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Tehan PE, Donnelly H, Martin E, Peterson B, Hawke F. Experiences and impact of a rural Australian high-risk foot service: A multiple-methods study. Aust J Rural Health 2024; 32:286-298. [PMID: 38337146 DOI: 10.1111/ajr.13087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 12/15/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024] Open
Abstract
OBJECTIVE Most podiatry-led high-risk foot services (HRFS) in Australia are located in metropolitan areas or large regional centres. In rural areas, where there are limited specialist services, individuals with diabetes-related foot ulceration are more likely to undergo amputation. This study aimed to explore clinicians' perceptions of a recently implemented HRFS in rural New South Wales, Australia, and compare trends of amputation and hospitalisation prior to and post-implementation of the service. SETTING Rural HRFS in Tamworth, New South Wales, Australia. PARTICIPANTS Health professionals working within the HRFS were recruited to participate. DESIGN This was a multiple-methods study. For the qualitative arm, semi-structured interviews were conducted, which were analysed using a reflexive thematic approach. The quantitative arm of the study utilised a retrospective analytic design which applied an interrupted time series to compare amputation and hospitalisation trends pre- and post-implementation of the HRFS utilising diagnostic and procedural ICD codes. RESULTS The qualitative arm of the study derived three themes: (1) navigating the divide, (2) rural community and rural challenges and (3) professional identity. Results of the interrupted time series indicate that there was a downward trend in major amputations following implementation of the HRFS; however, this was not statistically significant. CONCLUSION Clinicians were aware of the inequity in DFD outcomes between rural and metropolitan areas and were committed to improving outcomes, particularly with respect to First Nations peoples. Future research will explore service use and amputation rates in the longer term to further evaluate this specialised multidisciplinary care in a rural community.
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Affiliation(s)
- Peta Ellen Tehan
- Subfaculty of Clinical and Molecular Sciences, Faculty of Medicine, Nursing and Allied Health, Monash University, Clayton, Victoria, Australia
- Podiatry and High Risk Foot Service, Hunter New England Local Health District, Newcastle, New South Wales, Australia
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Hailey Donnelly
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
| | - Emma Martin
- Podiatry and High Risk Foot Service, Hunter New England Local Health District, Tamworth, New South Wales, Australia
| | - Benjamin Peterson
- Department of Podiatry, School of Health, Medical and Applied Sciences, CQUniversity, Rockhampton, Queensland, Australia
| | - Fiona Hawke
- School of Health Sciences, College of Health, Medicine and Wellbeing, University of Newcastle, Callaghan, New South Wales, Australia
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Martinez OP, Storo K, Provenzano Z, Murphy E, Tomita TM, Cox S. A systematic review and meta-analysis on the influence of sociodemographic factors on amputation in patients with peripheral arterial disease. J Vasc Surg 2024; 79:169-178.e1. [PMID: 37722513 DOI: 10.1016/j.jvs.2023.08.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To identify disparities in sociodemographic factors that are associated with major lower limb amputation in patients with peripheral arterial disease (PAD). METHODS A systematic review of the literature was performed to identify studies that reported major lower limb amputation rates in patients with PAD among different sociodemographic groups. Data that compared amputation rates on the basis of sex, race, ethnicity, income, insurance, geography, and hospital type were collected and described. Outcomes were then aggregated and standardized, and a meta-analysis was performed to synthesis data into single odds ratios (ORs). RESULTS Forty-one studies were included in the review. There was no association found between males and females (OR, 0.95; 95% confidence interval [CI], 0.90-1.00). Compared with Whites, higher rates of amputation were seen among Blacks/African Americans (OR, 2.02; 95% CI, 1.81-2.26) and Native Americans (OR, 1.22; 95% CI, 1.04-1.45). No significant association was found between Whites and Asians, Native Hawaiians, or Pacific Islanders (OR, 1.15; 95% CI, 1.00-1.33). Hispanics had higher rates of amputation compared with non-Hispanics (OR, 1.36; 95% CI, 1.22-1.52). Compared with private insurance, higher rates of amputation were seen among Medicare patients (OR, 1.38; 95% CI, 1.27-1.50), Medicaid patients (OR, 1.59; 95% CI, 1.44-1.76), and noninsured patients (OR, 1.41; 95% CI, 1.02-1.95). Compared with the richest income quartile, higher rates of amputation were seen among the second income quartile (OR, 1.10; 95% CI, 1.05-1.15), third income quartile (OR, 1.20; 95% CI, 1.07-1.35), and bottom income quartile (OR, 1.36; 95% CI, 1.24-1.49). There was no association found between rural and urban populations (OR, 1.35; 95% CI, 0.92-1.97) or between teaching and nonteaching hospitals (OR, 1.01; 95% CI, 0.91-1.12). CONCLUSIONS Our study has identified a number of disparities and quantified the influence of sociodemographic factors on major lower limb amputation rates owing to PAD between groups. We believe these findings can be used to better target interventions aimed at decreasing amputation rates, although further research is needed to better understand the mechanisms behind our findings.
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Affiliation(s)
- O Parker Martinez
- University of South Carolina School of Medicine Columbia, Columbia, SC.
| | - Katharine Storo
- University of South Carolina School of Medicine Columbia, Columbia, SC
| | | | - Eric Murphy
- University of South Carolina School of Medicine Columbia, Columbia, SC
| | - Tadaki M Tomita
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Huang YL, Ho WT, Wu CC, Li TC. The incidence and trend of geriatric amputations in Taiwan from 1996 to 2013. Prosthet Orthot Int 2022; 46:175-182. [PMID: 35412524 DOI: 10.1097/pxr.0000000000000072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND There has been a reported reduction in the incidence of amputation, but it is unclear whether the number of amputations has decreased in the elderly, a cohort that typically has the largest proportion of amputees. OBJECTIVES To investigate the incidence proportion and time trends of amputation in patients aged ≥ 65 years in Taiwan. STUDY DESIGN A retrospective cohort study from a large national database. METHODS The records of patients who underwent an amputation were collected from a nationally representative sample of 1,000,000 enrollees of Taiwan's National Health Insurance program during 1996-2013. The patients were divided into four age groups: ≤64, 65-74, 75-84, and ≥85 years. Joinpoint regression was performed with adjustment for age and sex to identify changes in incidence proportion by year. RESULTS During the 18 years, the incidence of upper and lower limb amputation decreased significantly in the total population, with the average annual percentage change (AAPC) of -6.1 and -1.8, respectively. However, in the elderly population over 65 years, the incidence did not decrease significantly for upper minor amputation, lower minor amputation, and major amputation with the AAPC of -1.1, -0.1, and -0.4, respectively. Although not significant, the incidence of major and minor lower limb amputation in the population over 85 years old showed an increasing trend, with the AAPC of 1.2 and 3.2, respectively. CONCLUSION During the study period, although the incidence of amputation of the overall population decreased in Taiwan, this trend was not simultaneously observed in the elderly and hence, it should not be ignored.
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Affiliation(s)
- Ya-Ling Huang
- Department of Physical Medicine and Rehabilitation, Cathay General Hospital, Taipei, Taiwan, Republic of China
| | - Wei-Te Ho
- Department of Physical Medicine and Rehabilitation, Cathay General Hospital, Taipei, Taiwan, Republic of China
| | - Chun-Chieh Wu
- Department of Physical Medicine and Rehabilitation, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan, Republic of China
| | - Tung-Chou Li
- Department of Physical Medicine and Rehabilitation, Cathay General Hospital, Taipei, Taiwan, Republic of China
- School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan, Republic of China
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Rodrigues BT, Vangaveti VN, Urkude R, Biros E, Malabu UH. Prevalence and risk factors of lower limb amputations in patients with diabetic foot ulcers: A systematic review and meta-analysis. Diabetes Metab Syndr 2022; 16:102397. [PMID: 35085918 DOI: 10.1016/j.dsx.2022.102397] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 12/24/2021] [Accepted: 01/12/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS The study aimed at determining prevalence and risk factors (RFs) of diabetic lower limb amputations (LLAs). METHODS Electronic databases including PubMed, Medline, Web of Science, and Cochrane Library were searched from January 2003 to April 2021. RESULTS Sixteen full-text published studies were reviewed. The prevalence of LLAs stood as high as 66%, with a combined prevalence of 19% (95% CI 10-29) using the random-effects model. The most prominent RFs for LLA were duration of diabetes mellitus (DM), age, renal impairment, and ethnic minority. Amongst Australians, Indigenous background is strongly associated with increased risk of the diabetic foot (DF) LLA. CONCLUSIONS LLAs are considerably prevalent amongst patients with the DF and occur at even higher rates in patients with multimorbidity.
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Affiliation(s)
- Beverly T Rodrigues
- Translational Research in Endocrinology and Diabetes, College of Medicine and Dentistry, James Cook University, Australia
| | - Venkat N Vangaveti
- Translational Research in Endocrinology and Diabetes, College of Medicine and Dentistry, James Cook University, Australia
| | - Ravindra Urkude
- Department of Neurology, Townsville University Hospital, Australia
| | - Erik Biros
- Translational Research in Endocrinology and Diabetes, College of Medicine and Dentistry, James Cook University, Australia
| | - Usman H Malabu
- Translational Research in Endocrinology and Diabetes, College of Medicine and Dentistry, James Cook University, Australia; Department of Diabetes and Endocrinology, Townsville University Hospital, Australia.
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Mikuls TR, Soto Q, Petro A, Helget L, Roul P, Sayles H, Cope B, Neogi T, LaMoreaux B, O’Dell JR, England BR. Comparison of Rates of Lower Extremity Amputation in Patients With and Without Gout in the US Department of Veterans Affairs Health System. JAMA Netw Open 2022; 5:e2142347. [PMID: 34989795 PMCID: PMC8739736 DOI: 10.1001/jamanetworkopen.2021.42347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/11/2021] [Indexed: 11/28/2022] Open
Abstract
Importance Cardiometabolic and other risk factors could render patients with gout more likely to undergo lower extremity amputation (LEA). Objective To examine the rate of and factors associated with LEA in patients with gout. Design, Setting, and Participants In this matched cohort study using national administrative data, multivariable Cox proportional hazards regression models were used to examine the associations of gout with LEA. In analyses limited to patients with gout, attributes of serum urate control and treatment with urate-lowering therapy were examined as factors associated with LEA. This study included patients who used US Department of Veterans Affairs services from January 1, 2000, to July 31, 2015. Patients with gout were identified using diagnostic codes and matched with up to 10 controls by age, sex, and year of benefit enrollment. Data analysis was performed from January 26, 2021, to September 3, 2021. Exposures Gout classification served as the primary independent variable of interest. In analyses limited to patients with gout, factors associated with serum urate control and urate-lowering therapy were examined. Main Outcomes and Measures Overall LEA, as well as toe, transmetatarsal, below-the-knee, and above-the-knee amputation. Results This cohort study included 5 924 918 patients, 556 521 with gout (mean [SD] age, 67 [12] years; 550 963 (99.0%) male; 88 853 [16.0%] Black non-Hispanic; 16 981 [4.3%] Hispanic/Latinx; 345 818 [62.1%] White non-Hispanic; 80 929 [14.5%] with race and ethnicity data missing; and 23 940 [4.3%] classified as other) and 5 368 397 without gout (mean [SD] age, 67 [12] years; 5 314 344 [99.0%] male; 558 464 [10.4%] Black non-Hispanic; 204 291 [3.0%] Hispanic/Latinx; 3 188 504 [59.4%] White non-Hispanic; 1 257 739 [23.4%)] with race and ethnicity data missing; and 159 399 [3.0%] classified as other). Compared with patients without gout, patients with gout were more likely to undergo amputation, an increased rate that remained after adjustment (adjusted hazard ratio, 1.20; 95% CI, 1.16-1.24) and was highest for below-the-knee amputation (adjusted hazard ratio, 1.59; 95% CI, 1.39-1.81). In those with gout, poor serum urate control (mean >7 mg/dL during the preceding year) was associated with a 25% to 37% increase in the rate of amputation. In contrast, treatment with urate-lowering therapy was not associated with the LEA rate. Conclusions and Relevance In this matched cohort study, patients with gout were more likely to undergo LEA. This increase was independent of other comorbidities that have been associated with amputation, including diabetes and peripheral vascular disease. Serum urate control was independently associated with the LEA rate, suggesting the possibility that lower extremity amputation may be preventable in some patients.
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Affiliation(s)
- Ted R. Mikuls
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Quint Soto
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Alison Petro
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Lindsay Helget
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Punyasha Roul
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Harlan Sayles
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha
| | - Brendan Cope
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Tuhina Neogi
- Section of Rheumatology, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | | | - James R. O’Dell
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Bryant R. England
- Veterans Affairs Nebraska–Western Iowa Health Care System, Omaha, Nebraska
- Division of Rheumatology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
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Lewis RH, Perkins M, Fischer PE, Beebe MJ, Magnotti LJ. Timing is everything: Impact of combined long bone fracture and major arterial injury on outcomes. J Trauma Acute Care Surg 2022; 92:21-27. [PMID: 34670960 DOI: 10.1097/ta.0000000000003430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Timing of extremity fracture fixation in patients with an associated major vascular injury remains controversial. Some favor temporary fracture fixation before definitive vascular repair to limit potential graft complications. Others advocate immediate revascularization to minimize ischemic time. The purpose of this study was to evaluate the timing of fracture fixation on outcomes in patients with concomitant long bone fracture and major arterial injury. METHODS Patients with a combined long bone fracture and major arterial injury in the same extremity requiring operative repair over 11 years were identified and stratified by timing of fracture fixation. Vascular-related morbidity (rhabdomyolysis, acute kidney injury, graft failure, extremity amputation) and mortality were compared between patients who underwent fracture fixation prerevascularization (PRE) or postrevascularization (POST). RESULTS One hundred four patients were identified: 19 PRE and 85 POST. Both groups were similar with respect to age, sex, Injury Severity Score, admission base excess, 24-hour packed red blood cells, and concomitant venous injury. The PRE group had fewer penetrating injuries (32% vs. 60%, p = 0.024) and a longer time to revascularization (9.5 vs. 5.8 hours, p = 0.0002). Although there was no difference in mortality (0% vs. 2%, p > 0.99), there were more vascular-related complications in the PRE group (58% vs. 32%, p = 0.03): specifically, rhabdomyolysis (42% vs. 19%, p = 0.029), graft failure (26% vs. 8%, p = 0.026), and extremity amputation (37% vs. 13%, p = 0.013). Multivariable logistic regression identified fracture fixation PRE as the only independent predictor of graft failure (odds ratio, 3.98; 95% confidence interval, 1.11-14.33; p = 0.03) and extremity amputation (odds ratio, 3.924; 95% confidence interval, 1.272-12.111; p = 0.017). CONCLUSION Fracture fixation before revascularization contributes to increased vascular-related morbidity and was consistently identified as the only modifiable risk factor for both graft failure and extremity amputation in patients with a combined long bone fracture and major arterial injury. For these patients, delaying temporary or definitive fracture fixation until POST should be the preferred approach. LEVEL OF EVIDENCE Prognostic study, Level IV.
