively measurable in diabetes.

The Influence of Diabetes Mellitus on Mortality of Patients After Lower Extremity Amputation: A Systematic Review and Meta-analysis

OBJECTIVE

The influence of diabetes mellitus (DM) on mortality following lower extremity amputation (LEA) remains controversial. This systematic review and meta-analysis aimed to determine the influence of DM on long-term mortality (LTM) and short-term mortality (STM) after amputation.

MATERIALS AND METHODS

The Medline, the Cochrane library, and Embase databases were searched. The primary and secondary outcomes were LTM and STM following amputation. One-year and 30-day all-cause mortality after amputation were considered as LTM and STM, respectively. A random-effects model was utilized to pool results. To evaluate the stability of results, subgroup analyses and sensitivity analyses were conducted.

RESULTS

Twenty-three cohort studies with a total of 58,219 patients were included, among which 31,750 (54.5%) patients had DM. The mean score of included studies evaluated by Newcastle-Ottawa Scale was 7.65, indicating moderate to high quality. The pooled results showed no significant difference in 1-year LTM (risk ratio [RR], 0.96; 95% CI 0.86-1.07) after amputation. However, 3-year (RR, 1.22; 95% CI 1.01-1.47) and 5-year (RR, 1.18; 95% CI 1.07-1.31) LTMs of DM patients were obviously higher than that of NDM (non-diabetes mellitus) patients. The STM of the DM group was significantly lower than the NDM group (RR, 0.80; 95% CI 0.64-0.98).

CONCLUSIONS

The current study revealed that DM patients had an obvious lower STM following LEA, but the risk of DM on LTM after amputation was gradually increased with time. More attention should be paid to the long-term survival of DM patients after LEA.

Pie diabético: tasas de mortalidad en pacientes con amputaciones mayores

Introducción: Las amputaciones mayores provocan una elevada tasa de morbimortalidad. Los objetivos de este estudio fueron evaluar la tasa de mortalidad al mes, y a los 2 y 5 años de una amputación por pie diabético y comparar la tasa de mortalidad en pacientes con amputación infrarrotuliana o supracondílea. Materiales y Métodos: Se evaluó retrospectivamente a 60 pacientes con 64 amputaciones mayores, operados entre 2010 y 2018. Se reunió la siguiente información: datos personales, lateralidad, puntaje de la clasificación de la Universidad de Texas, análisis bioquímicos, estudio Doppler, comorbilidades, supervivencia y causa del óbito. Se calculó la tasa de mortalidad general y por tipo de amputación al mes, a los 2 y 5 años. Resultados: Se realizaron 58 amputaciones en hombres y 6, en mujeres (37 derechas, 27 izquierdas), 39 fueron supracondíleas, y 25 infrarrotulianas. La edad promedio era de 68 años. Hubo 28 óbitos: 15 pacientes con amputación supracondílea y 13 con amputación infrarrotuliana. Las tasas de mortalidad fueron: 13,33% al mes; 33,3% a los 2 años y 46,42% a los 5 años (pacientes con amputación supracondílea 26,78%; pacientes con amputación infrarrotuliana 19,64%). Las diferencias en los niveles de creatinina de los pacientes que murieron fueron estadísticamente significativas. Las principales causas de muerte fueron las complicaciones cardiovasculares. Conclusiones: Las tasas de mortalidad fueron significativamente superiores en los pacientes con amputación supracondílea. La tasa de mortalidad al mes relacionada con sepsis fue alta. Los enfermos renales tuvieron una tasa de mortalidad mayor.

Modulatory effect of caffeic acid in alleviating diabetes and associated complications

Diabetes mellitus (DM) is one of the most common metabolic disorders characterized by elevated blood glucose levels. Prolonged uncontrolled hyperglycemia often leads to multi-organ damage including diabetic neuropathy, nephropathy, retinopathy, cardiovascular disorders, and diabetic foot ulcers. Excess production of free radicals causing oxidative stress in tissues is often considered to be the primary cause of onset and progression of DM and associated complications. Natural polyphenols can be used to induce or inhibit the expression of antioxidant enzymes such as glutathione peroxidase, heme oxygenase-1, superoxide dismutase, and catalase that are essential in maintaining redox balance, and ameliorate oxidative stress. Caffeic acid (CA) is a polyphenolderived from hydroxycinnamic acid and possesses numerous physiological properties includ-ing antioxidant, anti-inflammatory, anti-atherosclerotic, immune-stimulatory, cardioprotective, antiproliferative, and hepatoprotective activities. CA acts as a regulatory compound affecting numerous biochemical pathways and multiple targets. These include various transcription factors such as nuclear factor-B, tumor necrosis factor-α, interleukin-6, cyclooxygenase-2, and nuclear factor erythroid 2-related factor 2. Therefore, this review summarizes the pharmacological properties, molecular mechanisms, and pharmacokinetic profile of CA in mitigating the adverse effects of DM and associated complications. The bioavailability, drug delivery, and clinical trials of CA have also been discussed.

Analysis of 5-year Mortality following Lower Extremity Amputation due to Vascular Disease

Mortality rates following major lower extremity amputations (LEAs) 30 days-365 days postoperative have decreased, but 5-year rates remain high at 40.4%-70%. These data may not reflect recent advances in peripheral arterial disease (PAD) care, and comorbidities of chronic PAD may lead to mortality more frequently than the amputation itself. Mortality rates between diabetic and nondiabetic patients were also analyzed.

Methods

The California Office of Statewide Health Planning and Development hospital database was queried for patients admitted January 1, 2007-December 31, 2018. ICD-9-CM codes identified patients with vascular disease and an amputation procedure.

Results

There were 26,669 patients. The 30-day, 90-day, 1-year, and 5-year major LEA mortality rates were 4.82%, 8.62%, 12.47%, and 18.11%, respectively. Weighted averages of 30-day, 90-day, 1-year, and 5-year major LEA mortality rates in the literature are 13%, 15.40%, 47.93%, and 60.60%, respectively. Mortality risk associated with vascular disease after amputation (hazard ratio = 22.07) was 11 times greater than risk associated with amputation-specific complications from impaired mobility (hazard ratio = 1.90; P < 0.01). Having diabetes was associated with lower mortality at 30 days, 90 days, and 1 year (P < 0.01) but not at 5 years (P = 0.22).

Conclusions

This study suggests that people may be living longer after their major LEA than was previously thought. This study suggests that patients' PAD may play a bigger role in contributing to their mortality than complications from loss of mobility postamputation. Although having diabetes was associated with lower postamputation mortality, the difference was no longer significant by 5 years.

Mortality and Conversion Rates to Below-Knee or Above-Knee Amputation After Transmetatarsal Amputation

INTRODUCTION

The purpose of this study was to identify associated risk factors for complications, need for a higher level of amputation such as below-knee amputation (BKA) or above-knee amputation (AKA), and mortality after transmetatarsal amputation (TMA).

METHODS

We identified 265 patients who underwent 286 TMA procedures between June 2002 and July 2016. Medical records were reviewed for revision surgery and amputation. Mortality was verified using the National Death Index. We identified and documented potential risk factors including diabetes, hemoglobin A1c level, end-stage renal disease, cardiovascular disease, peripheral vascular disease, history of revascularization, contralateral amputation, and neuropathy. Sixty-eight percent were male, the mean age was 56.9 years (SD 12.8; range 24.1 to 92.1), and the median body mass index was 28.6 (interquartile range, 24.5 to 33.1).

