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Pitsenbarger LT, Som MN, Chao NT, Workneh EN, Karwoski AS, Dunlap E, Simmonds Fitzpatrick S, Nagarsheth KH. Moderate and Severe Chronic Kidney Disease Predict Greater 5-Year Mortality following Major Lower-Extremity Amputation. Ann Vasc Surg 2024; 105:307-315. [PMID: 38599481 DOI: 10.1016/j.avsg.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 02/08/2024] [Accepted: 02/10/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Severe chronic kidney disease (CKD) predicts greater mortality after major lower-extremity amputation (LEA), but it remains poorly understood whether patients with earlier stages of CKD share similar risk. METHODS We assessed long-term postoperative outcomes for patients with CKD in a retrospective chart review of 565 patients who underwent atraumatic major LEA at a large tertiary referral center from 2015 to 2021. We stratified patients by renal function and compared outcomes including survival. RESULTS Preoperative CKD diagnosis was related to many patient characteristics, co-occurred with many comorbidities, and was associated with less follow-up and survival. Kaplan-Meier and Cox Regression analyses showed significantly worse 5-year survival for major LEA patients with mild, moderate, or severe CKD compared to major LEA patients with no history of CKD at the time of amputation (P < 0.001). Severe CKD independently predicted worse mortality at 1-year (odds ratio [OR] 2.91; P = 0.003) and 5-years (OR 3.08; P < 0.001). Moderate CKD independently predicted worse 5-year mortality (OR 2.66; P = 0.029). CONCLUSIONS This study demonstrates that moderate and severe CKD predict greater long-term mortality following major LEA when controlling for numerous potential confounders. This finding raises questions about the underlying mechanism if causal and highlights an opportunity to improve outcomes with earlier recognition and optimization CKD preoperatively.
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Affiliation(s)
- Luke T Pitsenbarger
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Maria N Som
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie T Chao
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eyerusalem N Workneh
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Allison S Karwoski
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eleanor Dunlap
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Khanjan H Nagarsheth
- Department of Surgery, Vascular Division, University of Maryland School of Medicine, Baltimore, MD, USA
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Pitsenbarger LT, Som MN, Chao NT, Workneh EN, Dunlap N, Fitzpatrick SS, Nagarsheth KH. Chronic Kidney Disease Predicts Greater 5-Year Mortality Following Major Limb Amputation. Am Surg 2023; 89:3841-3843. [PMID: 37137167 DOI: 10.1177/00031348231173992] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Severe chronic kidney disease (CKD) predicts greater mortality after major lower extremity amputation (MLEA), but it remains poorly understood whether this finding extends to patients with earlier stages of CKD. We assessed outcomes for patients with CKD in a retrospective chart review of all patients who underwent MLEA at a large tertiary referral center from 2015 to 2021. We stratified 398 patients by glomerular filtration rate (GFR) and conducted Chi-Square and survival analysis. Preoperative CKD diagnosis was associated with many comorbidities, less 1-year follow-up, and greater 1- and 5-year mortality. Kaplan-Meier analysis showed worse 5-year survival for patients with any stage of CKD (62%) compared to patients without CKD (81%; P < .001). Greater 5-year mortality was independently predicted by moderate CKD (hazard ratio (HR) 2.37, P = .02) as well as severe CKD (HR 2.09, P = .005). These findings demonstrate the importance of identifying and treating CKD early preoperatively.