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Affiliation(s)
- Richard H Lewis
- From the Department of Surgery University of Tennessee Health Science Center, Memphis, Tennessee
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Abstract
OBJECTIVE The aim of this study was to evaluate associations between time since amputation (TSAmp) and mobility outcomes of adults with lower-limb amputation. DESIGN A secondary analysis of a cross-sectional dataset, including 109 community-dwelling adults, 1 yr or more after unilateral transfemoral (n = 39; mean age, 54 ± 15 yrs) or transtibial (n = 70; mean age = 58 ± 14 yrs) amputation, was conducted. Participants attended standardized clinical evaluations and completed mobility-related outcome measures: Prosthesis Evaluation Questionnaire-Mobility Subscale, timed up and go, 10-m walk test, and 6-min walk test. RESULTS After controlling for age, sex, amputation level, and etiology, TSAmp was significantly associated with each mobility outcome. Prosthesis Evaluation Questionnaire-Mobility Subscale and TSAmp were linearly associated, with TSAmp explaining 10.6% of the overall variance. Timed up and go test time and TSAmp were linearly associated, with TSAmp and an interaction term (LevelxTSAmp) explaining 8.4% of the overall variance; 10-m walk test speed and 6-min walk test distance had nonlinear associations with TSAmp, with TSAmp and nonlinear terms (TSAmp2) explaining 12.1% and 13.2% of the overall variance, respectively. CONCLUSIONS Based on the findings, longer TSAmp may be associated with better Prosthesis Evaluation Questionnaire-Mobility Subscale score and timed up and go test time, whereas longer TSAmp may be associated with better or worse 10-m walk test speed and 6-min walk test distance depending upon time elapsed since lower-limb amputation. Estimations of postamputation mobility among adults with lower-limb amputation should consider TSAmp.
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Affiliation(s)
- Mayank Seth
- Delaware Limb Loss Studies, University of Delaware, Department of Physical Therapy, Newark, Delaware, USA
| | - Emma Haldane Beisheim
- Delaware Limb Loss Studies, University of Delaware, Department of Physical Therapy, Newark, Delaware, USA
| | - Ryan Todd Pohlig
- University of Delaware, Biostatistics Core Facility, Newark, Delaware, USA
| | | | | | - Jaclyn Megan Sions
- Delaware Limb Loss Studies, University of Delaware, Department of Physical Therapy, Newark, Delaware, USA
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Weissler EH, Ford CB, Patel MR, Goodney P, Clark A, Long C, Jones WS. Younger patients with chronic limb threatening ischemia face more frequent amputations. Am Heart J 2021; 242:6-14. [PMID: 34371002 DOI: 10.1016/j.ahj.2021.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/02/2021] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Amputations among younger patients with chronic limb threatening ischemia (CLTI) may carry higher personal and societal costs, but younger patients are often not included in CLTI research because of dataset limitations. We aimed to characterize and compare outcomes between younger (<65 years old) and older patients with CLTI. METHODS This retrospective cohort study identified patients with CLTI between July 1, 2014 and December 31, 2017 in the MarketScan commercial claims database, a proprietary set of claims for over 50 million patients with private insurance in the United States. The primary outcome was major adverse limb events (MALE); secondary outcomes included amputations, major adverse cardiovascular events, and statin prescription fills. RESULTS The study cohort included 64,663 people with CLTI, of whom 25,595 (39.6%) were <65 years old. Younger patients were more likely to have diabetes mellitus (54.1% versus 49.9%, P<.001) but less likely to have other comorbidities. A higher proportion of younger patients suffered MALE (31.7% versus 30.2%, P=.002), specifically amputation (11.5% versus 9.3%, P<.001). After adjustment, age <65 years old was associated with a 24% increased risk of amputation (HRadj 1.24, 95%CI 1.18-1.32, P<.001) and a 10% increased risk of MALE (HRadj 1.10, 95%CI 1.07-1.14, P<.001). CONCLUSIONS A significant proportion of commercially insured patients with CLTI are under the age of 65, and younger patients have worse limb-related outcomes. These findings highlight the importance of aggressively treating risk factors for atherosclerosis and intentionally including younger patients with CLTI in future analyses to better understand their disease patterns and outcomes.
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Affiliation(s)
- E Hope Weissler
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC.
| | - Cassie B Ford
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Manesh R Patel
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Phil Goodney
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Amy Clark
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Chandler Long
- Division of Vascular and Endovascular Surgery, Duke University School of Medicine, Durham, NC
| | - W Schuyler Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC
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Helmink MAG, de Vries M, Visseren FLJ, de Ranitz WL, de Valk HW, Westerink J. Insulin resistance and risk of vascular events, interventions and mortality in type 1 diabetes. Eur J Endocrinol 2021; 185:831-840. [PMID: 34636745 DOI: 10.1530/eje-21-0636] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/11/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To identify determinants associated with insulin resistance and to assess the association between insulin resistance and cardiovascular events, vascular interventions and mortality in people with type 1 diabetes at high risk of cardiovascular disease. DESIGN Prospective cohort study. METHODS One hundred and ninety-five people with type 1 diabetes from the Secondary Manifestations of ARTerial disease (SMART) cohort were included. Insulin resistance was quantified by the estimated glucose disposal rate (eGDR) with higher eGDR levels indicating higher insulin sensitivity (i.e. lower eGDR levels indicating higher insulin resistance). Linear regression models were used to evaluate determinants associated with eGDR. The effect of eGDR on cardiovascular events, cardiovascular events or vascular interventions (combined endpoint) and on all-cause mortality was analysed using Cox proportional hazards models adjusted for confounders. RESULTS In 195 individuals (median follow-up 12.9 years, IQR 6.7-17.0), a total of 25 cardiovascular events, 26 vascular interventions and 27 deaths were observed. High eGDR as a marker for preserved insulin sensitivity was independently associated with a lower risk of cardiovascular events (HR: 0.75; 95% CI: 0.61-0.91), a lower risk of cardiovascular events and vascular interventions (HR: 0.74; 95% CI: 0.63-0.87) and a lower risk of all-cause mortality (HR: 0.81; 95% CI: 0.67-0.98). CONCLUSIONS Insulin resistance as measured by eGDR is an additional risk factor for cardiovascular disease in individuals with type 1 diabetes. Modification of insulin resistance by lifestyle interventions or pharmacological treatment could be a viable therapeutic target to lower the risk of cardiovascular disease.
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Affiliation(s)
- Marga A G Helmink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marieke de Vries
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Wendela L de Ranitz
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Harold W de Valk
- Department of Internal Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
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Hoyt BW, Wade SM, Harrington CJ, Potter BK, Tintle SM, Souza JM. Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes. Clin Orthop Relat Res 2021; 479:2388-2396. [PMID: 34398852 PMCID: PMC8509985 DOI: 10.1097/corr.0000000000001925] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 07/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Flap-based limb salvage surgery balances the morbidity and complexity of soft tissue transfer against the potential benefit of preserving a functional limb when faced with a traumatized extremity with composite tissue injury. These composite tissue injuries are well suited for multidisciplinary management between orthopaedic and plastic surgeons. Thus, it makes intuitive sense that a collaborative, orthoplastic approach to flap-based limb salvage surgery can result in improved outcomes with decreased risk of flap failure and other complications, raising the question of whether this orthoplastic team approach should be the new standard of care in limb salvage surgery. QUESTIONS/PURPOSES (1) Is there an association between increased annual institutional volume and perioperative complications to include free and local flap failure (substantial flap viability loss necessitating return to the operating room for debridement of a major portion or all of the flap or amputation)? (2) Is an integrated orthoplastic collaborative approach to managing combat-related traumatic injuries of the extremities individually associated with a decreased risk of flap failure and overall flap-related complications? (3) What other factors, such as location of injury, injury severity score, and initial inpatient length of stay, were associated with flap necrosis and flap-related complications? METHODS We performed a retrospective review of the electronic medical records of all patients who underwent flap-based limb salvage for combat-related extremity trauma in the United States Military Health System's National Capital Region between January 1, 2003 and December 31, 2012. In total, 307 patients underwent 330 flap procedures. Of the 330 flaps, 59% (195) were local or pedicled flaps and 41% (135) were free flaps. Patients were primarily male (99% [303]), with a median (interquartile range) age of 24 years old (IQR 21 to 29), and 87% (267 of 307) of injuries were sustained from a blast mechanism. We collected data on patient demographics, annual case volume involving flap coverage of extremities, mechanism of injury, flap characteristics, perioperative complications, flap failure, flap revision, isolated orthopaedic management versus an integrated orthoplastic approach, and other salvage procedures. For the purposes of this study, orthoplastic management refers to operative management of flap coverage with microvascular surgeons present for soft tissue transfer after initial debridement and fixation by orthopaedic surgery. The orthoplastic management was implemented on a case-by-case basis based on individual injury characteristics and the surgeon's discretion with no formal starting point. When implemented, the orthoplastic team consisted of an orthopaedic surgeon and microvascular-trained hand surgeons and/or plastic surgeons. In all, 77% (254 of 330) of flaps were performed using this model. We considered perioperative flap complications as any complication (such as infection, hematoma, dehiscence, congestion, or necrosis) resulting in return to the operating room for re-evaluation, correction, or partial debridement of the flap. We defined flap failure as a return to the operating room for debridement of a major portion of the flap or amputation secondary to complete or near-complete loss of flap viability. Of the flap procedures, 12% (40 of 330) were classified as a failure and 14% (46 of 330) experienced complications necessitating return to the operating room. Over the study period, free flaps were not more likely to fail than pedicled flaps (11% versus 13%; p = 0.52) or have complications necessitating additional procedures (14% versus 16%; p = 0.65). RESULTS Our multiple linear regression model demonstrated that an increased number of free flaps performed in our institution annually in any given year was associated with a lower likelihood of failure per case (r = -0.17; p = 0.03) and lower likelihood of reoperation for each flap (r = -0.34; p < 0.001), after adjusting for injury severity and team type (orthoplastic or orthopaedic only). We observed a similar relationship for pedicled flaps, with increased annual case volume associated with a decreased risk of flap failure and reoperation per case after adjusting for injury severity and team type (r = -0.21; p = 0.003 and r = -0.22; p < 0.001, respectively). Employment of a collaborative orthoplastic team approach was associated with decreased flap failures (odds ratio 0.4 [95% confidence interval 0.2 to 0.9]; p = 0.02). Factors associated with flap failure included a lower extremity flap (OR 2.7 [95% CI 1.3 to 6.2]; p = 0.01) and use of muscle flaps (OR 2.3 [95% CI 1.1 to 5.3]; p = 0.02). CONCLUSION Although prior reports of combat-related extremity trauma have described greater salvage success with the use of pedicled flaps, these reports are biased by institutional inexperience with free tissue transfer, the lack of a coordinated multiservice effort, and severity of injury bias (the most severe injuries often result in free tissue transfer). Our institutional experience, alongside a growing body of literature regarding complex extremity trauma in the civilian setting, suggest a benefit to free tissue coverage to treat complex extremity trauma with adequate practice volume and collaboration. We demonstrated that flap failure and flap-related complications are inversely associated with institutional experience regardless of flap type. Additionally, a collaborative orthoplastic approach was associated with decreased flap failures. However, these results must be interpreted with consideration for potential confounding between the increased case volume coinciding with more frequent collaboration between orthopaedic and plastic surgeons. Given these findings, consideration of an orthoplastic approach at high-volume institutions to address soft tissue coverage in complex extremity trauma may lead to decreased flap failure rates. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Benjamin W. Hoyt
- Department of Surgery, Uniformed Services University-Water Reed National Military Medical Center, Bethesda, MD, USA
| | - Sean M. Wade
- Department of Surgery, Uniformed Services University-Water Reed National Military Medical Center, Bethesda, MD, USA
| | - Colin J. Harrington
- Department of Surgery, Uniformed Services University-Water Reed National Military Medical Center, Bethesda, MD, USA
| | - Benjamin K. Potter
- Department of Surgery, Uniformed Services University-Water Reed National Military Medical Center, Bethesda, MD, USA
| | - Scott M. Tintle
- Department of Surgery, Uniformed Services University-Water Reed National Military Medical Center, Bethesda, MD, USA
| | - Jason M. Souza
- Department of Surgery, Uniformed Services University-Water Reed National Military Medical Center, Bethesda, MD, USA
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Matharu K, Chana K, Ferro CJ, Jones AM. Polypharmacology of clinical sodium glucose co-transport protein 2 inhibitors and relationship to suspected adverse drug reactions. Pharmacol Res Perspect 2021; 9:e00867. [PMID: 34586753 PMCID: PMC8480305 DOI: 10.1002/prp2.867] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 08/23/2021] [Accepted: 08/24/2021] [Indexed: 12/19/2022] Open
Abstract
Sodium glucose co-transporter 2 inhibitors (SGLT2i) are a promising second-line treatment strategy for type 2 diabetes mellitus (T2DM) with a developing landscape of both beneficial cardio- and nephroprotective properties and emerging adverse drug reactions (ADRs) including diabetic ketoacidosis (DKA), genetic mycotic infections, and amputations among others. A national register study (MHRA Yellow Card, UK) was used to quantify the SGLT2i's suspected ADRs relative to their Rx rate (OpenPrescribing, UK). The polypharmacology profiles of SGLT2i were data-mined (ChEMBL) for the first time. The ADR reports (n = 3629) and prescribing numbers (Rx n = 5,813,325) for each SGLT2i in the United Kingdom (from launch date to the beginning December 2019) were determined. Empagliflozin possesses the most selective SGLT2/SGLT1 inhibition profile at ~2500-fold, ~10-fold more selective than cangliflozin (~260-fold). Canagliflozin was found to also inhibit CYP at clinically achievable concentrations. We find that for overall ADR rates, empagliflozin versus dapagliflozin and empagliflozin versus canagliflozin are statistically significant (χ2 , p < .05), while dapagliflozin versus canagliflozin is not. In terms of overall ADRs, there is a greater relative rate for canagliflozin > dapagliflozin > empagliflozin. For fatalities, there is a greater relative rate for dapagliflozin > canagliflozin > empagliflozin. An organ classification that resulted in a statistically significant difference between SGLT2i was suspected infection/infestation ADRs between empagliflozin and dapagliflozin. Our findings at this stage of SGLT2i usage in the United Kingdom suggest that empagliflozin, the most selective SGLT2i, had the lowest suspected ADR incident rate (relative to prescribing) and in all reported classes of ADRs identified including infections, amputations, and DKA.
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Affiliation(s)
- Karan Matharu
- School of PharmacyInstitute of Clinical SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Kiran Chana
- School of PharmacyInstitute of Clinical SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Charles J. Ferro
- Birmingham Cardio‐Renal GroupInstitute of Cardiovascular SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
| | - Alan M. Jones
- School of PharmacyInstitute of Clinical SciencesCollege of Medical and Dental SciencesUniversity of BirminghamBirminghamUnited Kingdom
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12
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Fanaroff AC, Yang L, Nathan AS, Khatana SAM, Julien H, Wang TY, Armstrong EJ, Treat‐Jacobson D, Glaser JD, Wang G, Damrauer SM, Giri J, Groeneveld PW. Geographic and Socioeconomic Disparities in Major Lower Extremity Amputation Rates in Metropolitan Areas. J Am Heart Assoc 2021; 10:e021456. [PMID: 34431320 PMCID: PMC8649262 DOI: 10.1161/jaha.121.021456] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/24/2021] [Indexed: 11/16/2022]
Abstract
Background Rates of major lower extremity amputation in patients with peripheral artery disease are higher in rural communities with markers of low socioeconomic status, but most Americans live in metropolitan areas. Whether amputation rates vary within US metropolitan areas is unclear, as are characteristics of high amputation rate urban communities. Methods and Results We estimated rates of major lower extremity amputation per 100 000 Medicare beneficiaries between 2010 and 2018 at the ZIP code level among ZIP codes with ≥100 beneficiaries. We described demographic characteristics of high and low amputation ZIP codes, and the association between major amputation rate and 3 ZIP code-level markers of socioeconomic status-the proportion of patients with dual eligibility for Medicaid, median household income, and Distressed Communities Index score-for metropolitan, micropolitan, and rural ZIP code cohorts. Between 2010 and 2018, 188 995 Medicare fee-for-service patients living in 31 391 ZIP codes with ≥100 beneficiaries had a major lower extremity amputation. The median (interquartile range) ZIP code-level number of amputations per 100 000 beneficiaries was 262 (75-469). Though nonmetropolitan ZIP codes had higher rates of major amputation than metropolitan areas, 78.2% of patients undergoing major amputation lived in metropolitan areas. Compared with ZIP codes with lower amputation rates, top quartile amputation rate ZIP codes had a greater proportion of Black residents (4.4% versus 17.5%, P<0.001). In metropolitan areas, after adjusting for clinical comorbidities and demographics, every $10 000 lower median household income was associated with a 4.4% (95% CI, 3.9-4.8) higher amputation rate, and a 10-point higher Distressed Communities Index score was associated with a 3.8% (95% CI, 3.4%-4.2%) higher amputation rate; there was no association between the proportion of patients eligible for Medicaid and amputation rate. These findings were comparable to the associations identified across all ZIP codes. Conclusions In metropolitan areas, where most individuals undergoing lower extremity amputation live, markers of lower socioeconomic status and Black race were associated with higher rates of major lower extremity amputation. Development of community-based tools for peripheral artery disease diagnosis and management targeted to communities with high amputation rates in urban areas may help reduce inequities in peripheral artery disease outcomes.