RESULTS

Twenty-seven percent of the patients required a subsequent BKA or AKA after the index TMA surgery. The results of a multivariable model indicated that women (odds ratio [OR], 3.63; 95% confidence interval [CI], 1.716 to 7.672), patients aged 57 to 64 years (OR, 0.17; 95% CI, 0.06 to 0.51), and patients with a history of revascularization (OR, 7.06, 95% CI, 2.86 to 17.44) had markedly higher odds than the relevant comparison groups. Forty percent of the patients died after the index TMA at a median of 27 months. After adjusting for all patient factors, history of end-stage renal disease (OR, 2.2; 95% CI, 1.206 to 4.014) and cardiovascular disease (OR, 2.879; 95% CI, 1.615 to 5.131) remained markedly associated with mortality after TMA.

DISCUSSION

There are high rates of additional amputation after nontraumatic TMA and a high mortality rate. Surgeons should set realistic expectations with patients considered for TMA and identify risk factors, which may guide treatment. Treatment is multidisciplinary, requiring attention to surgical details, correction of vascular deficiency or contracture when present, and perioperative medical optimization.

LEVEL OF EVIDENCE

IV.

Could X-ray Predict Long-term Complications in Patients with Diabetic Foot Osteomyelitis?

OBJECTIVE

To analyze the association between radiologic changes on plain X-rays in patients with diabetic foot osteomyelitis and the development of complications at the 1-year follow-up.

METHODS

A prospective, observational study was conducted involving 115 patients with diabetic foot osteomyelitis. X-ray features that were evaluated during 1-year follow-up visits included affected bone marrow, active periosteal reaction, sequestrum, cortical disruption, and other types of signs. Researchers analyzed the association between the presence of X-ray changes and complication development, such as bone or soft tissue infections, ulcer recurrence, reulceration, amputation, death, and other diabetic foot disease-related events.

RESULTS

During follow-up, of 115 patients included in the study, 33 patients (28.7%) showed radiologic changes, and 85 (73.9%) developed complications. The presence of radiologic changes after ulcer healing had a significant association with complication development during the 1-year follow-up in addition to those found at different follow-up visits. Patients who showed radiologic changes had higher percentages of complications during the 1-year follow-up, and patients without radiologic changes had lower percentages of complications.

CONCLUSIONS

The presence of radiologic changes is related to the development of complications in patients who suffer from diabetic foot osteomyelitis.

Contribution of diabetes to amputations in sub-Sahara Africa: A systematic review and meta-analysis

Diabetes related amputations remain a major global problem, with devastating complications. We critically appraised relevant literature to quantify the prevalence of diabetes related amputations in sub-Saharan Africa (SSA). An electronic search was performed using the EMBASE and PubMed databases until 2020. Twenty-four out of 834 studies retrieved were included. The pooled prevalence of diabetic-related amputations was 36.9% (95%CI: 32.9%-40.8%). Complications of diabetes related amputations included infection, anaemia, foot deformity and mortality. The study revealed a substantial contribution of diabetes to the burden of amputations in SSA and suggests the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of macro and microvascular complications of diabetes in SSA.

Differential prognostic burden of cardiovascular disease and lower-limb amputation on the risk of all-cause death in people with long-standing type 1 diabetes

Background

Cardiovascular disease (CVD) and nontraumatic lower-limb amputation (LLA) each results in reduced life expectancy in patients with type 1 diabetes, but the differential burden between these conditions is unknown. We compared the effects of CVD and LLA on the risk of mortality in people with type 1 diabetes.

Methods

We used pooled data from the SURGENE, GENEDIAB, and GENESIS prospective cohorts. Data were divided into: 1/absence of CVD (myocardial infarction and/or stroke) nor LLA, 2/history of CVD alone without LLA, 3/LLA alone without CVD or 4/both conditions at baseline. Participants with baseline history of peripheral artery disease were excluded from groups 1 and 2. The study endpoint was any death occurring during follow-up, regardless of the causes.

Results

Among 1169 participants (male 55%, age 40 ± 13 years, diabetes duration 23 ± 11 years), CVD, LLA or both were present at baseline in 49 (4.2%), 62 (5.3%) and 20 (1.7%) subjects, respectively. All-cause death occurred in 304 (26%) participants during 17-year follow-up, corresponding to 18,426 person-years and an incidence rate of 16 (95%CI, 15–18) per 1000 person-years. The risk of death increased in individuals with baseline history of CVD (adjusted HR 2.00 [95% CI 1.34–3.01], p = 0.0008) or LLA (2.26 [1.56–3.28], p < 0.0001), versus no condition, with an additive effect in people with both conditions (5.32 [3.14–9.00], p < 0.0001). No incremental risk of death was observed in people with CVD versus LLA (0.87 [0.54–1.41]). Compared with no condition, CVD and LLA were similarly associated with reduced life expectancy during follow-up: 2.79 (95% CI 1.26–4.32) and 3.38 (1.87–4.88) years, respectively. Combined conditions expose to 7.04 (4.76–9.31) less years of life expectancy (all p < 0.0001).

Conclusions

CVD and LLA conferred a similar burden regarding mortality in type 1 diabetes population. Our findings encourage a careful consideration of people with type 1 diabetes and LLA as usually recommended for those with CVD, in terms of management of risk factors, treatments and prevention.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01487-8.

Beneficial Effects of Caffeic Acid Phenethyl Ester on Wound Healing in a Diabetic Mouse: Role of VEGF and NO

Cutaneous wound healing is delayed in patients with diabetes. Caffeic acid phenethyl ester (CAPE) has been identified as an effective constituent of propolis with improved wound healing abilities via an oxidative stress decrease. However, its impact on wound healing in diabetic models and its underlying mechanisms remain unclear. Determining the vascular endothelial growth factor (VEGF) contents in a human vascular smooth muscle cell (VSMC)-conditioned medium was assessed using human VEGF immunoassay and vascular reactivity using porcine coronary artery rings. Later, C57BL/6 or db/db mice were anesthetized, after which a 6-mm biopsy punch was manipulated for perforation via the back skin. Subsequently, CAPE was applied to the wound and changed daily. Furthermore, the injury in each mouse was digitally photographed, and the wound area was quantified. We observed that CAPE increased VEGF levels in human VSMC-conditioned medium, improved endothelium-dependent nitric oxide (NO)-mediated vasorelaxation, inhibited U46619-induced vasoconstriction porcine coronary artery, and enhanced cutaneous wound healing in the diabetic mouse model. Hence, we propose that CAPE improves wound healing in diabetic mice, which is aided by increased VEGF and NO expression.

Survival of Patients Following First Diagnosis of Diabetic Foot Complications: A Nationwide 15-Year Longitudinal Analysis

Background and Aims

The long-term survival in people with type 2 diabetes following first diagnosis of diabetic foot complications (FDDFC) is unclear. The object is to evaluate the mortality rate in subjects with type 2 diabetes following FDDFC and the impacts of the major cardiovascular comorbidities.

Methods

Nationwide data were analyzed for subjects with T2D and DFC between 2003 and 2017 according to ICD-9 coding. DFC was defined with the codes of ulcers, infections, or severe peripheral artery disease that required intervention (PAD) to mimic the real world diagnosis. Criteria of FDDFC were preceded by a period without any DFC for at least 5 years. Major cardiovascular comorbidities: established PAD and cardiovascular diseases (CVD: including coronary heart disease (CHD), stroke, or heart failure) before the index date as well as lower-extremity amputations (LEA) at the index episode were analyzed.