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Affiliation(s)
- Luke T Pitsenbarger
- Vascular Division, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Maria N Som
- Vascular Division, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie T Chao
- Vascular Division, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eyerusalem N Workneh
- Vascular Division, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nora Dunlap
- Vascular Division, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Khanjan H Nagarsheth
- Vascular Division, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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3
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Mufarrih SH, Qureshi NQ, Yunus RA, Katsiampoura A, Quraishi I, Sharkey A, Mahmood F, Matyal R. A Systematic Review and Meta-analysis of General versus Regional Anesthesia for Lower Extremity Amputation. J Vasc Surg 2022; 77:1542-1552.e9. [PMID: 36243265 DOI: 10.1016/j.jvs.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Postoperative morbidity in patients undergoing lower extremity amputation (LEA) has remained high. Studies investigating the influence of the anesthetic modality on the postoperative outcomes have yielded conflicting results. The aim of our study was to assess the effects of regional anesthesia vs general anesthesia on postoperative complications for patients undergoing LEA. METHODS We systematically searched PubMed, Embase, MEDLINE, Web of Science, and Google Scholar from 1990 to 2022 for studies investigating the effect of the anesthetic modality on the postoperative outcomes after LEA. Regional anesthesia (RA) included neuraxial anesthesia and peripheral nerve blocks. The outcomes included 30-day mortality, respiratory failure (unplanned postoperative intubation, failure to wean, mechanical ventilation >24 hours), surgical site infection, cardiac complications, urinary tract infection, renal failure, sepsis, venous thrombosis, pneumonia, and myocardial infarction. RESULTS Of the 25 studies identified, we included 10 retrospective observational studies with 81,736 patients, of whom 69,754 (85.3%) had received general anesthesia (GA) and 11,980 (14.7%) had received RA. In the GA group, 50,468 patients were men (63.8%), and in the RA group, 7813 patients were men (62.3%). The results of the meta-analyses revealed that GA was associated with a higher rate of respiratory failure (odds ratio, 1.38; 95% confidence interval, 1.06-1.80; P = .02) and sepsis (odds ratio, 1.21; 95% confidence interval, 1.11-1.33; P < .0001) compared with RA. No differences were found in postoperative 30-day mortality, surgical site infection, cardiac complications, urinary tract infection, renal failure, venous thrombosis, pneumonia, and myocardial infarction between the GA and RA groups. CONCLUSIONS The results of our meta-analysis have shown that GA could be associated with a higher rate of respiratory failure and sepsis compared with RA for LEA.
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4
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Clarke CE, Tettelbach WH. Unique closure of Gustilo IIIA fracture with a hard-to-heal lower extremity wound. J Wound Care 2021; 30:S24-S27. [PMID: 33573493 DOI: 10.12968/jowc.2021.30.sup2.s24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Consistently achieving wound closure requires a broad understanding of wound physiology, anatomy and wound healing phases. The multifaceted principles of wound closure are comprised of: perfusion evaluation; diabetes control; nutritional optimisation; infection control; mechanical stress avoidance; oedema management; wound bed preparation; and community care. Optimisation of each element is crucial to timely and durable resolution of acute and hard-to-heal wounds. This objective is realisable only through an interdisciplinary approach to wound healing. The reconstructive ladder represents the graduation of complex wound management as applied by the specialty of plastic surgery. The approach to reconstruction typically begins with the least invasive option, which is considered reliable. However, there are instances when the most reliable option on the reconstructive ladder is not a viable option and creative solutions for wound closure are required. The following case report demonstrates a unique approach to lower extremity salvage in a subacute compound fracture surgical site infection using a limited reconstructive ladder.
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Affiliation(s)
| | - William H Tettelbach
- 2 Medical Affairs, MiMedx Group, Inc., Marietta, GA.,3 Medical Director of Wound Care-Western Peaks Specialty Hospital, Bountiful, UT.,4 Adjunct Assistant Professor of Undersea & Hyperbaric Medicine-Duke University School of Medicine, Durham, NC.,5 Adjunct Professor of Podiatric Medicine & Surgery-Western University of Health Sciences, Pomona, CA
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Meshkin DH, Zolper EG, Chang K, Bryant M, Bekeny JC, Evans KK, Attinger CE, Fan KL. Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2021; 60:567-576. [PMID: 33509714 DOI: 10.1053/j.jfas.2020.06.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 02/03/2023]
Abstract
Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.