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Affiliation(s)
- Alexander C. Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Lin Yang
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Ashwin S. Nathan
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Sameed Ahmed M. Khatana
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Howard Julien
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPA
| | - Tracy Y. Wang
- Division of Cardiology and Duke Clinical Research InstituteDuke UniversityDurhamNC
| | | | | | - Julia D. Glaser
- Division of Vascular Surgery and Endovascular TherapyUniversity of PennsylvaniaPhiladelphiaPA
| | - Grace Wang
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Division of Vascular Surgery and Endovascular TherapyUniversity of PennsylvaniaPhiladelphiaPA
| | - Scott M. Damrauer
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Division of Vascular Surgery and Endovascular TherapyUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Division of Cardiovascular MedicineUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
| | - Peter W. Groeneveld
- Penn Cardiovascular Outcomes, Quality and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
- Corporal Michael J. Crescenz Veterans Affairs Medical CenterPhiladelphiaPA
- Division of General Internal MedicineUniversity of PennsylvaniaPhiladelphiaPA
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13
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Rastogi A, Dogra H, Jude EB. COVID-19 and peripheral arterial complications in people with diabetes and hypertension: A systematic review. Diabetes Metab Syndr 2021; 15:102204. [PMID: 34303918 PMCID: PMC8266514 DOI: 10.1016/j.dsx.2021.102204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 01/08/2023]
Abstract
AIMS Identify the prevalence, risk factors and outcomes of lower extremity ischemic complications. METHODS A systematic review was conducted by searching PubMed and SCOPUS databases for SARS-CoV-2, COVID-19 and peripheral arterial complications. RESULTS Overall 476 articles were retrieved and 31 articles describing 133 patients were included. The mean age was 65.4 years. Pain and gangrene were the most common presentation. Hypertension (51.3%), diabetes (31.9%) and hypercholesterolemia (17.6%) were associated co-morbidities. Overall, 30.1% of patients died and amputation was required in 11.8% patients. CONCLUSIONS COVID-19 patients with diabetes or hypertension are susceptible for lower limb complications and require therapeutic anti-coagulation.
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Affiliation(s)
- Ashu Rastogi
- Deptt of Endocrinology, PGIMER, Chandigarh, 160012, India.
| | - Himika Dogra
- Deptt of Endocrinology, PGIMER, Chandigarh, 160012, India
| | - Edward B Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust, Tameside on Lyne, UK
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14
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Tillmann BW, Guttman MP, Nathens AB, de Mestral C, Kayssi A, Haas B. The timing of amputation of mangled lower extremities does not predict post-injury outcomes and mortality: A retrospective analysis from the ACS TQIP database. J Trauma Acute Care Surg 2021; 91:447-456. [PMID: 34039934 DOI: 10.1097/ta.0000000000003302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND While limb salvage does not result in improved functional outcomes among patients with a mangled lower extremity, the impact of attempted limb salvage on mortality and complications is poorly understood. The objective of this study was to evaluate the relationship between attempted limb salvage and in-hospital outcomes among patients with a mangled lower extremity. METHODS We performed a retrospective cohort study of adults, 16 years or older, with a mangled lower extremity. Data were derived from the American College of Surgeons' Trauma Quality Improvement Program (2012-2017). We compared mortality, complications (severe sepsis, acute kidney injury [AKI], decubitus ulcers) and length of stay between patients managed with the intention of limb salvage (amputation beyond 24 hours or no amputation) and those who underwent early amputation (within 24 hours of presentation). Instrumental variable analysis was used to evaluate the relationship between management strategy and outcomes. RESULTS We identified 5,527 patients with a mangled lower extremity, of which 901 (16.3%) underwent early amputation. Among those managed with attempted limb salvage, 42.5% underwent amputation prior to discharge. After adjusting for patient and hospital characteristics, there was no association between initial management strategy and mortality (odds ratio, 1.20; 95% confidence interval [CI], 0.83-1.74 early amputation vs. attempted limb salvage). Early amputation was associated with lower odds of AKI (OR, 0.59; 95% CI, 0.39-0.88) and a trend toward shorter length of stay (relative risk, 0.77; 95% CI, 0.52-1.14). CONCLUSION Over half of patients who sustain a mangled lower extremity undergo amputation during their initial hospital course. While a limb salvage strategy is associated with an elevated risk of AKI, there is no association between attempted limb preservation and mortality. These findings suggest that in patients in which there is no clear indication for early amputation, attempts at limb salvage do not come at the cost of increased mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.
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Affiliation(s)
- Bourke W Tillmann
- From the Institute of Health Policy, Management, and Evaluation (B.W.T., M.P.G., A.B.N., B.H.), University of Toronto, Toronto, Ontario, Canada; Interdepartmental Division of Critical Care Medicine (B.W.T., B.H.), University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine (B.W.T., B.H.), Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery (M.P.G., A.B.N., C.dM., A.K., B.H.), University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute (A.B.N., A.K., B.H.), Toronto, Ontario, Canada; Division of Vascular Surgery (C.dM.), Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; and Division of Vascular Surgery (A.K.), Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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15
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Outcomes Following Severe Distal Tibial, Ankle, and/or Mid/Hindfoot Trauma: Comparison of Limb Salvage and Transtibial Amputation (OUTLET). J Bone Joint Surg Am 2021; 103:1588-1597. [PMID: 33979309 DOI: 10.2106/jbjs.20.01320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Selecting the best treatment for patients with severe terminal lower-limb injury remains a challenge. For some injuries, amputation may result in better outcomes than limb salvage. This study compared the outcomes of patients who underwent limb salvage with those that would have been achieved had they undergone amputation. METHODS This multicenter prospective observational study included patients 18 to 60 years of age in whom a Type-III pilon or IIIB or C ankle fracture, a Type-III talar or calcaneal fracture, or an open or closed blast/crush foot injury had been treated with limb salvage (n = 488) or amputation (n = 151) and followed for 18 months. The primary outcome was the Short Musculoskeletal Function Assessment (SMFA). Causal effect estimates of the improvement that amputation would have provided if it had been performed instead of limb salvage were calculated for the SMFA score, physical performance, pain, participation in vigorous activities, and return to work. RESULTS The patients who underwent limb salvage would have had small differences in most outcomes had they undergone amputation. The most notable difference was an improvement in the SMFA mobility score of 7 points (95% confidence interval [CI] = 2.0 to 10.7). Improvements were largest for pilon/ankle fractures and complex injury patterns. CONCLUSIONS Amputation should be considered a treatment option rather than a last resort for the most complex terminal lower-limb injuries. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Seldon C, Shrivastava G, Al-Awady A, Asher D, Ramey S, Fernandez M, Dooley S, Kwon D, Zhao W, Goel N, Diwanji T, Subhawong T, Trent J, Yechieli R. Variation in Management of Extremity Soft-Tissue Sarcoma in Younger vs Older Adults. JAMA Netw Open 2021; 4:e2120951. [PMID: 34415314 PMCID: PMC8379652 DOI: 10.1001/jamanetworkopen.2021.20951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE A large proportion of extremity soft-tissue sarcomas (ESS) occur among young adults, yet this group is underrepresented in clinical trials, resulting in limited data on this population. Younger patients present many complex challenges that affect clinical management. OBJECTIVE To investigate variations in treatment management in young adults vs older adults with ESS. DESIGN, SETTING, AND PARTICIPANTS This multicenter retrospective cohort study used the National Cancer Data Base (NCDB) to identify patients 18 years and older with ESS who received definitive treatment (ie, limb-sparing surgery [LSS] or amputation) between 2004 and 2014. Data analysis was conducted in November 2019. EXPOSURES Treatment regimen received among young adults (aged 18-39 years) and older adults (≥40 years) after diagnosis with ESS. MAIN OUTCOMES AND MEASURES To detect unique factors associated with treatment decisions in young adults with ESS, multivariable analyses used logistic regressions for patterns of treatment and their association with demographic factors and tumor characteristics. RESULTS Overall, 8953 patients were identified, and among these, 1280 (14.3%) were young adults. From the full cohort, 4796 patients (53.6%) identified as male and 6615 (73.9%) identified as non-Hispanic White. More young adults than older adults underwent amputation (age 18-39 years, 104 of 1280 [8.1%]; age 40-64 years, 217 of 3937 [5.5%]; aged ≥65 years, 199 of 3736 [5.3%]), but the association was not statistically significant (age ≥65 years, odds ratio [OR], 1.49; 95% CI, 1.00-2.23; P = .05). Young adults were more likely to receive chemotherapy than older patients (age 40-65 years, OR, 0.52; 95% CI, 0.45-0.60; P = .001; ≥65 years, OR, 0.16; 95% CI, 0.12-0.20; P = .001). Conversely, young adults were less likely to receive radiation therapy compared with older patients (age 40-65 years, OR, 1.40; 95% CI, 1.22-1.61; P = .001; ≥65 years, OR, 1.33; 95% CI, 1.10-1.61; P = .003). Unique to younger adults, clinical stage II disease vs stage I and positive surgical margins were not associated with use of radiation therapy (stage II disease: OR, 1.25; 95% CI, 0.81-1.91; P = .31; positive surgical margins: OR, 1.43; 95% CI, 0.93-2.22; P = .11). White Hispanic young adults were less likely than non-Hispanic White young adults to receive radiation therapy (OR, 0.53; 95% CI, 0.36-0.78; P = .002). CONCLUSIONS AND RELEVANCE In this study, young adults with ESS were more likely to receive chemotherapy and less likely to receive radiation therapy than older adults. Further study is warranted to identify the clinical outcomes of these practice disparities.
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Affiliation(s)
- Crystal Seldon
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Gautam Shrivastava
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | | | - David Asher
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Stephen Ramey
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Melanie Fernandez
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Sarah Dooley
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Deukwoo Kwon
- Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Wei Zhao
- Biostatistics and Bioinformatics Shared Resource, Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Neha Goel
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Tejan Diwanji
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Ty Subhawong
- Department of Radiology, University of Miami, Miami, Florida
| | - Jonathan Trent
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
| | - Raphael Yechieli
- Sylvester Comprehensive Cancer Center, University of Miami, Miami, Florida
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Mikdad S, Mokhtari AK, Luckhurst CM, Breen KA, Liu B, Kaafarani HMA, Velmahos G, Mendoza AE, Bloemers FW, Saillant N. Implications of the national Stop the Bleed campaign: The swinging pendulum of prehospital tourniquet application in civilian limb trauma. J Trauma Acute Care Surg 2021; 91:352-360. [PMID: 33901049 DOI: 10.1097/ta.0000000000003247] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Prehospital tourniquet (PHT) utilization has increased in response to mass casualty events. We aimed to describe the incidence, therapeutic effectiveness, and morbidity associated with tourniquet placement in all patients treated with PHT application. METHODS A retrospective observational cohort study was performed to evaluate all adults with a PHT who presented at two Level I trauma centers between January 2015 and December 2019. Medically trained abstractors determined if the PHT was clinically indicated (placed for limb amputation, vascular hard signs, injury requiring hemostasis procedure, or significant documented blood loss). Prehospital tourniquets were further designated as appropriately or inappropriately applied (based on PHT anatomic placement location, occurrence of a venous tourniquet, or ischemic time defined as >2 hours). Statistical analyses were performed to generate primary and secondary results. RESULTS A total of 147 patients met study inclusion criteria, of which 70% met the criteria for trauma registry inclusion. Total incidence of PHT utilization increased from 2015 to 2019, with increasing proportions of PHTs placed by nonemergency medical service personnel. Improvised PHTs were frequently used. Prehospital tourniquets were clinically indicated in 51% of patients. Overall, 39 (27%) patients had a PHT that was inappropriately placed, five of which resulted in significant morbidity. CONCLUSION In summary, prehospital tourniquet application has become widely adopted in the civilian setting, frequently performed by civilian and nonemergency medical service personnel. Of PHTs placed, nearly half had no clear indication for placement and over a quarter of PHTs were misapplied with notable associated morbidity. Results suggest that the topics of clinical indication and appropriate application of tourniquets may be important areas for continued focus in future tourniquet educational programs, as well as future quality assessment efforts. LEVEL OF EVIDENCE Epidemiological, level III; Therapeutic, level IV.
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Affiliation(s)
- Sarah Mikdad
- From the Division of Trauma, Emergency Surgery and Surgical Critical Care (S.M., A.K.M., C.M.L., K.A.B., B.L., H.M.A.K., G.V., A.E.M., N.S.), Massachusetts General Hospital, Boston, Harvard Medical School, Boston, Massachusetts; and Department of Trauma Surgery (S.M., F.W.B.), Amsterdam UMC, Amsterdam, the Netherlands
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Tran K, Stedman M, Chang TI. Intensive Blood Pressure Control and Diabetes Mellitus-Related Limb Events in Patients With Type 2 Diabetes Mellitus: Reanalysis of ACCORD. J Am Heart Assoc 2021; 10:e021407. [PMID: 34320842 PMCID: PMC8475694 DOI: 10.1161/jaha.121.021407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kenneth Tran
- Division of Vascular SurgeryDepartment of SurgeryStanford University School of MedicineStanfordCA
| | - Margaret Stedman
- Division of NephrologyDepartment of MedicineStanford University School of MedicineStanfordCA
| | - Tara I. Chang
- Division of NephrologyDepartment of MedicineStanford University School of MedicineStanfordCA
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Ilonzo N, Lee J, James C, Phair J, Ting W, Faries P, Vouyouka A. Sex-based differences in loss of independence after lower extremity bypass surgery. Am J Surg 2021; 223:170-175. [PMID: 34364654 DOI: 10.1016/j.amjsurg.2021.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/22/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study analyzes sex-based differences in the risk of discharge to a nonhome facility (loss of independence) after lower extremity revascularization and resultant outcomes. METHODS Data from the NSQIP database for years 2015-2017 was utilized to assess sex-based differences in loss of independence and associated unplanned readmission and 30-day amputation using chi-square, student t-test, and multivariate logistic regression analyses where appropriate. RESULTS There was increased loss of independence in women (34.9% vs. 26.1 %, p < .01) and associated increase in unplanned readmission (18.4% vs. 13.6 %, p = .01) and length of stay (12.1 days vs 6.5 days, p < .01). Endovascular revascularization was associated with decreased likelihood of loss of independence (OR 0.43, CI 0.36-0.50). CONCLUSION Loss of independence after lower extremity bypass surgery affects women more than men and it is associated with worse postoperative outcomes.
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Affiliation(s)
- Nicole Ilonzo
- Division of Vascular Surgery, Department of Surgery, Weill Cornell Medical Center, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Jonathan Lee
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Crystal James
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - John Phair
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Windsor Ting
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Peter Faries
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA
| | - Ageliki Vouyouka
- Division of Vascular Surgery, Department of Surgery, Mount Sinai Hospital, New York, USA.