Results

Among 300,115 subjects with DFC, a total of 103,396 patients had FDDFC. The mean 5-year survival rate of these subjects was 81.05%. Using subjects without associated major cardiovascular comorbidity as baseline, the adjusted hazard ratios (aHR) were1.43 (95% confidence interval 1.38-1.49) in group PAD-/CVD+, followed by 1.70 (1.59-1.80) in PAD+/CVD- and 1.98 (1.89-2.08) in PAD+/CVD+. The aHR was further increased in patients with PAD who additionally had heart failure (3.77, 3.50-4.05), stroke (2.06, 1.95-2.18), or CHD (1.89, 1.79-2.00). Subjects with PAD rather than other CVD were associated with LEA at FDDFC. Patients with major LEA (above the ankle) at FDDFC episode had lower 5-year survival rate (65.01%) followed by those with minor LEA (72.24%) and without LEA (81.61%).

Conclusions

Cardiovascular comorbidity as well as LEA status at the event of FDDFCs were both associated with patient survival outcomes. Earlier identification of this large population could lead to higher survival rates.

Lower extremity reamputation in people with diabetes: a systematic review and meta-analysis

In this study, we determined the reamputation-free survival to both limbs and to the contralateral limb only following an index amputation of any-level and assessed whether reamputation rates have changed over time. We completed a systematic search using PubMed and screened a total of 205 articles for data on reamputation rates. We reported qualitative characteristics of 56 studies that included data on reamputation rates and completed a meta-analysis on 22 of the studies which enrolled exclusively participants with diabetes. The random-effects meta-analysis fit a parametric survival distribution to the data for reamputations to both limbs and to the contralateral limb only. We assessed whether there was a temporal trend in the reamputation rate using the Mann-Kendall test. Incidence rates were high for reamputation to both limbs and to the contralateral limb only. At 1 year, the reamputation rate for all contralateral and ipsilateral reamputations was found to be 19% (IQR=5.1%-31.6%), and at 5 years, it was found to be 37.1% (IQR=27.0%-47.2%). The contralateral reamputation rate at 5 years was found to be 20.5% (IQR=13.3%-27.2%). We found no evidence of a trend in the reamputation rates over more than two decades of literature analyzed. The incidence of lower extremity reamputation is high among patients with diabetes who have undergone initial amputations secondary to diabetes, and rates of reamputation have not changed over at least two decades.

Diabetes and Peripheral Nerve Disease

It is increasingly recognized that diabetic neuropathy is associated with early diabetes, prediabetes, and the metabolic syndrome. Early detection and diagnosis are important to slow progression and prevent complications. Although strict glucose control is an effective treatment in type 1 diabetes, it is less effective in type 2 diabetes. There is a growing body of literature that lifestyle interventions may be able to prevent or slow progression of neuropathy in type 2 diabetes. In addition to the typical distal symmetric polyneuropathy, there are many types of "atypical" diabetic neuropathies that are important to recognize.

Medium-term outcomes of multi-disciplinary surgical management of non-ischemic diabetic heel ulcers

BACKGROUND

Heel ulcers in patients with peripheral neuropathy and diabetes pose a significant challenge to treating physicians. Infection spreading to the os calcis is associated with a poor prognosis. There is no consensus on which method of surgical treatments results in better outcomes. The aim of this study was to assess patients' survival, rate of ulcer healing following surgical treatment, along with limb salvage rate, time taken for healing, ulcer recurrence and patients' functional outcome after healing.

METHODS

We studied 29 patients (20 men, 9 women) presenting with diabetic neuropathic heel ulcers (30 feet) and no critical limb ischemia, were managed surgically in our unit and followed-up for a minimum of 12 months. We assessed their clinical and functional outcomes within a mean follow-up period of 28 months (12-83).

RESULTS

11 out of 29 patients died (38%) with mean duration of post op survival being 31months (range 4-70). 14 ulcers (50%) healed fully within a mean of 360 days (131-1676). Limb salvage was achieved in 29 feet (97%). Only 5 out of 17 patients with diabetic nephropathy (p value 0.016) and 9 out of 24 ulcers with calcaneal osteomyelitis (p value 0.044) achieved full ulcer healing. Ulcer recurrence rate was 36% (5/14) within 12 months of achieving ulcer healing. Six patients were able to return to independent walking in surgical shoes while 11 patients were mobilising using either a crutch or frame.

CONCLUSION

While excellent limb salvage can be anticipated from the outcome of surgically managed infected heel ulcers in patients with diabetes, complete healing can still be slow and unpredictable. Significant medical co-morbidities in these patients make them vulnerable to medium-term post-operative complication and survival.

Amputations of Lower Limb in Subjects with Diabetes Mellitus: Reasons and 30-Day Mortality

BACKGROUND

Diabetic foot is one of the leading causes of patient disability worldwide. Lower-extremity amputations (LEAs) resulting from this disease massively decrease quality of life, the function of the patient, and incur significant healthcare costs. The aim of this study was to assess trends in the number of amputations, the diagnosis at discharge, and diagnosis-related mortality after LEA procedures in a nationwide population.

METHODS

Datasets of the National Heath Fund containing information about all services within the public healthcare system in Poland, spanning the years 2010-2019, were analyzed. The source of data regarding mortality was the database of the Polish Ministry of Digital Affairs.

RESULTS

Between 2010 and 2019, the annual number of amputations in patients with diabetes increased significantly from 5,049 to 7,759 (p for trend < 0.000001). However, the number of amputations in patients with diabetes calculated as a number per 100,000 diabetics decreased significantly (p for trend < 0.0005) during this period. Amputations in patients with diabetes accounted for a majority of all amputations; the mean percentage of amputations in patients with diabetes was 68.6% of all amputations (from 61.1% in 2010 to 71.4% in 2019, p for trend < 0.0000001). The most common disease diagnosed at discharge after LEA in diabetic patients was diabetes itself. Vascular pathologies, such as soft-tissue/bone/joint infections and ulcerations, were the next most common. The 30-day mortality rate after LEA was rather high in patients with, as well as without, diabetes (depending on the cause for amputation 3.5-34% and 2.2-28.99%, respectively).

CONCLUSIONS

The number of LEA in patients with diabetes in Poland increased substantially between 2010 and 2019 along with an increasing number of diabetics. Vascular pathologies, infections, and ulcerations were the most common causes of LEA. The 30-day mortality rate after amputation was rather high and varied depending on the diagnoses at discharge.

Utility of Blood Parameters to Detect Complications during Long-Term Follow-Up in Patients with Diabetic Foot Osteomyelitis

The evidence is still unclear regarding the role of blood parameters in detecting complications in patients who suffer from diabetic foot osteomyelitis (DFO). In this study, the aim was to identify the capacity of different blood parameters in the diagnosis and prediction of the onset of complications. A cross-sectional prospective study was carried out with 116 DFO patients. The following blood parameters were evaluated during 1 year of follow-up: leukocytes, neutrophils, lymphocytes, monocytes, eosinophils, basophils, erythrocyte sedimentation rate (ESR), glycemia, glycosylated hemoglobin, C-reactive protein (CRP), alkaline phosphatase, albumin, and creatinine. Complication events were assessed for each participant during the study period. We investigated the association between blood parameter values and the onset of complication events by conducting a receiver operating characteristic curve analysis. Eighty-five (73.3%) patients developed complications. Regarding blood parameters, higher values of lymphocytes and albumin were predictive factors at the 12-month follow-up once the ulcer had healed. Higher values of ESR had predictive and diagnostic value for the onset of complication events, and higher values of CRP and hyperglycemia were diagnostic factors since they were elevated during the occurrence of an event. In conclusion, after suffering from DFO, the elevation of lymphocytes, ESR, CRP, albumin, and glycemia could be useful in detecting and diagnosing patients who are likely to develop a complication. Serial blood tests are a useful tool for early detection by healthcare professionals to prevent complications.