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Affiliation(s)
- Dean H Meshkin
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Elizabeth G Zolper
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Kevin Chang
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Meigan Bryant
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Christopher E Attinger
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Kenneth L Fan
- Assistant Professor Plastic Surgery, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
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6
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Cascini S, Agabiti N, Davoli M, Uccioli L, Meloni M, Giurato L, Marino C, Bargagli AM. Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems. BMJ Open Diabetes Res Care 2020; 8:8/1/e001355. [PMID: 32690575 PMCID: PMC7371030 DOI: 10.1136/bmjdrc-2020-001355] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/01/2020] [Accepted: 06/16/2020] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Silvia Cascini
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Luigi Uccioli
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Lazio, Italy
| | - Marco Meloni
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Lazio, Italy
| | - Laura Giurato
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Lazio, Italy
| | - Claudia Marino
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Lee SR, Zhuo H, Zhang Y, Dahl N, Dardik A, Ochoa Chaar CI. Risk factors and safe contrast volume thresholds for postcontrast acute kidney injury after peripheral vascular interventions. J Vasc Surg 2019; 72:603-610.e1. [PMID: 31843298 DOI: 10.1016/j.jvs.2019.09.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 09/24/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Postcontrast acute kidney injury (PC-AKI) is a dreaded complication of peripheral vascular interventions (PVIs) that depends on the volume of contrast administered as well as a patient's baseline kidney function. However, there is currently no guidance on the volume of contrast that is considered safe especially for patients with advanced chronic kidney disease (CKD). This study aims to characterize the incidence, risk factors for, and outcomes after PC-AKI and define thresholds of safety for contrast volume. METHODS The Vascular Quality Initiative files for PVI (2010-2018) were reviewed. Patients on dialysis, with renal transplants, or who developed a bleeding complication were excluded. Only records with complete data on baseline creatinine, contrast volume, and PC-AKI (creatinine increase of ≥0.5 mg/dL, or new dialysis requirement) were included. The cumulative incidence of PC-AKI with contrast volume at each stage of CKD was derived. A safe threshold for contrast volume was defined as the volume at which the cumulative incidence of PC-AKI is 0.5% or less. Multivariable logistic regression was used to define risk factors for PC-AKI, and survival analysis was performed using Kaplan-Meier and multivariable Cox proportional hazards regression. RESULTS A total of 53,780 procedures were included. There were 16,062 patients (29%) with normal kidney function or CKD1, 21,769 (39%) with CKD2, 14,234 (25%) with CKD3, 1471 (3%) with CKD4, and 199 (<1%) with CKD5. The incidence of PC-AKI was 0.9% and increased with each stage of CKD (CKD1, 0.39%; CKD2, 0.45%; CKD3, 1.5%; CKD4, 4.3%; and CKD5, 7.5%). The safe thresholds for contrast volume for advanced CKD were 50, 20, and 9 mL for CKD3, CKD4, and CKD5, respectively. Regression analysis demonstrated that white race (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.54-0.82) and elective surgery (OR, 0.77; 95% CI, 0.62-0.95) were associated with decreased risk of PC-AKI, whereas inpatient status (OR, 14.5; 95% CI, 9.97-21.2), diabetes (OR, 1.27; 95% CI, 1.02-1.58), advanced CKD (CKD3: OR, 3.65; 95% CI, 2.68-4.98; CKD4: OR, 6.98; 95% CI, 4.72-10.3; CKD5: OR, 8.94; 95% CI, 4.53-17.6), critical limb ischemia (OR, 1.51; 95% CI, 1.14-2.00), acute limb ischemia (OR, 2.47; 95% CI, 1.70-3.59), and contrast-to-eGFR ratio (CGR) (2 ≤ CGR < 3: OR, 1.33; 95% CI, 1.02-1.74; 3 ≤ CGR < 4: OR, 1.90; 95% CI, 1.32-2.75; CGR ≥ 4: OR, 1.79; 95% CI, 1.18-2.70) were significantly associated with increased risk for PC-AKI. Patients who developed PC-AKI had worse in-hospital (16.1% vs 0.45%; P < .01) mortality and long-term survival (log-rank P < .01) compared with those without PC-AKI. CONCLUSIONS PVI are associated with low risk of PC-AKI that significantly increases when patients with advanced CKD undergo high acuity cases. Given the strong association with short-term and long-term mortality, risk of PC-AKI should be minimized by using safe thresholds of contrast volume.
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Affiliation(s)
- Shin-Rong Lee
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Haoran Zhuo
- Surgical Outcomes and Epidemiology, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Yawei Zhang
- Surgical Outcomes and Epidemiology, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Neera Dahl
- Nephrology Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Alan Dardik
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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López-de-Andrés A, Jiménez-García R, Esteban-Vasallo MD, Hernández-Barrera V, Aragon-Sánchez J, Jiménez-Trujillo I, de Miguel-Diez J, Palomar-Gallego MA, Romero-Maroto M, Perez-Farinos N. Time Trends in the Incidence of Long-Term Mortality in T2DM Patients Who Have Undergone a Lower Extremity Amputation. Results of a Descriptive and Retrospective Cohort Study. J Clin Med 2019; 8:jcm8101597. [PMID: 31581755 PMCID: PMC6832955 DOI: 10.3390/jcm8101597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 01/22/2023] Open
Abstract
(1) Background: The aims of this study were to examine the incidence of lower extremity amputations (LEAs) among patients with type 2 diabetes mellitus (T2DM) and to compare the mortality risk of diabetic individuals who underwent LEA with age and sex-matched diabetic individuals without LEA. (2) Methods: We performed a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients. Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure (HR 1.75; 95% CI 1.65–1.87). Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk.