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Essien SK, Linassi G, Larocque M, Zucker-Levin A. Incidence and trends of limb amputation in first nations and general population in Saskatchewan, 2006-2019. PLoS One 2021; 16:e0254543. [PMID: 34252158 PMCID: PMC8274839 DOI: 10.1371/journal.pone.0254543] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/28/2021] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND There is conflicting evidence whether limb amputation (LA) disproportionately affects indigenous populations. To better understand this disparity, we compared the LA incidence rate between First Nations persons registered under the Indian Act of Canada (RI) and the general population (GP) in Saskatchewan. METHODS We used Saskatchewan's retrospective administrative data containing hospital discharge LA cases, demographic characteristics (age and sex), and residents population reported in the database stratified by RI and GP from 2006-2019. The LA cases for each stratified group were first disaggregated into three broad categories: overall LA (all reported LA), primary LA (first reported LA), and subsequent LA (revision or contralateral LA), with each category further split into the level of amputation defined as major amputation (through/above the ankle/wrist joint) and minor amputation (below the ankle/wrist joint). LA rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial regressions were performed to explore the trends further. RESULTS Overall, there were 1347 RI and 4520 GP LA cases reported in Saskatchewan from 2006-2019. Primary LA made up approximately 64.5% (869) of RI and 74.5% (3369) of GP cases, while subsequent LA constituted 35.5% (478) of RI and 25.5% (1151) of GP cases. The average age-adjusted LA rate was 153.9 ± 17.3 per 100,000 in the RI cohort and 31.1 ± 2.3 per 100,000 in the GP cohort. Overall and primary LA rates for the GP Group declined 0.7% and 1.0%, while subsequent LA increased 0.1%. An increased LA rate for all categories (overall 4.9%, primary 5.1%, and subsequent 4.6%) was identified in the RI group. Overall, minor and major LA increased by 6.2% and 3.3%, respectively, in the RI group compared to a 0.8% rise in minor LA and a 6.3% decline in major LA in the GP group. RI females and males were 1.98-1.66 times higher risk of LA than their GP counterparts likewise, RI aged 0-49 years and 50+ years were 2.04-5.33 times higher risk of LA than their GP cohort. Diabetes mellitus (DM) was the most prevalent amputation predisposing factor in both groups with 81.5% of RI and 54.1% of GP diagnosed with DM. Also, the highest proportion of LA was found in the lowest income quintile for both groups (68.7% for RI and 45.3% for GP). CONCLUSION Saskatchewan's indigenous individuals, specifically First Nations persons registered under the Indian Act of Canada, experience LA at a higher rate than the general population. This disparity exists for all variables examined, including overall, primary, and subsequent LA rates, level of amputation, sex, and age. Amplification of the disparities will continue if the rates of change maintain their current trajectories. These results underscore the need for a better understanding of underlying causes to develop a targeted intervention in these groups.
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Affiliation(s)
- Samuel Kwaku Essien
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, SK, Canada
| | - Gary Linassi
- Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Audrey Zucker-Levin
- School of Rehabilitation Science, University of Saskatchewan, Saskatoon, SK, Canada
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21
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Riandini T, Pang D, Toh MPHS, Tan CS, Liu DYK, Choong AMTL, Chandrasekar S, Tai ES, Tan KB, Venkataraman K. Diabetes-related lower extremity complications in a multi-ethnic Asian population: a 10 year observational study in Singapore. Diabetologia 2021; 64:1538-1549. [PMID: 33885933 PMCID: PMC8187215 DOI: 10.1007/s00125-021-05441-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/25/2021] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS Diabetes progression and complication risk are different in Asian people compared with those of European ancestry. In this study, we sought to understand the epidemiology of diabetes-related lower extremity complications (DRLECs: symptomatic peripheral arterial disease, ulceration, infection, gangrene) and amputations in a multi-ethnic Asian population. METHODS This was a retrospective observational study using data obtained from one of three integrated public healthcare clusters in Singapore. The population consisted of individuals with incident type 2 diabetes who were of Chinese, Malay, Indian or Other ethnicity. We examined incidence, time to event and risk factors of DRLECs and amputation. RESULTS Between 2007 and 2017, of the 156,593 individuals with incident type 2 diabetes, 20,744 developed a DRLEC, of whom 1208 underwent amputation. Age- and sex-standardised incidence of first DRLEC and first amputation was 28.29/1000 person-years of diabetes and 8.18/1000 person-years of DRLEC, respectively. Incidence of both was highest in individuals of Malay ethnicity (DRLEC, 36.09/1000 person-years of diabetes; amputation, 12.96/1000 person-years of DRLEC). Median time from diabetes diagnosis in the public healthcare system to first DRLEC was 30.5 months for those without subsequent amputation and 10.9 months for those with subsequent amputation. Median time from DRLEC to first amputation was 2.3 months. Older age (p < 0.001), male sex (p < 0.001), Malay ethnicity (p < 0.001), Indian ethnicity (p = 0.014), chronic comorbidities (nephropathy [p < 0.001], heart disease [p < 0.001], stroke [p < 0.001], retinopathy [p < 0.001], neuropathy [p < 0.001]), poorer or missing HbA1c (p < 0.001), lower (p < 0.001) or missing (p = 0.002) eGFR, greater or missing BMI (p < 0.001), missing LDL-cholesterol (p < 0.001) at diagnosis, and ever-smoking (p < 0.001) were associated with higher hazard of DRLEC. Retinopathy (p < 0.001), peripheral vascular disease (p < 0.001), poorer HbA1c (p < 0.001), higher (p = 0.009) or missing (p < 0.001) LDL-cholesterol and missing BMI (p = 0.008) were associated with higher hazard of amputation in those with DRLEC. Indian ethnicity (p = 0.007) was associated with significantly lower hazard of amputation. CONCLUSIONS/INTERPRETATION This study has revealed important ethnic differences in risk of diabetes-related lower limb complications, with Malays most likely to progress to DRLEC. Greater research efforts are needed to understand the aetiopathological and sociocultural processes that contribute to the higher risk of lower extremity complications among these ethnic groups.
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Affiliation(s)
- Tessa Riandini
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore
| | - Deanette Pang
- Policy Research & Evaluation Division, Ministry of Health, Singapore, Republic of Singapore
| | - Matthias P H S Toh
- National Public Health and Epidemiology Unit, National Centre for Infectious Diseases, Singapore, Republic of Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore
| | - Daveon Y K Liu
- Information Management, Group Health Informatics, National Healthcare Group, Singapore, Republic of Singapore
| | - Andrew M T L Choong
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
- Division of Vascular and Endovascular Surgery, National University Heart Centre, Singapore, Republic of Singapore
| | - Sadhana Chandrasekar
- Department of Vascular Surgery, Tan Tock Seng Hospital, Singapore, Republic of Singapore
| | - E Shyong Tai
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Republic of Singapore
| | - Kelvin B Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore
- Policy Research & Evaluation Division, Ministry of Health, Singapore, Republic of Singapore
| | - Kavita Venkataraman
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Republic of Singapore.
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Mariet AS, Benzenine E, Bouillet B, Vergès B, Quantin C, Petit JM. Impact of the COVID-19 Epidemic on hospitalization for diabetic foot ulcers during lockdown: A French nationwide population-based study. Diabet Med 2021; 38:e14577. [PMID: 33797791 DOI: 10.1111/dme.14577] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to examine the impact of the COVID-19 epidemic on the hospitalization rates for diabetic foot ulcer (DFU), osteomyelitis and lower limb revascularization procedure in people with DFU. METHODS This nationwide retrospective cohort study included hospital data on all people hospitalized in France for diabetes in weeks 2-43 in 2020, including the COVID-19 lockdown period, compared to same period in 2019. RESULTS The number of hospitalizations for DFU decreased significantly in weeks 12-19 (during the lockdown) (p < 10-4 ). Hospitalization for foot osteomyelitis also decreased significantly in weeks 12-19 (p < 10-4 ). The trend was the same for lower limb amputations and revascularizations associated with DFU or amputation. CONCLUSIONS/INTERPRETATION The marked drop in hospitalization rates for DFU, osteomyelitis and lower limb revascularization procedures in people with DFU observed in France during the lockdown period suggests that COVID-19 was a barrier to DFU care, and may illustrate the combined deleterious effects of hospital overload and changes in health-related behaviour.
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Affiliation(s)
- Anne-Sophie Mariet
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital, Dijon, France
- University of Burgundy and Franche-Comte, Dijon, France
- INSERM, CIC 1432, Dijon, France
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, Dijon, France
| | - Eric Benzenine
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital, Dijon, France
- University of Burgundy and Franche-Comte, Dijon, France
- INSERM, CIC 1432, Dijon, France
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, Dijon, France
| | - Benjamin Bouillet
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, Dijon, France
| | - Bruno Vergès
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, Dijon, France
| | - Catherine Quantin
- Biostatistics and Bioinformatics (DIM), Dijon University Hospital, Dijon, France
- University of Burgundy and Franche-Comte, Dijon, France
- INSERM, CIC 1432, Dijon, France
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon University Hospital, Dijon, France
| | - Jean-Michel Petit
- INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France
- Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, Dijon, France
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Beulens JWJ, Yauw JS, Elders PJM, Feenstra T, Herings R, Slieker RC, Moons KGM, Nijpels G, van der Heijden AA. Prognostic models for predicting the risk of foot ulcer or amputation in people with type 2 diabetes: a systematic review and external validation study. Diabetologia 2021; 64:1550-1562. [PMID: 33904946 PMCID: PMC8075833 DOI: 10.1007/s00125-021-05448-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/05/2021] [Indexed: 12/19/2022]
Abstract
AIMS/HYPOTHESIS Approximately 25% of people with type 2 diabetes experience a foot ulcer and their risk of amputation is 10-20 times higher than that of people without type 2 diabetes. Prognostic models can aid in targeted monitoring but an overview of their performance is lacking. This study aimed to systematically review prognostic models for the risk of foot ulcer or amputation and quantify their predictive performance in an independent cohort. METHODS A systematic review identified studies developing prognostic models for foot ulcer or amputation over minimal 1 year follow-up applicable to people with type 2 diabetes. After data extraction and risk of bias assessment (both in duplicate), selected models were externally validated in a prospective cohort with a 5 year follow-up in terms of discrimination (C statistics) and calibration (calibration plots). RESULTS We identified 21 studies with 34 models predicting polyneuropathy, foot ulcer or amputation. Eleven models were validated in 7624 participants, of whom 485 developed an ulcer and 70 underwent amputation. The models for foot ulcer showed C statistics (95% CI) ranging from 0.54 (0.54, 0.54) to 0.81 (0.75, 0.86) and models for amputation showed C statistics (95% CI) ranging from 0.63 (0.55, 0.71) to 0.86 (0.78, 0.94). Most models underestimated the ulcer or amputation risk in the highest risk quintiles. Three models performed well to predict a combined endpoint of amputation and foot ulcer (C statistics >0.75). CONCLUSIONS/INTERPRETATION Thirty-four prognostic models for the risk of foot ulcer or amputation were identified. Although the performance of the models varied considerably, three models performed well to predict foot ulcer or amputation and may be applicable to clinical practice.
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Affiliation(s)
- Joline W J Beulens
- Department of Epidemiology & Data Science, Amsterdam UMC - Location VUmc, Amsterdam Public Health, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands.
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands.
| | - Josan S Yauw
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Petra J M Elders
- Department of General Practice, Amsterdam UMC - Location VUmc, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Talitha Feenstra
- Groningen Research Institute of Pharmacy, University of Groningen, Groningen, the Netherlands
- Centre for Nutrition, Prevention and Health Services, Institute for Public Health and the Environment, Bilthoven, the Netherlands
| | - Ron Herings
- Department of Epidemiology & Data Science, Amsterdam UMC - Location VUmc, Amsterdam Public Health, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- PHARMO Institute for Drug Outcomes Research, Utrecht, the Netherlands
| | - Roderick C Slieker
- Department of Epidemiology & Data Science, Amsterdam UMC - Location VUmc, Amsterdam Public Health, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - Karel G M Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Giel Nijpels
- Department of General Practice, Amsterdam UMC - Location VUmc, Amsterdam Public Health, Amsterdam, the Netherlands
| | - Amber A van der Heijden
- Department of General Practice, Amsterdam UMC - Location VUmc, Amsterdam Public Health, Amsterdam, the Netherlands
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Abstract
Diabetic sensorimotor peripheral neuropathy (DSPN) is a serious complication of diabetes mellitus and is associated with increased mortality, lower-limb amputations and distressing painful neuropathic symptoms (painful DSPN). Our understanding of the pathophysiology of the disease has largely been derived from animal models, which have identified key potential mechanisms. However, effective therapies in preclinical models have not translated into clinical trials and we have no universally accepted disease-modifying treatments. Moreover, the condition is generally diagnosed late when irreversible nerve damage has already taken place. Innovative point-of-care devices have great potential to enable the early diagnosis of DSPN when the condition might be more amenable to treatment. The management of painful DSPN remains less than optimal; however, studies suggest that a mechanism-based approach might offer an enhanced benefit in certain pain phenotypes. The management of patients with DSPN involves the control of individualized cardiometabolic targets, a multidisciplinary approach aimed at the prevention and management of foot complications, and the timely diagnosis and management of neuropathic pain. Here, we discuss the latest advances in the mechanisms of DSPN and painful DSPN, originating both from the periphery and the central nervous system, as well as the emerging diagnostics and treatments.
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Affiliation(s)
- Gordon Sloan
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dinesh Selvarajah
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Oncology and Human Metabolism, University of Sheffield, Sheffield, UK
| | - Solomon Tesfaye
- Diabetes Research Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
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Wenhui L, Changgeng F, Lei X, Baozhong Y, Guobin L, Weijing F. Hyperbaric oxygen therapy for chronic diabetic foot ulcers: An overview of systematic reviews. Diabetes Res Clin Pract 2021; 176:108862. [PMID: 34015392 DOI: 10.1016/j.diabres.2021.108862] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/26/2021] [Accepted: 05/10/2021] [Indexed: 12/09/2022]
Abstract
OBJECTIVES Hyperbaric oxygen therapy in the treatment of diabetic foot ulcer has been widely used in medical practice, but its clinical effect is not clear. The purpose of this overview of systematic reviews is to evaluate the clinical evidence of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers. METHODS PubMed, Cochrane Library, Web of Knowledge, Embase, MEDLINE, Chinese National Knowledge Infrastructure Database, the Chongqing VIP Database, Chinese Biomedical Database, and Wanfang Database were searched in 1st December 2020. Systematic reviews (SRs) evaluating the effects of Hyperbaric oxygen therapy in people with diabetic foot ulcer were included. Methodological quality of the included SRs was assessed using the AMSTAR-2 tool. The quality of evidence of the primary studies was assessed using GRADE. The integrity of the included SRs was assessed using PRISMA. The bias risk of each SR was assessed using ROBIS evaluation tool. RESULTS Eleven SRs/MAs met all inclusion criteria. According to the results of the AMSTAR-2, only 1 included review were rated critically as being of high quality, 6 included review were rated critically as being of medium quality. With PRISMA, the reporting checklist was relatively complete, but some reporting weaknesses remained in the topics of the protocol and registration, search strategy, and additional analyses. Based on the ROBIS tool, only five SRs/MAs had a low risk of bias. With the GRADE system, no high-quality evidence was found, and only 13 outcomes provided moderate-quality evidence. CONCLUSIONS There is limited clinical evidence to support hyperbaric oxygen therapy in the treatment of diabetic foot ulcers, it is not recommended to routinely apply hyperbaric oxygen therapy to all patients with diabetic foot ulcers, especially those with non-ischemic diabetic foot ulcers. Hyperbaric oxygen therapy has certain potential to promote ulcer healing and reduce amputation rate in patients with ischemic diabetic foot ulcers, but due to the low quality and small quantity of the SRs/MAs supporting these results, high-quality studies with rigorous study designs and larger samples are needed before widespread recommendations can be made.
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Affiliation(s)
- Li Wenhui
- Shanghai University of Medicine & Health Sciences, China
| | - Fu Changgeng
- Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, China
| | - Xv Lei
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, China
| | - Yang Baozhong
- Dongfang Hospital Affiliated to Beijing University of Chinese Medicine, China
| | - Liu Guobin
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, China.
| | - Fan Weijing
- Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, China.