Randomized controlled clinical trial evaluating the efficacy of hyperbaric oxygen therapy in facilitating the healing of chronic foot ulcers in diabetic patients: the study protocol

Background

Diabetic limb ulcers are highly prevalent and contribute to a significant increase in cost for the treatment of these patients in health services. However, healing of these wounds is a major health problem and may even lead to amputation. The primary aim of the current study is to evaluate the efficacy of hyperbaric oxygen therapy (HBOT) in facilitating the healing of diabetic foot ulcers, in addition to secondarily evaluating whether it reduces the number of amputations and improves the quality of life in these patients.

Methods

A non-blind randomized clinical study will be conducted in the city of Imperatriz, Maranhão state, Brazil, from 2019 to 2020, in diabetic patients with chronic foot ulcers (classified as Wagner grades 2, 3 and 4, persisting for more than 1 month). The outpatient follow-up for diabetic foot patients will be done at the Unified Health System, with a sample size of 120 patients (the randomization allocation will be 1:1, being 60 patients for each arm). Half of the patients will receive standard treatment, i.e. dressings, debridement, antibiotics and load relief, along with HBOT (HBOT group), and the other half will receive only standard treatment (control group). The patients of the HBOT group will be evaluated upon admission, after 10, 20, 30 and 35 HBOT sessions, and after 6 months and 1 year. The patients of the control group will also be evaluated at equivalent periods (upon admission, after 2, 4, 6 and 7 weeks, 6 months and 1 year). The SF-36 quality of life questionnaire will be filled upon admission and after 3 months of follow-up in both groups. The primary and secondary endpoints will be assessed with 1 year of follow-up.

Discussion

Diabetic foot ulcers are a highly prevalent complication of diabetes with serious consequences. A study to assess the efficacy of HBOT in healing the ulcers and reducing the rate of amputations in diabetic patients is justified, which will eventually aid in the development of guidelines for treating these ulcers.

Trial registration

Registration number RBR-7bd3xy. Registered on 17 July 2019—Retrospectively registered.

Combining diabetic foot and retinopathy screening: A step in the right direction? - a feasibility study

Objectives

Peripheral artery disease is a major cardiovascular disease affecting more than 200 million people globally and up to 4 times more frequent in the diabetic population. It can lead to lower extremity amputations or revascularisation and is associated with an increased risk of myocardial infarction, stroke and early mortality. This novel cross-sectional study aimed to explore the feasibility and acceptability of incorporating diabetic foot screening at routine diabetic retinopathy screening appointments.

Methods

Participants underwent foot screening during the interval between pupil dilatation and retinal photography as part of the eye screening procedure. Lower limb arterial assessment included ankle brachial index, pulse volume waveform and protective light touch sensation.

Results

Of 364 participants invited, 88% (n = 321) met the inclusion criteria. About 26.4% (n = 86) had asymptomatic peripheral artery disease and 3% (n = 10) had peripheral sensory neuropathy. Binary logistical regression analysis identified age (p < 0.005), existing coronary heart disease (p < 0.005) and gender (p = 0.03) as predictors of peripheral artery disease.

Conclusion

Incorporating foot examination during eye screening appointments is feasible and was well received by participants and staff alike. Undiagnosed early peripheral artery disease was evident in a third of the study population emphasising the benefit of introducing foot surveillance into eye screening appointments for the early identification of lower limb arterial disease and peripheral sensory neuropathy.

Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems

INTRODUCTION

The aim of the study was to identify the sociodemographic and clinical factors associated with death after the first lower-extremity amputation (LEA), minor and major separately, using data from regional health administrative databases.

RESEARCH DESIGN AND METHODS

We carried out a population-based cohort study including patients with diabetes residing in the Lazio region and undergoing a primary amputation in the period 2012-2015. Each individual was followed up for at least 2 years. Kaplan-Meier analysis was used to evaluate long-term survival; Cox proportional regression models were applied to identify factors associated with all-cause mortality.

RESULTS

The cohort included 1053 patients, 72% were male, 63% aged ≥65 years, and 519 (49%) died by the end of follow-up. Mortality rates at 1 and 4 years were, respectively, 33% and 65% for major LEA and 18% and 45% for minor LEA. Significant risk factors for mortality were age ≥65, diabetes-related cardiovascular complications, and chronic renal disease for patients with minor LEA, and age ≥75 years, chronic renal disease and antidepressant drug consumption for subjects with major LEA.

CONCLUSIONS

The present study confirms the high mortality rates described in patients with diabetes after non-traumatic LEA. It shows differences between minor and major LEA in terms of mortality rates and related risk factors. The study highlights the role of depression as specific risk factor for death in patients with diabetes after major LEA and suggests including its definition and management in strategies to reduce the high mortality rate observed in this group of patients.

Pilot Experience on the Use of S54P4 Bioactive Glass in the Surgical Management of Diabetic Foot Osteomyelitis

To test safety and efficacy of bioactive glass, a novel material used to replace bone, able to completely bond itself to the host tissues on patients treated for osteomyelitis (OM) complicating a diabetic foot (DF). We evaluated a group of patients consecutively admitted in our department between September and December 2018, who underwent surgical DF procedures for OM and in whom the use of bioactive glass could limit the demolition phase of surgical procedure. Patients were treated with bioactive glass S53P4 on top of standard treatment directly in operating room. The patients were weekly controlled for 6 months or until complete healing. During follow-up, we analyzed primarily healing rate and secondarily time of healing, need for further debridement procedures, recurrences, and adverse or hypersensitivity reactions to study treatment. Ten DF patients were enrolled (male/female 6/4; mean age 56 ± 11 years; mean duration of diabetes 10.5 ± 4.7 years, mean hemoglobin A1c 7.2 ± 0.9%). Patients underwent surgical procedure during which, after an accurate debridement, bioactive glass was applied. A healing rate of 80% in a mean time of 34 ± 2 days, with only 1 patient who needed a second surgical look, was observed. Neither recurrences nor adverse events during follow-up were observed in treated patients. This pilot experience demonstrated that bioactive glass can be considered a useful tool for the surgical treatment of DF-related OM.

Digital Subtraction Angiography Prior to an Amputation for Critical Limb Ischemia (CLI): An Expert Recommendation Statement From the CLI Global Society to Optimize Limb Salvage

Despite recent guideline updates on peripheral artery disease (PAD) and critical limb ischemia (CLI) treatment, the optimal treatment for CLI is still being debated. As a result, care is inconsistent, with many CLI patients undergoing an amputation prior to what many consider to be mandatory: consultation with an interdisciplinary specialty care team and a comprehensive imaging assessment. More importantly, quality imaging is critical in CLI patients with below-the-knee disease. Therefore, the CLI Global Society has put forth an interdisciplinary expert recommendation for superselective digital subtraction angiography (DSA) that includes the ankle and foot in properly indicated CLI patients to optimize limb salvage. A recommended imaging algorithm for CLI patients is included.

Nurses' Perspective of Treating Patients With an Amputation Due to Diabetic Foot Syndrome

BACKGROUND

Expert nurses must provide both physical and emotional care to patients with diabetic foot syndrome (DFS) who require an amputation. This includes helping patients and families to cope with this situation, while ensuring the maximum level of comfort.

PURPOSE

The aim of this study was to explore the perspective of expert nurses on the needs and hospital care of people requiring an amputation due to DFS.