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Affiliation(s)
- Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain.
| | | | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier Aragon-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, 35005 Las Palmas de Gran Canaria, Spain.
| | - Isabel Jiménez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain.
| | - Maria A Palomar-Gallego
- Basic Science Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Martin Romero-Maroto
- Medical Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Napoleón Perez-Farinos
- Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Malaga, 29071 Malaga, Spain.
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9
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Leite JO, Costa LO, Fonseca WM, Souza DU, Goncalves BC, Gomes GB, Cruz LA, Nister N, Navarro TP, Bath J, Dardik A. General outcomes and risk factors for minor and major amputations in Brazil. Vascular 2017; 26:291-300. [PMID: 29041830 DOI: 10.1177/1708538117736677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Major and minor amputations are associated with significant rates of mortality. However, little is known about the impact of unplanned redo-amputation during the same hospitalization on outcomes. The objectives of this study were to identify the risk factors associated with in-hospital mortality after both major and minor amputations as well as the results of unplanned redo-amputation on outcome. Methods Retrospective study of 342 consecutive patients who were treated with lower extremity amputation in Brazil between January 2013 and October 2014. Results The in-hospital mortality rate was higher in major compared to minor amputation (25.6% vs. 4.1%; p < 0.0001). Whereas chronic kidney disease, chronic obstructive pulmonary disease, and planned staged amputation predicted in-hospital mortality after major amputation, age, and congestive heart failure predicted mortality after minor amputation. The white blood cell count predicted in-hospital mortality following both major and minor amputation. However, postoperative infection predicted in-hospital mortality only following major amputation. Conclusions In-hospital mortality was high after major amputations. Unplanned redo-amputation was not a predictor of in-hospital mortality after major or minor amputation. Planned staged amputation was associated with reduced survival after major but not minor amputation. Postoperative infection predicted mortality after major amputation. Systemic diseases and postoperative white blood cell were associated with in-hospital mortality. This study suggests a possible link between a pro-inflammatory state and increased in-hospital mortality following amputation.
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Affiliation(s)
- Jose O Leite
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Leandro O Costa
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Walter M Fonseca
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Debora U Souza
- 2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil.,3 Faculdade de Fisioterapia, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Barbara C Goncalves
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Gabriela B Gomes
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Lucas A Cruz
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Nilder Nister
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Tulio P Navarro
- 1 Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil.,2 Departamento de Cirurgia Vascular, Hospital Risoleta Tolentino Neves, Belo Horizonte, Brazil
| | - Jonathan Bath
- 4 Department of Surgery, Division of Vascular Surgery, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Alan Dardik
- 5 Department of Surgery, Division of Vascular Surgery, Yale School of Medicine, Yale University, New Haven, USA
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Lopez-de-Andres A, Hernandez-Barrera V, Lopez R, Martin-Junco P, Jimenez-Trujillo I, Alvaro-Meca A, Salinero-Fort MA, Jimenez-Garcia R. Predictors of in-hospital mortality following major lower extremity amputations in type 2 diabetic patients using artificial neural networks. BMC Med Res Methodol 2016; 16:160. [PMID: 27876006 PMCID: PMC5120563 DOI: 10.1186/s12874-016-0265-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/16/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Outcome prediction is important in the clinical decision-making process. Artificial neural networks (ANN) have been used to predict the risk of post-operative events, including survival, and are increasingly being used in complex medical decision making. We aimed to use ANN analysis to estimate predictive factors of in-hospital mortality (IHM) in patients with type 2 diabetes (T2DM) after major lower extremity amputation (LEA) in Spain. METHODS We design a retrospective, observational study using ANN models. We used the Spanish National Hospital Discharge Database to select all hospital admissions of major LEA procedure in T2DM patients. MAIN OUTCOME MEASURES Predictors of IHM using 4 ANN models: i) with all discharge diagnosis included in the database; ii) with all discharge diagnosis included in the database, excluding infectious diseases; iii) comorbidities included in the Charlson Comorbidities Index; iv) comorbidities included in the Elixhauser Comorbidity Index. RESULTS From 2003 to 2013, 40,857 major LEAs in patients with T2DM were identified with a 10.0% IHM. We found that Elixhauser Comorbidity Index model performed better in terms of sensitivity, specificity and precision than Charlson Comorbidity Index model (0.7634 vs 0.7444; 0.9602 vs 0.9121; 0.9511 vs 0.888, respectively). The area under the ROC curve for Elixhauser comorbidity model was 91.7% (95% CI 90.3-93.0) and for Charlson comorbidity model was 88.9% (95% CI; 87.590.2) p = 0.043. Models including all discharge diagnosis with and without infectious diseases showed worse results. In the Elixhauser Comorbidity Index model the most sensitive parameter was age (variable sensitive ratio [VSR] 1.451) followed by female sex (VSR 1.433), congestive heart failure (VSR 1.341), renal failure (VSR 1.274) and chronic pulmonary disease (VSR 1.266). CONCLUSIONS Elixhauser Comorbidity Index is a superior comorbidity risk-adjustment model for major LEA survival prediction in patients with T2DM than Charlson Comorbidity Index model using ANN models. Female sex, congestive heart failure, and renal failure are strong predictors of mortality in these patients.