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Meza-Torres B, Carinci F, Heiss C, Joy M, de Lusignan S. Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis. Acta Diabetol 2021; 58:735-747. [PMID: 33547497 PMCID: PMC7864802 DOI: 10.1007/s00592-020-01662-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/17/2020] [Indexed: 01/21/2023]
Abstract
AIMS Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers. METHODS We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models. RESULTS A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91). CONCLUSIONS Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.
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Affiliation(s)
- Bernardo Meza-Torres
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK.
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Fabrizio Carinci
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Department of Statistical Sciences, University of Bologna, Bologna, Italy
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Salinero-Fort MA, Gómez-Campelo P, Cárdenas-Valladolid J, San Andrés-Rebollo FJ, de Miguel-Yanes JM, de Burgos-Lunar C. Effect of depression on mortality in type 2 diabetes mellitus after 8 years of follow-up. The DIADEMA study. Diabetes Res Clin Pract 2021; 176:108863. [PMID: 33992707 DOI: 10.1016/j.diabres.2021.108863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 04/18/2021] [Accepted: 05/11/2021] [Indexed: 11/28/2022]
Abstract
AIM To assess the effect of depression on all-cause mortality in patients with type 2 diabetes mellitus (T2DM) followed up during 8 years in primary care in Spain. METHODS Depression was diagnosed according to MINI 5.0.0 questionnaire, physician-diagnosis or following antidepressant therapy for at least two months in 3923 people with T2DM. We analyzed mortality-rates/10,000 person-years. We compared survival according to baseline depression with Kaplan-Meier estimates and the log-rank test. We performed Cox proportional hazard model analyses. RESULTS Baseline depression was diagnosed in 22.1% of participants. Mortality was higher in patients with depression (31.9% vs. 26.9%; p = 0.003), who had a significantly poorer survival (median survival = 7.4 vs. 7.8 years, respectively; Log Rank = 15.83; p < 0.001). Depression showed an adjusted mortality hazard ratio (HR) = 1.40 (95%CI:1.20-1.65; p < 0.001). The strongest predictive factors were: age >75 years (HR = 6.04; 95%CI:4.62-7.91; p < 0.001), insulin use (HR = 2.37; 95%CI:1.86-3.00; p < 0.001), lower limb amputation (HR = 1.99; 95%CI:1.28-3.11; p = 0.002), heart failure (HR = 1.94; 95%CI:1.63-2.30; p < 0.001), and male gender (HR = 1.90; 95%CI:1.59-2.27). CONCLUSION In a Spanish cohort of older T2DM patients, depression was associated with a higher mortality risk. More efforts are needed to minimize the influence of depression on mortality in people with T2DM and to implement measures that allow its early diagnosis and effective treatment.
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Affiliation(s)
- M A Salinero-Fort
- Subdirección General de Investigación Sanitaria, Consejería de Sanidad de Madrid, Spain; Fundación de Investigación e Innovación Biosanitaria de Atención Primaria, Madrid, Spain; Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Madrid, Spain; Grupo de Investigación en Envejecimiento y Fragilidad, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain.
| | - P Gómez-Campelo
- Grupo de Investigación en Envejecimiento y Fragilidad, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Fundación de Investigación Biomédica del Hospital Universitario La Paz, Madrid, Spain
| | - J Cárdenas-Valladolid
- Fundación de Investigación e Innovación Biosanitaria de Atención Primaria, Madrid, Spain; Grupo de Investigación en Envejecimiento y Fragilidad, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Dirección Técnica de Sistemas de Información Sanitaria, Gerencia Asistencial de Atención Primaria, Madrid, Spain
| | - F J San Andrés-Rebollo
- Fundación de Investigación e Innovación Biosanitaria de Atención Primaria, Madrid, Spain; Centro de Salud Las Calesas, Gerencia Asistencial de Atención Primaria, Madrid, Spain
| | - J M de Miguel-Yanes
- Instituto de Investigación Sanitaria del Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - C de Burgos-Lunar
- Fundación de Investigación e Innovación Biosanitaria de Atención Primaria, Madrid, Spain; Red de Investigación en Servicios Sanitarios en Enfermedades Crónicas (REDISSEC), Madrid, Spain; Grupo de Investigación en Envejecimiento y Fragilidad, Instituto de Investigación Sanitaria del Hospital Universitario La Paz (IdiPAZ), Madrid, Spain; Hospital Universitario Clínico de San Carlos, Madrid, Spain
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Jeffcoate W, Game F, Morbach S, Narres M, Van Acker K, Icks A. Assessing data on the incidence of lower limb amputation in diabetes. Diabetologia 2021; 64:1442-1446. [PMID: 33783587 DOI: 10.1007/s00125-021-05440-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/18/2021] [Indexed: 01/22/2023]
Affiliation(s)
- William Jeffcoate
- Department of Medical Physics and Clinical Engineering, Nottingham University Hospitals Trust, Nottingham, UK.
| | - Frances Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Stephan Morbach
- Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Department of Diabetes and Angiology, Marienkrankenhaus, Soest, Germany
| | - Maria Narres
- Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Kristien Van Acker
- Centre de Santé des Fagnes Clinique Chimay, Department of Diabetology, Endocrinology and Wound Care, Chimay, Belgium
| | - Andrea Icks
- Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Institute for Health Services Research and Health Economics, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), München-Neuherberg, Germany
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Su MI, Liu CW. Neutrophil-to-lymphocyte ratio associated with an increased risk of mortality in patients with critical limb ischemia. PLoS One 2021; 16:e0252030. [PMID: 34043672 PMCID: PMC8158906 DOI: 10.1371/journal.pone.0252030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/08/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose Association of the neutrophil-to-lymphocyte ratio (NLR) with mortality has not been comprehensively explored in critical limb ischemia (CLI) patients. We investigated the association between the NLR and clinical outcomes in CLI. Materials and methods We retrospectively enrolled consecutive CLI patients between 1/1/2013 and 12/31/2018. Receiver operating characteristic curve analysis determined NLR cutoffs for 1-year in-hospital, all-cause and cardiac-related mortality; major adverse cardiovascular events (MACEs); and major adverse limb events (MALEs). Results Among 195 patients (age, 74.0 years, SD: 11.5; 51.8% male; body mass index, 23.4 kg/m2, SD: 4.2), 14.4% exhibited acute limb ischemia. After 1 year, patients with NLR>8 had higher in-hospital mortality (21.1% vs. 3.6%, P<0.001), all-cause mortality (54.4% vs. 13.8%, P<0.001), cardiac-related mortality (28.1% vs. 6.5%, P<0.001), MACE (29.8% vs. 13.0%, P = 0.008), and MALE (28.1% vs. 13.0%, P = 0.021) rates than those with NLR<8. In multivariate logistic regression, NLR≥8 was significantly associated with all-cause (P<0.001) and cardiac-related (adjusted HR: 5.286, 95% CI: 2.075–13.47, P<0.001) mortality, and NLR≥6 was significantly associated with MALEs (adjusted HR: 2.804, 95% CI: 1.292–6.088, P = 0.009). Each increase in the NLR was associated with increases in all-cause (adjusted HR: 1.028, 95% CI: 1.008–1.049, P = 0.007) and cardiac-related (adjusted HR:1.027, 95% CI: 0.998–1.057, P = 0.073) mortality but not in-hospital mortality or MACEs. Conclusion CLI patients with high NLRs had significantly higher risks of 1-year all-cause and cardiac-related mortality and MALEs. The NLR can be used for prognostic prediction in these patients.
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Affiliation(s)
- Min-I. Su
- Division of Cardiology, Department of Internal Medicine, Taitung MacKay Memorial Hospital, Taitung City, Taiwan
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Cheng-Wei Liu
- Department of Internal Medicine, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
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Raimbeau A, Pistorius MA, Goueffic Y, Connault J, Plissonneau-Duquene P, Maurel B, Reignier J, Asehnoune K, Artifoni M, Didier Q, Gautier G, Trochu JN, Rozec B, N’Gohou C, Durant C, Pottier P, Denis Le Sève J, Brebion N, Agard C, Espitia O. Digital ischaemia aetiologies and mid-term follow-up: A cohort study of 323 patients. Medicine (Baltimore) 2021; 100:e25659. [PMID: 34011027 PMCID: PMC8136985 DOI: 10.1097/md.0000000000025659] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 04/05/2021] [Indexed: 12/30/2022] Open
Abstract
Upper extremity digital ischaemia (UEDI) is a rare heterogeneous condition whose frequency is 40 times less than that of toe ischaemia. Using a large cohort, the aim of this study was to evaluate aetiologies, prognosis and midterm clinical outcomes of UEDI.All patients with UEDI with or without cutaneous necrosis in a university hospital setting between January 2000 to December 2016 were included. Aetiologies, recurrence of UEDI, digital amputation and survival were analyzed retrospectively.Three hundred twenty three patients were included. UEDI due to cardio-embolic disease (DICE) was the highest occurring aetiology with 59 patients (18.3%), followed by DI due to Systemic Sclerosis (SSc) (16.1%), idiopathic causes (11.7%), Thromboangiitis obliterans (TAO) (9.3%), iatrogenic causes (9.3%), and cancer (6.2%). DICE patients tended to be older and featured more cases with arterial hypertension whereas TAO patients smoked more tobacco and cannabis. During follow-up, recurrences were significantly more frequent in SSc than in all other tested groups (P < .0001 vs idiopathic and DICE, P = .003 vs TAO) and among TAO patients when compared to DICE patients (P = .005). The cumulated rate of digital amputation was higher in the SSc group (n = 18) (P = .02) and the TAO group (n = 7) (P = .03) than in DICE (n = 2).This retrospective study suggests that main aetiologies of UEDI are DICE, SSc and idiopathic. This study highlights higher frequency of iatrogenic UEDI than previous studies. UEDI associated with SSc has a poor local prognosis (amputations and recurrences) and DICE a poor survival. UEDI with SSc and TAO are frequently recurrent.
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Affiliation(s)
| | | | - Yann Goueffic
- Department of Vascular Surgery, University Hospital of Nantes
| | | | | | - Blandine Maurel
- Department of Vascular Surgery, University Hospital of Nantes
| | | | | | | | | | | | | | | | - Chan N’Gohou
- Department of Medical Data Processing, University Hospital of Nantes
| | | | | | | | - Nicolas Brebion
- Department of Vascular Medicine, Hospital of La Roche sur Yon, France
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Subramanian N, Han J, Leeper NJ, Ross EG, Montez-Rath ME, Chang TI. Comparison of Pre-Amputation Evaluation in Patients with and without Chronic Kidney Disease. Am J Nephrol 2021; 52:388-395. [PMID: 33957619 DOI: 10.1159/000516017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Patients with chronic kidney disease (CKD) and peripheral artery disease (PAD) are more likely to undergo lower extremity amputation than patients with preserved kidney function. We sought to determine whether patients with CKD were less likely to receive pre-amputation care in the 1-year prior to lower extremity amputation compared to patients without CKD. METHODS We conducted a retrospective observational study of patients with PAD-related lower extremity amputation between January 2014 and December 2017 using a large commercial insurance database. The primary exposure was CKD identified using billing codes and laboratory values. The primary outcomes were receipt of pre-amputation care, defined as diagnostic evaluation (ankle-brachial index, duplex ultrasound, and computed tomographic angiography), specialty care (vascular surgery, cardiology, orthopedic surgery, and podiatry), and lower extremity revascularization in the 1-year prior to amputation. We conducted separate logistic regression models to estimate the adjusted odds ratio (aOR) and 95% confidence intervals (CIs) among patients with and without CKD. We assessed for effect modification by age, sex, Black race, and diabetes status. RESULTS We identified 8,554 patients with PAD-related amputation. In fully adjusted models, patients with CKD were more likely to receive diagnostic evaluation (aOR 1.30; 95% CI 1.17-1.44) and specialty care (aOR 1.45, 95% CI 1.27-1.64) in the 1-year prior to amputation. There was no difference in odds of revascularization by CKD status (aOR 1.03, 0.90-1.19). Age, sex, Black race, and diabetes status did not modify these associations. DISCUSSION/CONCLUSION Patients with CKD had higher odds of receiving diagnostic testing and specialty care and similar odds of lower extremity revascularization in the 1-year prior to amputation than patients without CKD. Disparities in access to pre-amputation care do not appear to explain the higher amputation rates seen among patients with CKD.
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Affiliation(s)
- Nivetha Subramanian
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jialin Han
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nicholas J Leeper
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - Elsie G Ross
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, California, USA
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Tara I Chang
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Ogura K, Yakoub MA, Boland PJ, Healey JH. Finn/Orthopaedic Salvage System Distal Femoral Rotating-Hinge Megaprostheses in Oncologic Patients: Long-Term Complications, Reoperations, and Amputations. J Bone Joint Surg Am 2021; 103:705-714. [PMID: 33411462 PMCID: PMC8493615 DOI: 10.2106/jbjs.20.00696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is a lack of evidence regarding long-term outcomes of rotating-hinge knee prostheses with distal femoral replacement in a large oncologic patient series. In this study, we investigated the proportion of patients experiencing complications requiring surgery in the long term, as well as the cumulative incidence of implant removal/revision and amputation at 5, 10, 15, and 20 years through competing risk analyses. METHODS We retrospectively studied 214 patients treated with a Finn/Orthopaedic Salvage System (OSS) knee prosthesis (Zimmer Biomet) after distal femoral resection from 1991 to 2017. The study end points were postoperative complications requiring surgery. Reoperations were classified as major when there was (1) removal of the metal-body femoral component, the tibial component, or the bone-implant fixation; (2) major revision (exchange of the metal-body femoral component, the tibial component, or the bone-implant fixation); or (3) amputation. Minor reoperations were defined as all other reoperations. Competing risk analysis was used to estimate the cumulative incidence of implant removal/revision or amputation. RESULTS There were 312 reoperations in 113 patients (98 major reoperations in 68 patients and 214 minor reoperations). Seventeen patients (8%) required ≥5 additional operations, and 21 patients (10%) required >1 major reoperation. Although the number of reoperations decreased over time, major and minor reoperations continuously accrued after 10 years. The cumulative incidences of implant removal or revision for any reason at 5, 10, 15, and 20 years were 22.6%, 30.1%, 34.3%, and 42.5%, respectively. Although most implant removals/revisions occurred in the first 10 years, the risk persisted after 10 years, at a mean of 1.24%/year, mainly due to deep infection (1.06%/year). CONCLUSIONS The long-term outcomes of treatment with a Finn/OSS distal femoral rotating-hinge knee prosthesis showed it to be a durable reconstruction technique. The rate of implant removal/revisions after 10 years was gradual (1.24%/year). Deep infection remains a major late-failure mechanism, and lifetime surveillance for prosthetic problems is needed. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Koichi Ogura
- Department of Surgery, Orthopaedic Service, Memorial Sloan Kettering Cancer Center, New York, NY
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Pacha HM, Al-Khadra Y, Darmoch F, Soud M, Kwok CS, Mamas MA, Ashraf S, Sattar Y, Ullah W, Banerjee S, Arain SA, Feldman DN, Abu-Fadel M, Aronow HD, Shishehbor MH, Alraies MC. In-Hospital Outcomes and Trends of Endovascular Intervention vs Surgical Revascularization in Octogenarians With Peripheral Artery Disease. Am J Cardiol 2021; 145:143-150. [PMID: 33460607 DOI: 10.1016/j.amjcard.2020.12.091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/26/2020] [Accepted: 12/31/2020] [Indexed: 01/22/2023]
Abstract
It is unknown whether endovascular intervention (EVI) is associated with superior outcomes when compared with surgical revascularization in octogenarian. National Inpatient Sample (NIS) database was used to compare the outcomes of limb revascularization in octogenarians who had surgical revascularization versus EVI. The NIS database's information on PAD patients ≥80-year-old who underwent limb revascularization between 2002 and 2014 included 394,504 octogenarian patients, of which 184,926 underwent surgical revascularization (46.9%) and 209,578 underwent EVI (53.1%). Multivariate analysis was performed to examine in-hospital outcomes. Trend over time in limb revascularization utilization was examined using Cochrane-Armitage test. EVI group had lower odds of in-hospital mortality (adjusted odds ratio [aOR]: 0.61 [95% CI: 0.58 to 0.63], myocardial infarction (aOR: 0.84 [95% CI: 0.81 to 0.87]), stroke (aOR: 0.93 [95% CI: 0.89 to 0.96]), acute kidney injury (aOR: 0.79 [95% CI: 0.77 to 0.81]), and limb amputation (aOR: 0.77 [95% CI: 0.74 to 0.79]) compared with surgical group (p < 0.001 for all). EVI group had higher risk of bleeding (aOR: 1.20 [95% CI: 1.18 to 1.23]) and vascular complications (3.2% vs 2.7%, aOR: 1.25 [95% CI: 1.19 to 1.30]) compared with surgical group (p < 0.001 for all). Within study period, EVI utilization increased in octogenarian patients from 2.6% to 8.9% (ptrend < 0.001); whereas use of surgical revascularization decreased from 11.6% to 5.2% (ptrend < 0.001). In conclusion, the utilization of EVI in octogenarians is increasing, and associated with lower risk of in-hospital mortality and adverse cardiovascular and limb outcomes as compared with surgical revascularization.