METHOD

This was a qualitative multicenter study involving 8 hospitals in Spain and Portugal. In-depth interviews with expert nurses were transcribed verbatim to enable content analysis.

RESULTS

Twenty-four expert nurses were interviewed about their knowledge and experience of treating patients with diabetic foot disease. Two themes emerged from the qualitative analysis: (1) poor self-care and the disease trajectory, and (2) effective hospital care.

CONCLUSIONS

The results of this study highlight the key role that expert nurses play in the care of patients with DFS. Expert nurses considered that amputation leaves the individual physically and psychologically vulnerable, especially upon discharge from hospital. It is therefore essential to provide these patients with comprehensive and multidisciplinary care that includes emotional support.

One-Year Outcomes of Peripheral Endovascular Device Intervention in Critical Limb Ischemia Patients: Sub-Analysis of the LIBERTY 360 Study

Background

High-risk patients with advanced peripheral artery disease (PAD), including critical limb ischemia (CLI), are often excluded from peripheral endovascular device intervention clinical trials, leading to difficulty in translating trial results into real-world practice. There is a need for prospectively assessed studies to evaluate peripheral endovascular device intervention outcomes in CLI patients.

Methods

LIBERTY 360 is a prospective, observational, multi-center study designed to evaluate the procedural and long-term clinical outcomes of peripheral endovascular device intervention in real-world patients with symptomatic lower-extremity PAD. One thousand two hundred and four patients were enrolled and stratified based on Rutherford Classification (RC): RC2-3 (N=501), RC4-5 (N=603), and RC6 (N=100). For this sub-analysis, RC5 and RC6 patients (RC5-6; N=404) were pooled and 1-year outcomes were assessed.

Results

Procedural complications rarely (1.7%) resulted in post-procedural hospitalization and 89.1% of RC5-6 patients were discharged to home. Considering the advanced disease state in RC5-6 patients, there was a high freedom from 1-year major adverse event rate of 65.5% (defined as target vessel revascularization, death to 30 days, and major target limb amputation). At 1 year, freedom from major amputation was 89.6%. Wounds identified at baseline on the target limb had completely healed in 172/243 (70.8%) of the RC5-6 subjects by 1 year. Additionally, the overall quality of life, as measured by VascuQoL, improved from baseline to 1 year.

Conclusion

LIBERTY investigated real-world PAD patients with independent oversight of outcomes. This analysis of LIBERTY RC5-6 patients demonstrates that peripheral endovascular device intervention can be successful in CLI patients, with low rates of major amputation and improvement in wound healing and quality of life through 1-year follow-up.

LIBERTY 360, https://clinicaltrials.gov/ct2/show/NCT01855412, ClinicalTrials.gov Identifier: NCT01855412.

The role of Sudoscan feet asymmetry in the diabetic foot

The aim of this study was to investigate the role of Sudoscan asymmetry parameters in the diabetic foot.

PATIENTS AND METHODS

In this study we included 165 participants: 84 type 2 diabetes patients divided into three HbA1c matched groups - group 1: newly diagnosed diabetics (n = 31), group 2: people with longer diabetes duration and established neuropathy (n = 33), group 3: patients with diabetic foot ulcer (n = 20), and a control group of 81 people with prediabetes. All subjects underwent peripheral sudomotor evaluation using Sudoscan device (Impeto Medical, Paris).

RESULTS

Patients with diabetic foot had significantly higher Sudoscan feet asymmetry (19.6%) compared to those with only diabetic neuropathy (7.9%), compared to the group with newly diagnosed diabetes (7.44%), and compared to controls (2.5%). This test has shown a good discriminative value (with a threshold of 9.5%) for diabetic foot with area under the ROC curve of 0.955 (p = 0.001). Additionally, in a regression model feet asymmetry proved its predictive value for participants with diabetic foot.

CONCLUSION

In this study Sudoscan feet asymmetry proved to be a novel discriminator and predictor for diabetic foot patients. It might be considered as a marker for early damage in the neuropathy evaluation protocol.

Evaluation of the quality of life in individuals with amputations in relation to the etiology of their amputation. A case-control study

Objectives: Several studies indicate that limb amputations have a negative influence in the quality of life of those individuals who underwent amputation surgery. The aims of this study were to evaluate the quality of life in Mexican individuals with limb amputations compared with a control group, to identify demographic and clinical differences related to the etiology of the amputation, and to determine if they are associated with the quality of life observed in these patients. Methods: All participants were recruited from the Hospital "Dr Gustavo A. Rovirosa Pérez". The quality of life of all participants was evaluated using SF-36. Results: Individuals with amputations of vascular or trauma etiology, showed a diminished health-related quality of life when compared with the control group (p < .001). We observed that individuals with amputations due to trauma were younger, mostly single, with more upper limb amputations and with a shorter period since amputation at the current assessment in comparison to individuals with amputations. Conclusions: Although limb amputation represents a surgical procedure necessary to preserve the life of a person, our results support that it negatively impacts the health-related quality of life of these individuals. Regardless of the etiology of the amputation, rehabilitation programs are primarily focused on reintegrating individuals to their everyday life. However, these programs may have poor results when patients have a poor quality of life. Therefore, quality of life assessment and early inclusion in programs that aim to improve the quality of life of individuals with amputations should be always taken into consideration.

Diabetes and Sarcopenic Obesity: Pathogenesis, Diagnosis, and Treatments

Sarcopenic obesity and diabetes are two increasing health problems worldwide, which both share many common risk factors, such as aging, and general obesity. The pathogenesis of sarcopenic obesity includes aging, physical inactivity, malnutrition, low-grade inflammation, insulin resistance, and hormonal changes. Nevertheless, there are two major reasons to cause diabetes: impaired insulin secretion and impaired insulin action. Furthermore, the individual diagnosis of obesity and sarcopenia should be combined to adequately define sarcopenic obesity. Also, the diagnosis of diabetes includes fasting plasma glucose test (FPG), 2-h oral glucose tolerance test (OGTT), glycated hemoglobin (A1C), and random plasma glucose coupled with symptoms. Healthy diet and physical activity are beneficial to both sarcopenic obesity and diabetes, but there are only recommended drugs for diabetes. This review consolidates and discusses the latest research in pathogenesis, diagnosis, and treatments of diabetes and sarcopenic obesity.

Pre- and Post-diagnosis Diabetes as a Risk Factor for All-Cause and Cancer-Specific Mortality in Breast, Prostate, and Colorectal Cancer Survivors: a Prospective Cohort Study