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Affiliation(s)
- Ana Lopez-de-Andres
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avda. de Atenas s/n, 28922, Alcorcón, Comunidad de Madrid, Spain.
| | - Valentin Hernandez-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avda. de Atenas s/n, 28922, Alcorcón, Comunidad de Madrid, Spain
| | | | | | - Isabel Jimenez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avda. de Atenas s/n, 28922, Alcorcón, Comunidad de Madrid, Spain
| | - Alejandro Alvaro-Meca
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avda. de Atenas s/n, 28922, Alcorcón, Comunidad de Madrid, Spain
| | - Miguel Angel Salinero-Fort
- Dirección Técnica de Docencia e Investigación, Gerencia Atención Primaria, Madrid, Comunidad de Madrid, Spain
| | - Rodrigo Jimenez-Garcia
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, Avda. de Atenas s/n, 28922, Alcorcón, Comunidad de Madrid, Spain
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Venkataraman K, Fong NP, Chan KM, Tan BY, Menon E, Ee CH, Lee KK, Koh GCH. Rehabilitation Outcomes After Inpatient Rehabilitation for Lower Extremity Amputations in Patients With Diabetes. Arch Phys Med Rehabil 2016; 97:1473-1480. [PMID: 27178094 DOI: 10.1016/j.apmr.2016.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 04/05/2016] [Accepted: 04/14/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify factors associated with functional gain, discharge destination, and long-term survival after inpatient rehabilitation in patients with lower extremity amputation and diabetes. DESIGN Retrospective medical records review. SETTING All community hospitals. PARTICIPANTS Patients with diabetes (N=256) admitted for inpatient rehabilitation after lower extremity amputation. INTERVENTIONS Not applicable. MAIN OUTCOMES MEASURES Absolute functional gain (AFG) using the Shah-modified Barthel Index, discharge destination, and long-term survival for each patient. RESULTS Length of stay (B=.15; 95% confidence interval [CI], .08-.21; P<.001) and admission functional status (B=-.09; 95% CI, -.18 to -.01; P=.032) were significantly associated with AFG. Availability of caregiver (foreign domestic worker: odds ratio [OR], 16.39; 95% CI, 4.65-57.78; P<.001; child: OR, 3.82; 95% CI, 1.31-11.12; P=.014; spouse: OR, 2.82; 95% CI, 1.07-7.46; P=.037 vs none), Charlson Comorbidity Index of 1 (OR, 4.32; 95% CI, 1.34-13.93; P=.014 vs ≥4), and younger age (OR, .96; 95% CI, .93-.99; P=.02) were significantly associated with being discharged home. Admission functional status (hazard ratio [HR], .98; 95% CI, .97-.99; P<.001), AFG (HR, .99; 95% CI, 0.97-1.00; P=.058), Charlson Comorbidity Index (1 vs ≥4: HR, .42; 95% CI, .24-.77; P=.004), ischemic heart disease (HR, 2.25; 95% CI, 1.27-4.00; P=.006), discharge destination (other vs home: HR, 1.82; 95% CI, 1.02-3.23; P=.041), age (HR, 1.02; 95% CI, 1.00-1.03; P=.082), and ethnicity (Malay vs Chinese: HR, .37; 95% CI, .16-.87; P=.022) predicted survival postamputation. CONCLUSIONS Admission functional status predicted both functional gain during rehabilitation and survival in these patients. We also found ethnic differences in outcomes, with Malays having better survival after amputation. Lastly, there appears to be greater reliance on foreign domestic workers as caregivers, with patients with foreign domestic workers as their primary caregiver having the highest odds of being discharged home.
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Affiliation(s)
- Kavita Venkataraman
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Ngan Phoon Fong
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - Kin Ming Chan
- Medical Services, Ang Mo Kio Thye Hua Kwan Hospital, Singapore
| | | | - Edward Menon
- Medical Services, St Andrew's Community Hospital, Singapore
| | - Chye Hua Ee
- Elder Care and Health Consultancy, Singapore
| | | | - Gerald Choon-Huat Koh
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore.
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