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Affiliation(s)
- Homam Moussa Pacha
- University of Texas Health Science Center, McGovern Medical School, Memorial Hermann Heart & Vascular Institute, Houston, Texas
| | | | - Fahed Darmoch
- Beth Israel Deaconess Medical center/Harvard medical school, Boston, Massachusetts
| | | | - Chun Shing Kwok
- Keele Cardiovascular Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Mamas A Mamas
- Keele Cardiovascular Group, Centre for Prognosis Research, Keele University, Stoke-on-Trent, UK; Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Said Ashraf
- Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, Michigan
| | - Yasar Sattar
- Icahn school of medicine at Mount Sinai Elmhurst Hospital New York
| | - Waqas Ullah
- Abington Jefferson Health, Abington, Pennsylvania
| | | | - Salman A Arain
- University of Texas Health Science Center, McGovern Medical School, Memorial Hermann Heart & Vascular Institute, Houston, Texas
| | - Dmitriy N Feldman
- Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | | | - Herbert D Aronow
- Alpert Medical School at Brown University/Lifespan Cardiovascular Institute, Providence, Rhode Island
| | - Mehdi H Shishehbor
- University Hospital Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, Michigan.
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Carter TM, Strassle PD, Ollila DW, Stitzenberg KB, Meyers MO, Maduekwe UN. Does acral lentiginous melanoma subtype account for differences in patterns of care in Black patients? Am J Surg 2021; 221:706-711. [PMID: 33461732 PMCID: PMC8376182 DOI: 10.1016/j.amjsurg.2020.12.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 12/11/2020] [Accepted: 12/21/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Melanoma-specific outcomes for Black patients are worse when compared to non-Hispanic white (NHW) patients. We sought to evaluate whether acral lentiginous melanoma, seen more commonly in Black patients, was associated with racial disparities in outcomes METHODS: The National Cancer Database was analyzed for major subtypes of stage I-IV melanoma diagnosed from 2004 to 2016. The association between Black race and (Siegel et al., Jan) 1 acral melanoma diagnosis and (Bradford et al., Apr) 2 receipt of major amputation for surgical management of melanoma was evaluated using multivariable logistic regression. RESULTS 251,864 patients were included (1453 Black). Black patients had increased odds of acral melanoma (odds ratio [OR] = 27.6, 95% CI]: 24.4, 31.2) compared to NHW patients. Black patients still had higher odds ratios of major amputation across all stages after adjusting for acral histology and other potential confounders CONCLUSIONS: Increased prevalence of acral melanoma in Black patients does not fully account for increased receipt of major amputation.
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Affiliation(s)
- Taylor M Carter
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Paula D Strassle
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - David W Ollila
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Karyn B Stitzenberg
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Michael O Meyers
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Ugwuji N Maduekwe
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
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Spraul AMS, Schönbach AM, Müller N, Müller UA, Koller A, Spraul M. Long-term outcome of persons with diabetic and non-diabetic neuro-osteoarthropathy after foot correction using external fixation. Diabet Med 2021; 38:e14404. [PMID: 32949070 DOI: 10.1111/dme.14404] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/28/2020] [Accepted: 09/10/2020] [Indexed: 11/29/2022]
Abstract
AIM Diabetic neuro-osteoarthropathy (Charcot foot) is a serious form of diabetic foot syndrome, often leading to severe deformity of the foot and subsequently to ulcers and osteomyelitis. The aim of this retrospective study was to determine the success rate and long-term outcomes for a Charcot foot operation using external fixation in 115 individuals who underwent surgery between July 2008 and December 2012. METHODS Some 115 consecutive persons, 78 (68%) men and 37 (32%) women, were enrolled in this study. The eligibility criterion for this retrospective study was reconstructive foot surgery using a Hoffmann II external fixator in diabetic and non-diabetic neuro-osteoarthropathy. The main examination parameters in the follow-up were walking ability, amputation and mortality. Average follow-up was 5.7 (± 3.2) years. RESULTS Ninety-seven per cent of people were able to walk after the operation with bespoke shoes or an orthosis. At follow-up, 77% were able to walk and 51% were fully mobile even outside the home. Subsequent amputations were performed in 29 individuals (26%), with 17 (15%) minor and 12 (11%) major amputations. Forty-seven individuals died before follow-up, the majority (53%) from cardiovascular events. Average survival time post surgery was 4.5 (± 2.9) years. CONCLUSION Reconstruction surgery using external fixation is a very useful method for maintaining walking ability in the case of conservatively non-treatable diabetic and non-diabetic neuro-osteoarthropathy. Individuals with severe Charcot foot disease had a low rate of major amputations. Osteomyelitis was the main reason for major amputations.
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Affiliation(s)
- A M S Spraul
- Department for Internal Medicine III, Mathias-Spital Rheine, Rheine, Germany
| | - A M Schönbach
- Department for Internal Medicine III, Mathias-Spital Rheine, Rheine, Germany
| | - N Müller
- Department for Internal Medicine III, Jena University Hospital, Jena, Germany
| | - U A Müller
- Practice for Endocrinology and Diabetology, Dr. Kielstein Ambulante Medizinische Betreuung GmbH, Jena, Germany
| | - A Koller
- Department of Foot Surgery, Klinik Dr Guth, Hamburg, Germany
| | - M Spraul
- Department for Internal Medicine III, Mathias-Spital Rheine, Rheine, Germany
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Abstract
BACKGROUND We identified the need to modernize frostbite management in our northern centre and implemented a treatment protocol in 2015. Our aim was to describe the clinical course of patients presenting to the hospital since the implementation of the protocol. METHODS This was a retrospective case series from Whitehorse General Hospital, Whitehorse, Yukon Territory, Canada. We reviewed the charts of patients who presented to the hospital with grade 2-4 frostbite and were treated as per our protocol between Feb. 9, 2015, and Feb. 8, 2020. Patients with grade 2-4 frostbite received iloprost; in addition, those with grade 4 frostbite received alteplase and heparin. We determined the number of digits affected and salvaged, and the time from presentation to the emergency department to treatment initiation. We also examined patients' demographic characteristics, predisposing events, frostbite severity and adverse drug reactions. RESULTS In 22 patients treated for grade 2-4 frostbite, 142 digits were affected: 59 with grade 2 frostbite, 25 with grade 3 frostbite and 58 with grade 4 frostbite; of the 142, 113 (79.6%) were salvaged. All 29 digits amputated had grade 4 frostbite. The mean time from presentation to iloprost initiation was reduced from 32.9 hours in 2015 to 3.0 hours in 2020. Sports (10 cases [45%]) and alcohol use (6 [27%]) were the most common precipitating events, with alcohol use tending to result in more severe injury (grade 4 in 5 of 6 cases). Adverse reactions with iloprost (e.g., headache) were common but mild. Adverse reactions with alteplase (e.g., bleeding) were less common but of greater clinical significance. INTERPRETATION Over the study period, our protocol contributed to improvement in frostbite care at our institution, resulting in a digit salvage rate comparable to other published results. Our 5-year experience shows that advanced medical care of frostbite can be achieved, even at a rural centre.
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Affiliation(s)
- Alexander Poole
- Whitehorse General Hospital (Poole), Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Whitehorse General Hospital (Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; University of Saskatchewan (Gauthier), Saskatoon, Sask.; Department of Surgery (MacLennan), McMaster University, Hamilton, Ont.; Harvard T.H. Chan School of Public Health (MacLennan), Boston, Mass.
| | - Josianne Gauthier
- Whitehorse General Hospital (Poole), Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Whitehorse General Hospital (Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; University of Saskatchewan (Gauthier), Saskatoon, Sask.; Department of Surgery (MacLennan), McMaster University, Hamilton, Ont.; Harvard T.H. Chan School of Public Health (MacLennan), Boston, Mass
| | - Mira MacLennan
- Whitehorse General Hospital (Poole), Whitehorse, Yukon; Department of Surgery (Poole), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Whitehorse General Hospital (Gauthier), Yukon Hospital Corporation, Whitehorse, Yukon; University of Saskatchewan (Gauthier), Saskatoon, Sask.; Department of Surgery (MacLennan), McMaster University, Hamilton, Ont.; Harvard T.H. Chan School of Public Health (MacLennan), Boston, Mass
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Lim LL, Lau ESH, Fu AWC, Ray S, Hung YJ, Tan ATB, Chamnan P, Sheu WHH, Chawla MS, Chia YC, Chuang LM, Nguyen DC, Sosale A, Saboo BD, Phadke U, Kesavadev J, Goh SY, Gera N, Huyen Vu TT, Ma RCW, Lau V, Luk AOY, Kong APS, Chan JCN. Effects of a Technology-Assisted Integrated Diabetes Care Program on Cardiometabolic Risk Factors Among Patients With Type 2 Diabetes in the Asia-Pacific Region: The JADE Program Randomized Clinical Trial. JAMA Netw Open 2021; 4:e217557. [PMID: 33929522 PMCID: PMC8087959 DOI: 10.1001/jamanetworkopen.2021.7557] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Many health care systems lack the efficiency, preparedness, or resources needed to address the increasing number of patients with type 2 diabetes, especially in low- and middle-income countries. OBJECTIVE To examine the effects of a quality improvement intervention comprising information and communications technology and contact with nonphysician personnel on the care and cardiometabolic risk factors of patients with type 2 diabetes in 8 Asia-Pacific countries. DESIGN, SETTING, AND PARTICIPANTS This 12-month multinational open-label randomized clinical trial was conducted from June 28, 2012, to April 28, 2016, at 50 primary care or hospital-based diabetes centers in 8 Asia-Pacific countries (India, Indonesia, Malaysia, the Philippines, Singapore, Taiwan, Thailand, and Vietnam). Six countries were low and middle income, and 2 countries were high income. The study was conducted in 2 phases; phase 1 enrolled 7537 participants, and phase 2 enrolled 13 297 participants. Participants in both phases were randomized on a 1:1 ratio to intervention or control groups. Data were analyzed by intention to treat and per protocol from July 3, 2019, to July 21, 2020. INTERVENTIONS In both phases, the intervention group received 3 care components: a nurse-led Joint Asia Diabetes Evaluation (JADE) technology-guided structured evaluation, automated personalized reports to encourage patient empowerment, and 2 or more telephone or face-to-face contacts by nurses to increase patient engagement. In phase 1, the control group received the JADE technology-guided structured evaluation and automated personalized reports. In phase 2, the control group received the JADE technology-guided structured evaluation only. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of a composite of diabetes-associated end points, including cardiovascular disease, chronic kidney disease, visual impairment or eye surgery, lower extremity amputation or foot ulcers requiring hospitalization, all-site cancers, and death. The secondary outcomes were the attainment of 2 or more primary diabetes-associated targets (glycated hemoglobin A1c <7.0%, blood pressure <130/80 mm Hg, and low-density lipoprotein cholesterol <100 mg/dL) and/or 2 or more key performance indices (reduction in glycated hemoglobin A1c≥0.5%, reduction in systolic blood pressure ≥5 mm Hg, reduction in low-density lipoprotein cholesterol ≥19 mg/dL, and reduction in body weight ≥3.0%). RESULTS A total of 20 834 patients with type 2 diabetes were randomized in phases 1 and 2. In phase 1, 7537 participants (mean [SD] age, 60.0 [11.3] years; 3914 men [51.9%]; 4855 patients [64.4%] from low- and middle-income countries) were randomized, with 3732 patients allocated to the intervention group and 3805 patients allocated to the control group. In phase 2, 13 297 participants (mean [SD] age, 54.0 [11.1] years; 7754 men [58.3%]; 13 297 patients [100%] from low- and middle-income countries) were randomized, with 6645 patients allocated to the intervention group and 6652 patients allocated to the control group. In phase 1, compared with the control group, the intervention group had a similar risk of experiencing any of the primary outcomes (odds ratio [OR], 0.94; 95% CI, 0.74-1.21) but had an increased likelihood of attaining 2 or more primary targets (OR, 1.34; 95% CI, 1.21-1.49) and 2 or more key performance indices (OR, 1.18; 95% CI, 1.04-1.34). In phase 2, the intervention group also had a similar risk of experiencing any of the primary outcomes (OR, 1.02; 95% CI, 0.83-1.25) and had a greater likelihood of attaining 2 or more primary targets (OR, 1.25; 95% CI, 1.14-1.37) and 2 or more key performance indices (OR, 1.50; 95% CI, 1.33-1.68) compared with the control group. For attainment of 2 or more primary targets, larger effects were observed among patients in low- and middle-income countries (OR, 1.50; 95% CI, 1.29-1.74) compared with high-income countries (OR, 1.20; 95% CI, 1.03-1.39) (P = .04). CONCLUSIONS AND RELEVANCE In this 12-month clinical trial, the use of information and communications technology and nurses to empower and engage patients did not change the number of clinical events but did reduce cardiometabolic risk factors among patients with type 2 diabetes, especially those in low- and middle-income countries in the Asia-Pacific region. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01631084.
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Affiliation(s)
- Lee-Ling Lim
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Asia Diabetes Foundation, Shatin, Hong Kong Special Administrative Region, China
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Eric S. H. Lau
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Asia Diabetes Foundation, Shatin, Hong Kong Special Administrative Region, China
| | - Amy W. C. Fu
- Asia Diabetes Foundation, Shatin, Hong Kong Special Administrative Region, China
| | | | - Yi-Jen Hung
- Tri-Service General Hospital, Taipei, Taiwan
| | - Alexander T. B. Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Now with Sunway Medical Centre, Selangor, Malaysia
| | | | | | | | - Yook-Chin Chia
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | | | | | | | | | | | - Su-Yen Goh
- Department of Endocrinology, Singapore General Hospital, Outram Road, Singapore
| | - Neeru Gera
- Max Healthcare Institute, New Delhi, India
| | - Thi Thanh Huyen Vu
- Department of Internal Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Ronald C. W. Ma
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
| | - Vanessa Lau
- Asia Diabetes Foundation, Shatin, Hong Kong Special Administrative Region, China
| | - Andrea O. Y. Luk
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Asia Diabetes Foundation, Shatin, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
| | - Alice P. S. Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
| | - Juliana C. N. Chan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Asia Diabetes Foundation, Shatin, Hong Kong Special Administrative Region, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong Special Administrative Region, China
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Chang HY, Chou YY, Tang W, Chang GM, Hsieh CF, Singh S, Tung YC. Association of antidiabetic therapies with lower extremity amputation, mortality and healthcare cost from a nationwide retrospective cohort study in Taiwan. Sci Rep 2021; 11:7000. [PMID: 33772082 PMCID: PMC7997872 DOI: 10.1038/s41598-021-86516-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/15/2021] [Indexed: 12/17/2022] Open
Abstract
We compared risks of clinical outcomes, mortality and healthcare costs among new users of different classes of anti-diabetic medications. This is a population-based, retrospective, new-user design cohort study using the Taiwan National Health Insurance Database between May 2, 2015 and September 30, 2017. An individual was assigned to a medication group based on the first anti-diabetic prescription on or after May 1, 2016: SGLT-2 inhibitors, DPP-4 inhibitors, GLP-1 agonists or older agents (metformin, etc.). Clinical outcomes included lower extremity amputation, peripheral vascular disease, critical limb ischemia, osteomyelitis, and ulcer. We built three Cox proportional hazards models for clinical outcomes and mortality, and three regression models with a log-link function and gamma distribution for healthcare costs, all with propensity-score weighting and covariates. We identified 1,222,436 eligible individuals. After adjustment, new users of SGLT-2 inhibitors were associated with 73% lower mortality compared to those of DPP-4 inhibitors or users of older agents, while 36% lower total costs against those of GLP-1 agonists. However, there was no statistically significant difference in the risk of lower extremity amputation across medication groups. Our study suggested that SGLT-2 inhibitors is associated with lower mortality compared to DPP 4 inhibitors and lower costs compared to GLP-1 agonists.