Objective: The relationship between diabetes and all- and cause-specific mortality in individuals with common cancers (breast, colorectal, and prostate) remains both under-researched and poorly understood. Methods: Cancer survivors (N = 37,993) from the National Health Interview Survey with linked data retrieved from the National Death Index served as our study participants. Cox proportional-hazards models were used to assess associations between pre- and post-diabetes and all-cause and cause-specific mortality. Results: Over a median follow-up period of 13 years, 2,350 all-cause, 698 cancer, and 506 CVD deaths occurred. Among all cancer survivors, patients with diabetes had greater risk of: all-cause mortality [hazard ratio (HR) 1.35, 95% CI = 1.27-1.43], cancer-specific mortality (HR: 1.14, 95% CI = 1.03-1.27), CVD mortality (HR: 1.36, 95% CI = 1.18-1.55), diabetes related mortality (HR: 17.18, 95% CI = 11.51-25.64), and kidney disease mortality (HR: 2.51, 95% CI = 1.65-3.82), compared with individuals without diabetes. The risk of all-cause mortality was also higher amongst those with diabetes and specific types of cancer: breast cancer (HR: 1.28, 95% CI = 1.12-1.48), prostate cancer (HR: 1.20, 95% CI = 1.03-1.39), and colorectal cancer (HR: 1.29, 95% CI = 1.10-1.50). Diabetes increased the risk of cancer-specific mortality among colorectal cancer survivors (HR: 1.36, 95% CI = 1.04-1.78) compared to those without diabetes. Diabetes was associated with higher risk of diabetes-related mortality when compared to non-diabetic breast (HR: 9.20, 95% CI = 3.60-23.53), prostate (HR: 18.36, 95% CI = 6.01-56.11), and colorectal cancer survivors (HR: 12.18, 95% CI = 4.17-35.58). Both pre- and post-diagnosis diabetes increased the risk of all-cause mortality among all cancer survivors. Cancer survivors with diabetes had similar risk of all-cause and CVD mortality during the second 5 years of diabetes and above 10 years of diabetes as compared to non-diabetic patients. Conclusions: Diabetes increased the risk of all-cause mortality among breast, prostate, and colorectal cancer survivors, not for pre- or post-diagnosis diabetes. Greater attention on diabetes management is warranted in cancer survivors with diabetes.

Major lower extremity amputation: a contemporary analysis from an academic tertiary referral centre in a developing community

Background

We aimed to explore the surgical outcomes of major lower extremity amputation (MLEA) and influencing factors at an academic tertiary referral centre in north Jordan, optimistically providing a platform for future health care policies and initiatives to improve the outcomes of MLEA in Jordan.

Methods

Clinical records of patients who had undergone MLEA between January 2012 and December 2017 were identified and retrospectively reviewed. International Classification of Diseases codes were used to identify the study cohort from a prospectively maintained computerised database. We included adult patients of both genders who underwent amputations for ischemic lower limb (acute and chronic) and diabetic foot syndrome (DFS). We excluded patients for whom MLEA surgery was performed for other indications (trauma and tumors). Outcomes of interest included patient demographics and comorbidities, type of amputation and indications, length of hospital stay (LOS), the need for revision surgery (ipsilateral conversion to a higher level of amputation), and cumulative mortality rate at 1 year. The impact of the operating surgeon’s specialty (vascular vs. non-vascular surgeon) on outcomes was evaluated.

Results

The study cohort comprised 140 patients who underwent MLEA (110 below-knee amputations [BKA] and 30 above-knee amputations [AKA]; ratio: 3:1; 86 men; 54 women; mean age, 62.9 ± 1.1 years). Comorbidities included diabetes, hypertension, dyslipidaemia, ischaemic heart disease, congestive heart failure, chronic kidney disease, stroke, and Buerger disease. The only associated comorbidity was chronic kidney disease, which was more prevalent among BKA patients (p = 0.047). Indications for MLEA included DFS, and lower limb ischaemia. Acute limb ischaemia was more likely to be an indication for AKA (p = 0.006). LOS was considerably longer for AKA (p = 0.035). The cumulative mortality rate at 1 year was 30.7%. Revision surgery rates and LOS improved significantly with increased rate of vascular surgeon-led MLEA.

Conclusions

In developing countries, the adverse impact of MLEA is increased because of limited resources and increased prevalence of diabetes-related foot complications. Vascular surgeon-led MLEA is associated with decreased revision rates, LOS and possibly improved outcomes, particularly when it is performed for vascular insufficiency. It is important to formulate national health care policies to improve patient outcomes in these countries.

Time Trends in the Incidence of Long-Term Mortality in T2DM Patients Who Have Undergone a Lower Extremity Amputation. Results of a Descriptive and Retrospective Cohort Study

(1) Background: The aims of this study were to examine the incidence of lower extremity amputations (LEAs) among patients with type 2 diabetes mellitus (T2DM) and to compare the mortality risk of diabetic individuals who underwent LEA with age and sex-matched diabetic individuals without LEA. (2) Methods: We performed a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients. Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure (HR 1.75; 95% CI 1.65–1.87). Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk.

Low Back Pain in Adults With Transfemoral Amputation: A Retrospective Population-Based Study

BACKGROUND

Low back pain (LBP) is common among individuals with transfemoral amputation (TFA) and has a negative impact on quality of life. Little is known about health care utilization for LBP in this population and whether utilization varies by amputation etiology.

OBJECTIVE

To determine if individuals with TFA have an increased likelihood of seeking care or reporting symptoms of acute or chronic LBP during physician visits after amputation compared with matched individuals without amputation.

DESIGN

Retrospective cohort.

SETTING

Olmsted County, Minnesota (2010 population: 144 248).

PARTICIPANTS

All individuals with incident TFA (N = 96), knee disarticulation, and transfemoral amputation residing in Olmsted County between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency. Individuals were divided by etiology of amputation: dysvascular and trauma/cancer.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

Death and presentation for evaluation of LBP (LBP event) while residing in Olmsted County. LBP events were identified using validated International Classification of Diseases, Ninth Revision (ICD-9) codes and corresponding Berkson, Hospital International Classification of Diseases Adapted (HICDA), and ICD-10 diagnostic codes. Hurdle and competing-risk Cox proportional hazard models were used.

RESULTS

Having a TFA of either etiology did appear to correlate with increased frequency of LBP events, although this association was only statistically significant within the dysvascular TFA cohort (dysvascular TFA cohort: relative risk [RR] 1.80, 95% confidence interval [CI] 1.07-3.03, median follow-up 0.78 years; trauma/cancer TFA cohort: RR 1.14, 95% CI 0.58-2.22, median follow-up 7.95 years). In time to event analysis, dysvascular TFA had an increased risk of death and event. Obesity did not significantly correlate with increased frequency of LBP events or time to event for either cohort. At any given point in time, individuals with TFA of either etiology who had phantom limb pain were 90% more likely to have an LBP event (hazard ratio [HR] 1.91, 95% CI 1.11-3.31). Conditional on not dying and no LBP event within the first 2.5 years, individuals with prosthesis had a decreased risk of LBP events in subsequent years.

CONCLUSIONS

Risk of LBP events appears to vary by TFA etiology. Obesity did not correlate significantly with increased frequency of LBP event or time to event. Phantom limb pain correlated with decreased time to LBP event after amputation. The association between prosthesis receipt and LBP events is ambiguous.

LEVEL OF EVIDENCE

III.

Risk factors for reoperation, readmission, and early complications after below knee amputation

BACKGROUND

Many patients undergoing below knee amputations (BKA) return for subsequent unplanned operations, hospital readmission, or postoperative complications. This unplanned medical management negatively impacts both patient outcomes and our healthcare system. This study primarily investigates the risk factors for unplanned reoperation following BKA.

METHODS

Below knee amputations from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from the years 2012-2014 were identified by CPT code 27880 for amputation through the tibia and fibula. Our query identified 4631 BKA cases, including 30 day complications. Multivariate logistic regression modeling was performed on several patient demographic and disease factors to assess for independent predictors of unplanned reoperation. Secondary outcomes of unplanned and related readmissions (related to the procedure), major complications, minor complications, and mortality were also included in the analysis.