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Affiliation(s)
- Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Population Health IT, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Ying-Yi Chou
- Institute of Health Policy and Management, School of Public Health, National Taiwan University, Room 634, No.17, Xu-Zhou Road, Taipei, 100, Taiwan
| | - Wenze Tang
- Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA
| | - Guann-Ming Chang
- Department of Family Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Feng Hsieh
- School of Medicine for International Students, I- Shou University, Kaohsiung, Taiwan
| | - Sonal Singh
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Yu-Chi Tung
- Institute of Health Policy and Management, School of Public Health, National Taiwan University, Room 634, No.17, Xu-Zhou Road, Taipei, 100, Taiwan.
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Abstract
BACKGROUND Malignant cutaneous adnexal tumors (MCATs) are rare and their natural history is poorly understood. Available literature indicates aggressive behavior with a significant risk of metastasis. STUDY DESIGN Retrospective review of our institutional surgical oncology databases was performed for patients diagnosed with MCATs (2001-2020). We hypothesized that most patients have a low risk of lymph node involvement, recurrence, and death. Kaplan-Meier statistical analysis was used to assess risk of recurrence and 5-year survival. RESULTS We identified 41 patients diagnosed with MCATs (median age 59 years, 68% were men). Most patients had long-standing cutaneous lesions (median 24 months) and no palpable adenopathy. Most patients had stage I or II disease (98%). Primary tumors were treated with wide local excision (n = 28 [68%]), Mohs surgery (n = 5 [12%]), or amputation (n = 8 [19%]). Of 25 patients who underwent SLNB (61%), 1 had lymphatic metastasis. These include apocrine carcinoma (1 of 3), digital papillary adenocarcinoma (0 of 8), porocarcinoma (0 of 4), and additional MCAT sub-types (0 of 10). Three patients (7%) had disease recurrence at a median interval of 3.6 years (interquartile range 1.5 to 4.4 years). Five patients (12%) died at a median interval of 7 years (interquartile range 6.7 to 9.2 years), but only 1 patient was known to have succumbed to MCAT. Overall 5-year survival rate was 96% (95% CI, 75% to 99%). CONCLUSIONS Despite the historical impression that MCATs have a high metastatic potential, most patients have low recurrence rates and excellent 5-year survival rates. Lymphatic disease identified after SLNB in early-stage tumors is rare and the value of this staging procedure in MCAT remains unclear.
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Affiliation(s)
- Alessandra Storino
- Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Reed E Drews
- Division of Hematology-Oncology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Nicholas E Tawa
- Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.
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Abstract
The risk of amputation is a sequelae of diabetic foot ulceration, which are significantly increased in diabetic patients and caused huge morbidly and mortality. However, whether the risk amputation in diabetic patients are differing in male and female remains inconclusive. We therefore conducted a systematic review and meta-analysis to assess the sex difference for the risk of amputation in diabetic patients. We systematically searched PubMed, EmBase, and the Cochrane library to identify eligible study from their inception up to November 2020. The diagnostic value of male patients on subsequent amputation risk were assessed by using sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic odds ratio (DOR), and area under the receiver operating characteristic curve (AUC). Twenty-two studies recruited a total of 33,686,171 diabetic patients were selected for quantitative analysis. The risk of amputation in male diabetic patients was greater than female diabetic patients (DOR: 1.38; 95%CI: 1.13–1.70; P<0.001). The sensitivity and specificity for male diabetic patients on the risk of amputation were 0.72 (95%CI: 0.72–0.73), and 0.51 (95%CI: 0.51–0.51), respectively. Moreover, the PLR and NLR of male diabetic patients for predicting amputation were 1.13 (95%CI: 1.05–1.22), and 0.82 (0.72–0.94), respectively. Furthermore, the AUC for male diabetic patients on amputation risk was 0.56 (95%CI: 0.48–0.63). This study found male diabetic patients was associated with an increased risk of amputation than female diabetic patients, and the predictive value of sex difference on amputation risk in diabetic patients was mild.
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Affiliation(s)
- Lei Fan
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Department of Orthopedic Surgery, People’s Hospital of Zhengzhou University, Zhengzhou, China
| | - Xue-Jian Wu
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- * E-mail:
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Baysal Ö, Sağlam F, Sofulu Ö, Yiğit O, Şirin E, Erol B. Indications of amputation after limb-salvage surgery of patients with extremity-located bone and soft-tissue sarcomas: A retrospective clinical study. Acta Orthop Traumatol Turc 2021; 55:154-158. [PMID: 33847578 DOI: 10.5152/j.aott.2021.20115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to investigate amputation-related factors after limb-salvage surgery (LSS) in patients with extremity-located bone and soft-tissue sarcomas and determine the relationship between these factors and patient survival. METHODS In this retrospective study at our institution, patients in whom LSS was first performed because of an extremity-located musculoskeletal sarcoma, and subsequently amputation was carried out for various indications were included. Patient and tumor characteristics, details of surgical procedures, indications of amputation, number of operations, presence of metastasis before amputation, and post-amputation patient survival rates were analyzed. RESULTS A total of 25 patients (10 men, 15 women; mean age=41.96±21.88 years), in whom amputation was performed after LSS as initial resection of an extremity sarcoma or re-resection(s) of a local recurrence, were included in the study. The leading oncological indication for amputation was local recurrence that occurred in 18 (72%) patients. Non-oncological indications included prosthetic infection in 5 (20%), mechanical failure in 1 (4%), and skin necrosis in 1 (4%) patient. The patients underwent a median of 2 (range, 1-4) limb-salvage procedures before amputation. Distant organ metastasis was detected in 22 (88%) patients during follow-up; in 13 (52%) of these patients, metastasis was present before amputation. A total of 11 (44%) patients were alive at the time of study with no evidence of the disease (n=3) or with disease (n=8), and 14 (56%) patients died of disease. The mean overall and post-amputation survival were 47±20.519 (range, 11-204) months and 22±4.303 (range, 2-78) months, respectively. The median follow-up was 27 (range, 6-125) months. CONCLUSION The most common causes of amputation after LSS were local recurrence and prosthetic infection. Patients who underwent amputation after LSS developed a high rate of distant organ metastasis during follow-up and had reduced survival. LEVEL OF EVIDENCE Level IV, Therapeutic Study.
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Affiliation(s)
- Özgür Baysal
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Fevzi Sağlam
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Ömer Sofulu
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Okan Yiğit
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Evrim Şirin
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
| | - Bülent Erol
- Department of Orthopaedic and Traumatology, Marmara University Pendik Training and Research Hospital, İstanbul, Turkey
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Lilja E, Gottsäter A, Miftaraj M, Ekelund J, Eliasson B, Svensson AM, Zarrouk M, Nilsson P, Acosta S. The impact of diabetes mellitus on major amputation among patients with chronic limb threatening ischemia undergoing elective endovascular therapy- a nationwide propensity score adjusted analysis. J Diabetes Complications 2021; 35:107675. [PMID: 32828647 DOI: 10.1016/j.jdiacomp.2020.107675] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/30/2020] [Accepted: 07/08/2020] [Indexed: 01/13/2023]
Abstract
AIM To investigate the risk of major amputation after elective endovascular therapy in patients with chronic limb threatening ischemia (CLTI) comparing patients with and without diabetes mellitus (DM). METHODS In this nationwide cohort study, all patients registered in the Swedish Vascular Register after elective endovascular therapy for CLTI caused by infra-inguinal arterial disease from 2010 to 2014 were included. Among 4578 individuals, 2251 had DM and were registered in the National Diabetes Register between 2009 and 2014. A propensity score adjusted Cox regression analysis was conducted to compare outcomes between groups. Median follow-up was 4.0 and 3.6 years for patients with DM and without DM, respectively. RESULTS The incidence rates of major amputation and acute myocardial infarction (AMI) were 43% (95% CI 1.23-1.67) and 37% (95% CI 1.13-1.67) higher, respectively, among patients with DM compared to patients without DM. There was no difference in mortality (HR 1.04, 95% CI 0.95-1.14). CONCLUSIONS Patients with DM had a higher risk of major amputation and AMI compared to those without DM after elective endovascular therapy for CLTI. Prevention of DM with CLTI is of utmost importance to reduce the risk of adverse limb and cardiovascular outcomes.
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Affiliation(s)
- Erika Lilja
- Department of Clinical Sciences, Malmö, Lund University, Sweden.
| | - Anders Gottsäter
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Mervete Miftaraj
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Jan Ekelund
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
| | - Björn Eliasson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ann-Marie Svensson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Moncef Zarrouk
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
| | - Peter Nilsson
- Department of Clinical Sciences, Malmö, Lund University, Sweden
| | - Stefan Acosta
- Department of Clinical Sciences, Malmö, Lund University, Sweden; Vascular Center, Department of Cardio-Thoracic Surgery and Vascular Diseases, Skåne University Hospital, Sweden
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Lee AS, Twigg SM, Flack JR. Metabolic syndrome in type 1 diabetes and its association with diabetes complications. Diabet Med 2021; 38:e14376. [PMID: 32738821 DOI: 10.1111/dme.14376] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 06/15/2020] [Accepted: 07/27/2020] [Indexed: 01/01/2023]
Abstract
AIM To assess the prevalence of metabolic syndrome in type 1 diabetes, and its age-related association with diabetes complications. METHODS Australian National Diabetes Information Audit and Benchmarking (ANDIAB) was a well-established quality audit programme. It provided cross-sectional data on people attending specialist diabetes services across Australia. We determined the prevalence of metabolic syndrome (WHO criteria) in adults with type 1 diabetes and its associations with diabetes complications across age groups. RESULTS Metabolic syndrome prevalence was 30% in 2120 adults with type 1 diabetes. Prevalence increased with age: 21% in those aged <40 years, 35% in those aged 40-60 years, and 44% in those aged >60 years (P<0.001), which was driven by an increase in hypertension rate. Metabolic syndrome was associated with a higher prevalence of microvascular, macrovascular and foot complications, with the greatest impact at a younger age. The odds ratio for macrovascular complications with metabolic syndrome, compared with without, was 5.9 (95% CI 2.1-16.4) in people aged <40 years, 2.7 (95% CI 1.7-4.2) in those aged 40-60 years, and 1.7 (95% CI 1.1-2.7) in those aged >60 years (all P < 0.05). Metformin use was higher in those with metabolic syndrome (16% vs 4%; P<0.001). CONCLUSIONS In this large Australian cohort, metabolic syndrome was common in type 1 diabetes and identified people at increased risk of the spectrum of diabetes complications, particularly in young to middle-aged adults. Potential clinical implications are that therapies targeting insulin resistance in this high-risk group may reduce diabetes complications and should be explored.
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Affiliation(s)
- Angela S Lee
- Department of Endocrinology, Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Central Clinical School in Sydney Medical School, Faculty of Medicine and Health, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
- Department of Diabetes and Endocrinology, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
| | - S M Twigg
- Department of Endocrinology, Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Central Clinical School in Sydney Medical School, Faculty of Medicine and Health, Charles Perkins Centre, University of Sydney, Sydney, NSW, Australia
| | - J R Flack
- Department of Diabetes and Endocrinology, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Western Sydney University, Sydney, NSW, Australia
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Boschert EN, Stubblefield CE, Reid KJ, Schwend RM. Twenty-two Years of Pediatric Musculoskeletal Firearm Injuries: Adverse Outcomes for the Very Young. J Pediatr Orthop 2021; 41:e153-e160. [PMID: 33055517 DOI: 10.1097/bpo.0000000000001682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Firearm injuries are a significant cause of morbidity and mortality for children in the United States. The purpose of this study is to investigate the 22-year experience of pediatric firearm-related musculoskeletal injuries at a major pediatric level 1 hospital and to analyze the risk of adverse outcomes in children under 10 years of age. METHODS An institutional review board-approved, retrospective cohort analysis was conducted on pediatric firearm-related musculoskeletal injuries at our institution from 1995 to 2017. A total of 189 children aged 0 to 18 years were identified using International Classification of Diseases, 9th Revision/10th Revision codes, focusing on musculoskeletal injuries by firearms. Exclusion criteria were primary treatment at an outside hospital, isolated nonmusculoskeletal injuries (eg, traumatic brain injury), and death before orthopaedic intervention. Two cohorts were included: age below 10 years and age 10 years and above. Primary outcome measure was a serious adverse outcome (death, growth disturbance, amputation, or impairment). Standard statistical analysis was used for demographic data, along with linear mixed models and multivariable logistic regression for adverse outcome. RESULTS Of the 189 children, 46 (24.3%) were below 10 years of age and 143 (75.7%) were 10 years and above. Fifty-two (27.5%) of the total group had an adverse outcome, with 19 (41.3%) aged below 10 years and 33 (23.1%) aged 10 years and above (P=0.016). Adverse outcomes were 3 deaths, 17 growth disturbances, 7 amputations, and 44 impairments. For those below 10 years of age, rural location (P=0.024), need for surgical treatment (P=0.041), femur injury (P=0.032), peripheral nerve injury (P=0.006), and number of surgeries (P=0.022) were associated with an adverse outcome. CONCLUSIONS Over one fourth of survivors of musculoskeletal firearm injuries had an adverse outcome. Children 10 years and above represent the majority of firearm injuries in our population; however, when injured, those below 10 years are more likely to have an adverse outcome. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Connor E Stubblefield
- Children's Mercy Hospital, Kansas City, MO
- University of Kansas School of Medicine, Kansas City, KS
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Tavares KB, Russell DM, Conrad RJ, Sizemore GC, Nguyen SH, Moon AY, Colgan BA, Condon FJ, Mayo JS, Criman ET, Lim RB. Time to weigh in on obesity and associated comorbidities in combat-wounded amputees. J Trauma Acute Care Surg 2021; 90:325-330. [PMID: 33075023 DOI: 10.1097/ta.0000000000002999] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Joint Trauma System database estimates that about 1,200 individuals have sustained a combat-related amputation during the Global War on Terror. Previous retrospective studies have demonstrated that combat-related amputees develop obesity and cardiovascular disease, but the incidence of obesity and associated comorbidities in this population is unknown. The objectives of this study are to determine the prevalence of obesity in the military amputee population and to compare this with the general population. METHODS This is a retrospective review of 978 patients who sustained a combat-related amputation from 2003 to 2014. Prevalence of obesity and comorbid conditions were determined. A multivariate logistic regression model was performed to identify risk factors for postamputation obesity. Kaplan-Meier curves were constructed using obesity as the event of interest. RESULTS A total of 1,233 charts were reviewed with 978 patients included for analysis. The median age of injury was 24 years. Median follow-up time was 8.7 years, ranging from 0.5 years to 16.9 years. The average Injury Severity Score was 23.3. The average body mass index preinjury was 25.6 kg/m2, and the average most recent corrected body mass index was found to be 31.4 kg/m2. Prevalence of comorbidities was higher in the amputee population. Fifty percent of patients who progressed to obesity did so within 1.3 years. CONCLUSION There is a notable prevalence of obesity that develops in the amputee population that is much higher than the general population. We determined that the amputee population is at risk, and these patients should be closely monitored for 1 to 2.5 years following injury. This study provides a targeted period for which monitoring and intervention can be implemented. LEVEL OF EVIDENCE Retrospective, basic science, outcomes analysis, level III/IV.
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Affiliation(s)
- Kelli B Tavares
- From the Department of General Surgery (K.B.T., D.M.R., R.J.C., G.C.S., S.H.N., A.Y.M., B.A.C., F.J.C., J.S.M., E.T.C.), Tripler Army Medical Center, Honolulu, Hawaii; and Department of General Surgery (R.B.L.), University of Oklahoma, Tulsa, Oklahoma
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Sen P, Demirdal T. Predictive ability of LRINEC score in the prediction of limb loss and mortality in diabetic foot infection. Diagn Microbiol Infect Dis 2021; 100:115323. [PMID: 33556651 DOI: 10.1016/j.diagmicrobio.2021.115323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/03/2021] [Accepted: 01/18/2021] [Indexed: 01/22/2023]
Abstract
It was aimed to analyze the effectiveness of the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score in predicting amputation and mortality in diabetic foot infection (DFI). Data of 416 patients who were hospitalized for DFI were recorded retrospectively. LRINEC scores were calculated for each patient from laboratory data. The diagnostic performance of LRINEC score was investigated in amputated/nonamputated and survived/deceased patient groups. Median LRINEC score of patients who underwent amputation was higher than those without amputation (P < 0.001). The area under the curve (AUC) value for LRINEC score was 0.638 with the cut-off point of ≥5 in predicting amputation. Median LRINEC score of deceased patients was higher than those who survived (P= 0.022). AUC value for LRINEC score was 0.663 with the cut-off point of ≥7 in predicting mortality. LRINEC score may be a promising scoring system in predicting both amputation and mortality in DFI.
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Affiliation(s)
- Pinar Sen
- Izmir Katip Celebi University Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey.
| | - Tuna Demirdal
- Izmir Katip Celebi University Ataturk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Izmir, Turkey
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Shabhay A, Horumpende P, Shabhay Z, Mganga A, Van Baal J, Msuya D, Chilonga K, Chugulu S. Clinical profiles of diabetic foot ulcer patients undergoing major limb amputation at a tertiary care center in North-eastern Tanzania. BMC Surg 2021; 21:34. [PMID: 33435942 PMCID: PMC7802243 DOI: 10.1186/s12893-021-01051-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers complications are the major cause of non-traumatic major limb amputation. We aimed at assessing the clinical profiles of diabetic foot ulcer patients undergoing major limb amputation in the Surgical Department at Kilimanjaro Christian Medical Centre (KCMC), a tertiary care hospital in North-eastern Tanzania. METHODS A cross-sectional hospital-based study was conducted from September 2018 through March 2019. Demographic data were obtained from structured questionnaires. Diabetic foot ulcers were graded according to the Meggitt-Wagner classification system. Hemoglobin and random blood glucose levels data were retrieved from patients' files. RESULTS A total of 60 patients were recruited in the study. More than half (31/60; 51.67%) were amputated. Thirty-five (58.33%) were males. Fifty-nine (98.33%) had type II diabetes. Nearly two-thirds (34/60; 56.67%) had duration of diabetes for more than 5 years. The mean age was 60.06 ± 11.33 years (range 30-87). The mean haemoglobin level was 10.20 ± 2.73 g/dl and 9.84 ± 2.69 g/dl among amputees. Nearly two thirds (42/60; 70.00%) had a haemoglobin level below 12 g/dl, with more than a half (23/42; 54.76%) undergoing major limb amputation. Two thirds (23/31; 74.19%) of all patients who underwent major limb amputation had mean hemoglobin level below 12 g/dl. The mean Random Blood Glucose (MRBG) was 13.18 ± 6.17 mmol/L and 14.16 ± 6.10 mmol/L for amputees. Almost two thirds of the study population i.e., 42/60(70.00%) had poor glycemic control with random blood glucose level above 10.0 mmol/L. More than half 23/42 (54.76%) of the patients with poor glycemic control underwent some form of major limb amputation; which is nearly two thirds (23/31; 74.19%) of the total amputees. Twenty-eight (46.67%) had Meggitt-Wagner classification grade 3, of which nearly two thirds (17:60.71%) underwent major limb amputation. CONCLUSION In this study, the cohort of patients suffering from diabetic foot ulcers treated in a tertiary care center in north-eastern Tanzania, the likelihood of amputation significantly correlated with the initial grade of the Meggit-Wagner ulcer classification. High blood glucose levels and anaemia seem to be also important risk factors but correlation did not reveal statistical significance.
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Affiliation(s)
- Ahmed Shabhay
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
- Institute of Infectious Diseases and Research, Lugalo Military College of Medical Sciences (MCMS) and General Military Hospital (GMH), Mwenge area, P.O. Box 60000, Dar es Salaam, Tanzania
| | - Pius Horumpende
- Institute of Infectious Diseases and Research, Lugalo Military College of Medical Sciences (MCMS) and General Military Hospital (GMH), Mwenge area, P.O. Box 60000, Dar es Salaam, Tanzania
- Kilimanjaro Clinical Research Institute (KCRI), P.O. Box 2236, Moshi, Tanzania
| | - Zarina Shabhay
- Department of Neuro-Surgery, Muhimbili Orthopedic Institute, P.O. Box 65474, Dar es Salaam, Tanzania
| | - Andrew Mganga
- Department of Public Health, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
| | - Jeff Van Baal
- ZGT Academy, Hospital Group Twente, Almelo, Hengelo, The Netherlands
- Cardiff University, Cardiff, Wales UK
| | - David Msuya
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Kondo Chilonga
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Samwel Chugulu
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
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Cai M, Xie Y, Bowe B, Gibson AK, Zayed MA, Li T, Al-Aly Z. Temporal Trends in Incidence Rates of Lower Extremity Amputation and Associated Risk Factors Among Patients Using Veterans Health Administration Services From 2008 to 2018. JAMA Netw Open 2021; 4:e2033953. [PMID: 33481033 PMCID: PMC7823225 DOI: 10.1001/jamanetworkopen.2020.33953] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
IMPORTANCE Lower extremity amputation (LEA) is associated with significant morbidity and mortality. However, national temporal trends of LEA incidence rates among US veterans and associated factors have not been well characterized. OBJECTIVE To describe the temporal trends of LEA, characterize associated risk factors, and decompose the associations of these risk factors with changes in temporal trends of LEA among US veterans using Department of Veteran Affairs (VA) services between 2008 and 2018. DESIGN, SETTING, AND PARTICIPANTS This cohort study used VA data from 2008 to 2018 to estimate incidence rates of LEA among veterans using VA services. Cox regression models were used to identify risk factors associated with LEA. Decomposition analyses estimated the associations of changes in prevalence of risk factors with changes in LEA rates. Data were analyzed from October 1, 2007, to September 30, 2018. MAIN OUTCOMES AND MEASURES Toe, transmetatarsal, below-knee, or above-knee LEA. RESULTS A total of 6 493 141 veterans were included (median [interquartile range] age, 64 [54-76] years; 6 060 390 [93.4%] men). Veterans were studied for a median (interquartile range) of 10.9 (5.6-11.0) years. Between 2008 and 2018, rates of LEA increased from 12.89 (95% CI, 12.53-13.25) LEA per 10 000 persons to 18.12 (95% CI, 17.70-18.54) LEA per 10 000 persons, representing a net increase of 5.23 (95% CI, 4.68-5.78) LEA per 10 000 persons. Between 2008 and 2018, toe amputation rates increased by 3.24 (2.89-3.59) amputations per 10 000 persons, accounting for 62.0% of the total increase in LEA rates. Transmetatarsal amputations increased by 1.54 (95% CI, 1.27-1.81) amputations per 10 000 persons; below-knee amputation rates increased by 0.81 (95% CI, 0.56-1.05) amputations per 10 000 persons; and above-knee amputation rates decreased by 0.37 (95% CI, 0.14-0.59) amputations per 10 000 persons. Compared with men, women had decreased risk of any LEA (hazard ratio [HR], 0.34 [95% CI, 0.31-0.37]). Factors associated with increased risk of any LEA included Black race (HR, 1.25 [95% CI, 1.21-1.28]) or another non-White race (ie, Asian, Latino, or other; HR, 2.36 [95% CI, 2.30-2.42]), obesity (HR, 1.59 [95% CI, 1.55-1.63]), diabetes (HR, 6.38 [95% CI, 6.22-6.54]), chronic kidney disease (CKD; eg, CKD stage 5: HR, 3.94 [95% CI, 3.22-4.83]), and smoking status (eg, current smoking: HR, 1.97 [95% CI, 1.92-2.03]). Decomposition analyses suggested that while changes in demographic composition, primarily driven by increased proportion of women veterans, associated with a decrease of 0.18 (95% CI, 0.14-0.22) LEA per 10 000 persons, and decreases in smoking rates, associated with a decrease of 0.88 (95% CI, 0.79-0.97) LEA per 10 000 persons. However, these were overwhelmed by increased rates of diabetes, associated with an increase of 1.86 (95% CI, 1.72-1.99) LEA per 10 000 persons; peripheral arterial disease, associated with an increase of 1.53 (95% CI, 1.41-1.65) LEA per 10 000 persons; CKD, associated with an increase of 1.45 (95% CI, 1.33-1.57) LEA per 10 000 persons; and other clinical factors, including body mass index, cancer, cardiovascular disease, cerebrovascular disease, chronic lung disease, dementia, and hypertension, associated with an increase of 1.45 (95% CI, 1.33-1.57) LEA per 10 000 persons. CONCLUSIONS AND RELEVANCE This cohort study found that incidence rates of LEA among veterans using VA services increased between 2008 and 2018. Efforts aimed at reducing burden of LEA should target the reduction of diabetes, peripheral arterial disease, and CKD at the individual and population levels.
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Affiliation(s)
- Miao Cai
- Clinical Epidemiology Center, Department of Veterans Affairs, St Louis Health Care Systems, St Louis, Missouri
- Veterans Research and Education Foundation of St Louis, St Louis, Missouri
| | - Yan Xie
- Clinical Epidemiology Center, Department of Veterans Affairs, St Louis Health Care Systems, St Louis, Missouri
- Veterans Research and Education Foundation of St Louis, St Louis, Missouri
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, St Louis University, St Louis, Missouri
| | - Benjamin Bowe
- Clinical Epidemiology Center, Department of Veterans Affairs, St Louis Health Care Systems, St Louis, Missouri
- Veterans Research and Education Foundation of St Louis, St Louis, Missouri
- Department of Epidemiology and Biostatistics, College for Public Health and Social Justice, St Louis University, St Louis, Missouri
| | - Andrew K. Gibson
- Clinical Epidemiology Center, Department of Veterans Affairs, St Louis Health Care Systems, St Louis, Missouri
| | - Mohamed A. Zayed
- Section of Vascular Surgery, Department of Surgery, School of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Surgery, Veterans Affairs St Louis Health Care System, St Louis, Missouri
| | - Tingting Li
- Clinical Epidemiology Center, Department of Veterans Affairs, St Louis Health Care Systems, St Louis, Missouri
- Division of Nephrology, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Ziyad Al-Aly
- Clinical Epidemiology Center, Department of Veterans Affairs, St Louis Health Care Systems, St Louis, Missouri
- Veterans Research and Education Foundation of St Louis, St Louis, Missouri
- Department of Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
- Nephrology Section, Medicine Service, Department of Veteran Affairs St Louis Health Care System, St Louis, Missouri
- Institute for Public Health, Washington University in St Louis, St Louis, Missouri
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Lo J, Chan L, Flynn S. A Systematic Review of the Incidence, Prevalence, Costs, and Activity and Work Limitations of Amputation, Osteoarthritis, Rheumatoid Arthritis, Back Pain, Multiple Sclerosis, Spinal Cord Injury, Stroke, and Traumatic Brain Injury in the United States: A 2019 Update. Arch Phys Med Rehabil 2021; 102:115-131. [PMID: 32339483 PMCID: PMC8529643 DOI: 10.1016/j.apmr.2020.04.001] [Citation(s) in RCA: 160] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To present recent evidence on the prevalence, incidence, costs, activity limitations, and work limitations of common conditions requiring rehabilitation. DATA SOURCES Medline (PubMed), SCOPUS, Web of Science, and the gray literature were searched for relevant articles about amputation, osteoarthritis, rheumatoid arthritis, back pain, multiple sclerosis, spinal cord injury, stroke, and traumatic brain injury. STUDY SELECTION Relevant articles (N=106) were included. DATA EXTRACTION Two investigators independently reviewed articles and selected relevant articles for inclusion. Quality grading was performed using the Methodological Evaluation of Observational Research Checklist and Newcastle-Ottawa Quality Assessment Form. DATA SYNTHESIS The prevalence of back pain in the past 3 months was 33.9% among community-dwelling adults, and patients with back pain contribute $365 billion in all-cause medical costs. Osteoarthritis is the next most prevalent condition (approximately 10.4%), and patients with this condition contribute $460 billion in all-cause medical costs. These 2 conditions are the most prevalent and costly (medically) of the illnesses explored in this study. Stroke follows these conditions in both prevalence (2.5%-3.7%) and medical costs ($28 billion). Other conditions may have a lower prevalence but are associated with relatively higher per capita effects. CONCLUSIONS Consistent with previous findings, back pain and osteoarthritis are the most prevalent conditions with high aggregate medical costs. By contrast, other conditions have a lower prevalence or cost but relatively higher per capita costs and effects on activity and work. The data are extremely heterogeneous, which makes anything beyond broad comparisons challenging. Additional information is needed to determine the relative impact of each condition.
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Affiliation(s)
- Jessica Lo
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD
| | - Leighton Chan
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD.
| | - Spencer Flynn
- Rehabilitation Medicine Department, National Institutes of Health, Bethesda, MD
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Mundy LR, Truong T, Shammas RL, Cunningham D, Hollenbeck ST, Pomann GM, Gage MJ. Amputation Rates in More Than 175,000 Open Tibia Fractures in the United States. Orthopedics 2021; 44:48-53. [PMID: 33284985 DOI: 10.3928/01477447-20201202-03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/06/2019] [Indexed: 02/03/2023]
Abstract
Open tibia fractures are often associated with considerable soft tissue injuries. Management of open tibia fractures can be challenging, and some patients require amputation. The patient and treatment factors have not been described on a population level in the United States. A retrospective analysis was completed using the 2000 to 2011 Nationwide Inpatient Sample. Amputation rates during the index hospitalization after open tibia fracture were computed based on injury, patient, and hospital characteristics in patients 18 years or older. The overall amputation rate in open tibia fractures during the index hospitalization was 2.2% (n=3769). Patients with midshaft tibia fractures comprised the largest portion of patients undergoing amputation (46.8% of total amputations) compared with distal tibia (34.0%) and proximal tibia (19.3%) fractures. Patients with no neurovascular injury comprised the largest portion of patients undergoing amputation (85.9%), followed by isolated arterial injury (11.1%), combined neurovascular injury (1.9%), and isolated nerve injury (1.1%). Amputation rates were significantly increased for midshaft tibia fractures with neurovascular injury (odds ratio, 12.39; 95% CI, 5.52-27.83) and distal tibia fractures with neurovascular injury (odds ratio, 5.45; 95% CI, 1.73-17.19) compared with tibia fractures with no neurovascular injury while controlling for confounders. On the basis of a review of the Nationwide In-patient Sample during the past decade, the authors have shown that the early amputation rate in open tibia fractures for all-comers is 2.2%. Rates of amputation varied based on fracture site, associated neurovascular injury, medical comorbidities, and hospital location. [Orthopedics. 2021;44(1):48-53.].
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