RESULTS

Of 4631 BKAs identified, 9.63% (446/4631) underwent unplanned reoperations and 8.75% (405/4631) had unplanned and related readmissions. Major complications were experienced by 12.8% (593/4631) and minor complications by 8.7% (401/4631). Thirty day mortality rate was 5.14% (238/4631). The most common procedures for unplanned operations were thigh amputations (128/446, 28.7%), debridement/secondary closure (114/446, 25.6%), and revision leg amputations (46/446, 10.32%). Factors associated with an increased risk of unplanned reoperation included patients transferred from another facility (Adjusted Odds Ratio [AOR] = 1.28; p = .04), recent smokers (AOR = 1.34; p = .02), bleeding disorder (AOR = 1.30; p = .02), and preoperative ventilator use (AOR = 2.38; p = .01).

CONCLUSION

Patients that were ongoing/recent smokers, had diagnosed bleeding disorders, required preoperative ventilator use, or were transferred in from another facility were associated with the highest risks of reoperation following BKA. This patient population experiences high rates of reoperation, readmission, complication, and mortality.

Neuropathic diabetic foot ulcers treated with cerium dioxide nanoparticles: A case report

Wound healing in diabetes is frequently impaired and its treatment remains a challenge. The ability of topical application of cerium (Ce) dioxide nanoparticles (CNPs) to accelerate wound healing in an animal model provides a rationale to develop this technology for use in humans affected by traumatic injury, diabetes and burns. We first described a case report of successful topical treatment of neuropathic diabetic foot ulcers with novel gel containing CNPs. The CNPs has bacteriostatic activity, anti-inflammatory properties and can penetrated into the wound tissue and reduced oxidative damage therefore protect regenerative tissue, suggesting a therapeutic potential for topical treatment of diabetic foot ulcers.

Optimal management of diabetic foot osteomyelitis: challenges and solutions

Purpose: Diabetic foot osteomyelitis (DFO) is the most frequent infection associated with diabetic foot ulcers, occurs in >20% of moderate infections and 50%-60% of severe infections, and is associated with high rates of amputation. DFO represents a challenge in both diagnosis and therapy, and many consequences of its condition are related to late diagnosis, delayed referral, or ill-indicated treatment. This review aimed to analyze the current evidence on DFO management and to discuss advantages and disadvantages of different treatment options. Methods: A narrative review of the evidence was begun by searching Medline and PubMed databases for studies using the keywords "management", "diabetic foot", "osteomyelitis", and "diabetic foot osteomyelitis" from 2008 to 2018. Results: We found a great variety of studies focusing on both medical and surgical therapies showing a similar rate of effectiveness and outcomes; however, the main factors in choosing one over the other seem to be associated with the presence of soft-tissue infection or ischemia and the clinical presentation of DFO. Conclusion: Further randomized controlled trials with large samples and long-term follow-up are necessary to demonstrate secondary outcomes, such as recurrence, recurrent ulceration, and reinfection associated with both medical and surgical options.

Amputation-free survival in 17,353 people at high risk for foot ulceration in diabetes: a national observational study

AIMS/HYPOTHESIS

Our aim was to investigate amputation-free survival in people at high risk for foot ulceration in diabetes ('high-risk foot'), and to compare different subcategories of high-risk foot.

METHODS

Overall, 17,353 people with diabetes and high-risk foot from January 2008 to December 2011 were identified from the Scotland-wide diabetes register (Scottish Care Information-Diabetes: N = 247,278). Participants were followed-up for up to 2 years from baseline and were categorised into three groups: (1) those with no previous ulcer, (2) those with an active ulcer or (3) those with a healed previous ulcer. Participants with prior minor or major amputation were excluded. Accelerated failure time models were used to compare amputation-free survival up to 2 years between the three exposure groups.

RESULTS

The 2 year amputation-free survival rate in all people with diabetes with high-risk foot was 84.5%. In this study group, 270 people (10.0%) had an amputation and 2424 (90.0%) died during the 2 year follow-up period. People who had active and healed previous ulcers at baseline had significantly lower 2 year amputation-free survival compared with those who had no previous ulcer (both p < 0.0001). The percentage of people who died within 2 years for those with healed ulcer, active ulcer or no baseline ulcer was 22.8%, 16% and 12.1%, respectively.

CONCLUSIONS/INTERPRETATION

In people judged to be at high risk of foot ulceration, the risk of death was up to nine times the risk of amputation. Death rates were higher for people with diabetes who had healed ulcers than for those with active ulcers. However, people with active ulcers had the highest risk of amputation.

The risk of major cardiovascular events for adults with transfemoral amputation

BACKGROUND

It is well-known that the risk of cardiac disease is increased for those with lower-limb amputations, likely as a result of the etiology of the amputation. Using a longitudinal population-based dataset, we examined the association between transfemoral amputation (TFA) status and the risk of experiencing a major cardiac event for those undergoing either dysvascular or traumatic amputations. The association of receiving a prosthesis with the risk of experiencing a major cardiac event was also examined.

METHODS

Study Population: All individuals with TFA (N 162), i.e. knee disarticulation and transfemoral amputation, residing in Olmsted County, MN, between 1987 and 2014. Each was matched (1:10 ratio) with non-TFA adults on age, sex, and duration of residency.

DATA ANALYSIS

A competing risk Cox proportional hazard model was used to estimate the relative likelihood of an individual with a TFA experiencing a major cardiac event in a given time period as compared to the matched controls. The cohort was divided by amputation etiology: dysvascular vs trauma/cancer. Additional analysis was performed by combining all individuals with a TFA to look at the relationship between prosthesis receipt and major cardiac events.

RESULTS

Individuals with a dysvascular TFA had an approximately four-fold increased risk of a cardiac event after undergoing an amputation (HR 3.78, 95%CI: 3.07-4.49). These individuals also had an increased risk for non-cardiac mortality (HR 6.27, 95%CI: 6.11-6.58). The risk of a cardiac event was no higher for those with a trauma/cancer TFA relative to the able-bodied controls (HR 1.30, 95%CI: 0.30-5.85). Finally, there was no difference in risk of experiencing a cardiac event for those with or without prosthesis (HR 1.20, 95%CI: 0.55-2.62).

CONCLUSION

The high risk of initial mortality stemming from an amputation event may preclude many amputees from cardiovascular disease progression. Amputation etiology is also an important factor: cardiac events appear to be more likely among patients with a dysvascular TFA. Providing a prosthesis does not appear to be associated with a reduced risk of a major cardiac event following amputation.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perioperative and long-term all-cause mortality in patients with diabetes who underwent a lower extremity amputation

INTRODUCTION

Long-term mortality of patients with diabetes who undergo lower extremity amputation (LEA) has not been reported in Spain.

METHODS

The retrospective cohort included all subjects who underwent LEAs from January 1, 2005 to December 31, 2015 in San Jorge Hospital, Huesca, Spain. Live status of every patient up to September 2017 and the date of death were retrieved using the national death index.

RESULTS

The series included 203 patients: 116 patients (57.1%) underwent a minor amputation and 87 patients (42.9%) underwent a major amputation. Twenty-five patients (12.3%) died in the perioperative period. Significant risk factors of perioperative mortality were undergoing an above-the-knee amputation, postoperative cardiac complications, age >74 years and acute renal failure. Survival rates at 1, 3, and 5 years were 90.6, 72.8, and 55.5% in patients who underwent a minor amputation compared with 70.8, 41.3, and 34.4% in patients who underwent a major amputation, respectively. Log-rank test between the two groups was χ² = 12.7 (p < 0.01).

CONCLUSIONS

Long-term survival was worse in patients who underwent a major amputation with a 5-year mortality of 65.6%. This mortality is worse than what has been reported for some types of common malignancies.

Postoperative Death After Lower-Limb Amputation in a National Prevalent Cohort of Patients With Diabetes

OBJECTIVE

The objectives of this study were to 1) describe postoperative mortality after lower-limb amputation in a national prevalent cohort of patients with diabetes, and 2) investigate whether postoperative mortality differs by demographic subgroup, patient morbidity level, and health system factors related to the facility in which the amputation occurred.

RESEARCH DESIGN AND METHODS

A national prevalent cohort of 302,339 individuals diagnosed with diabetes between 2005 and 2014 was followed until the end of 2014 for major and minor lower-limb amputation and subsequent postoperative mortality by using national health data collections. Kaplan-Meier survival analysis was used to determine postoperative survival, whereas Cox proportional hazards models were used to describe the relative hazard of postoperative mortality, adjusted for covariates.

RESULTS

A total of 6,352 lower-limb amputations occurred over the study period (2,570 major amputations, 3,782 minor amputations). More than 11% of patients who underwent major amputation died within 30 days, whereas nearly 18% died within 90 days. Death was most common among older patients and indigenous Māori. Sex, deprivation, rurality, hospital volume, admission type, and patient comorbidity were not consistently or substantially independently associated with risk of postoperative mortality.

CONCLUSIONS

In a national prevalent cohort of patients with diabetes, there was high risk of postoperative mortality as well as a differential risk of postoperative mortality by demographic subgroup. Further work is required to investigate the drivers of postoperative mortality among patients with diabetes who undergo amputation.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Effectiveness of offloading methods in preventing primary diabetic foot ulcers in adults with diabetes: a systematic review

BACKGROUND

The incidence of foot ulceration related to diabetes is increasing. Many foot care professionals recommend offloading measures as part of management strategies for modulating excess pressure to prevent development of diabetic foot ulcers (DFUs). These measures may include padding, insoles/orthotic devices and footwear. There is a lack of evidence-based guidance on the effectiveness of the different offloading options for preventing primary ulceration in those with diabetes.

OBJECTIVES

To identify, critically appraise and synthesize the best available evidence on methods of offloading to prevent the development, and reduce the risk, of primary foot ulceration in adults with diabetes.The question addressed by the review was: what is the effectiveness of methods of offloading in preventing primary DFUs in adults with diabetes?

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Adults 18 years and older with diabetes mellitus, regardless of age, gender, ethnicity, duration or type of diabetes, with no history of DFUs and in any clinical setting will be included.

TYPES OF INTERVENTIONS AND COMPARATORS

Interventions will include all external methods of offloading. All comparators will be considered. Studies that utilize interventions not considered usual practice in the prevention of DFUs will be excluded.

OUTCOMES

The primary outcome will be primary foot ulceration. The secondary outcome will be indications of changes in plantar pressure.

TYPES OF STUDIES

This review will consider all quantitative study designs.

SEARCH STRATEGY

A three-step strategy for published and unpublished literature will be used. Fourteen databases will be searched for studies in English up to November 2013.

DATA EXTRACTION

The JBI-MAStARI extraction tool was used to extract relevant data.

DATA SYNTHESIS

Results were summarized using narrative and tables.

RESULTS

Three studies which examined the effectiveness of four different offloading interventions met the inclusion criteria. There is limited evidence that use of a footwear system (prototype shoe plus polyurethane or cork insole) may prevent a break in the skin; use of customized rigid orthotic devices may contribute to a reduction in the grade and number of calluses; and a manufactured shoe plus customized insole may reduce plantar pressure and therefore reduce the potential risk of skin ulceration.

CONCLUSION

There is limited and low-quality evidence that in a population of adults with diabetes with no history of DFU, the use of footwear with customized or prefabricated orthotic devices may provide some reduction in plantar pressure and therefore help to prevent a primary DFU. There is a lack of evidence on the relative effectiveness of different offloading options.

Diabetes, Frequency of Exercise, and Mortality Over 12 Years: Analysis of the National Health Insurance Service-Health Screening (NHIS-HEALS) Database

BACKGROUND

The goal of this study was to analyze the relationship between exercise frequency and all-cause mortality for individuals diagnosed with and without diabetes mellitus (DM).

METHODS

We analyzed data for 505,677 participants (53.9% men) in the National Health Insurance Service-National Health Screening (NHIS-HEALS) cohort. The study endpoint variable was all-cause mortality.

RESULTS

Frequency of exercise and covariates including age, sex, smoking status, household income, blood pressure, fasting glucose, body mass index, total cholesterol, and Charlson comorbidity index were determined at baseline. Cox proportional hazard regression models were developed to assess the effects of exercise frequency (0, 1-2, 3-4, 5-6, and 7 days per week) on mortality, separately in individuals with and without DM. We found a U-shaped association between exercise frequency and mortality in individuals with and without DM. However, the frequency of exercise associated with the lowest risk of all-cause mortality was 3-4 times per week (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.65-0.73) in individuals without DM, and 5-6 times per week in those with DM (HR, 0.93; 95% CI, 0.78-1.10).

CONCLUSION

A moderate frequency of exercise may reduce mortality regardless of the presence or absence of DM; however, when compared to those without the condition, people with DM may need to exercise more often.

Global aetiology and epidemiology of type 2 diabetes mellitus and its complications

Globally, the number of people with diabetes mellitus has quadrupled in the past three decades, and diabetes mellitus is the ninth major cause of death. About 1 in 11 adults worldwide now have diabetes mellitus, 90% of whom have type 2 diabetes mellitus (T2DM). Asia is a major area of the rapidly emerging T2DM global epidemic, with China and India the top two epicentres. Although genetic predisposition partly determines individual susceptibility to T2DM, an unhealthy diet and a sedentary lifestyle are important drivers of the current global epidemic; early developmental factors (such as intrauterine exposures) also have a role in susceptibility to T2DM later in life. Many cases of T2DM could be prevented with lifestyle changes, including maintaining a healthy body weight, consuming a healthy diet, staying physically active, not smoking and drinking alcohol in moderation. Most patients with T2DM have at least one complication, and cardiovascular complications are the leading cause of morbidity and mortality in these patients. This Review provides an updated view of the global epidemiology of T2DM, as well as dietary, lifestyle and other risk factors for T2DM and its complications.

Role of plasma growth factor in the healing of chronic ulcers of the lower legs and foot due to ischaemia in diabetic patients

Introduction

It has been demonstrated that plasma growth factor (PGF) responsible for proliferation of smooth muscle cells and fibroblasts significantly shortens treatment duration.

Aim

To determine the role of human growth factor in the healing of ulcers due to ischaemic diabetic foot syndrome (DFS) following previous angioplasty of the blood vessels of the lower leg and foot.

Material and methods

The study group included 50 patients with ischaemic diabetic foot complicated by lower leg ulcers in which angioplasty of the stenotic arteries in the distal lower leg and foot was performed. It has been assumed that the area of the ulcer cannot exceed 5 cm². Following surgical debridement, each patient received platelet-rich plasma in the form of dressings applied on an ulcer, followed by hydrocolloid dressings. Each dressing was replaced after 10 days, and this procedure was repeated after 20 and 30 days of treatment. The control group included 50 patients with ischaemic diabetic foot complicated by an ulcer up to 5 cm². Angioplasty of the lower leg arteries was also performed in this group. However, after surgical debridement, wounds were covered with hydrocolloid dressings.

Results

After 3 months of combined treatment, all wounds in the study group healed whereas in the control group, only wounds of the smallest size healed.

Conclusions

Combined treatment of ulcers due to ischaemic DFS with endovascular procedures to re-establish blood flow to the vessels and dressings with autologous platelet-rich plasma significantly shortens the healing time.