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

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

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

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

Introduction

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

Aim

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

Material and methods

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

Results

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

Conclusions

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

Diagnostic and therapeutic update on diabetic foot osteomyelitis

Diabetic foot osteomyelitis (DFO) is the most common infection associated to diabetic foot ulcers (DFU). This review is designed to provide an update on the diagnosis and treatment of DFO based on an analysis of MEDLINE through PubMed using as search criterion "Diabetic Foot Osteomyelitis". Authors have included in this review the most relevant manuscripts regarding diagnosis and treatment of DFO. After review and critical analysis of publications, it may be concluded that diagnosis of DFO is not simple because of its heterogeneous presentation. Clinical inflammatory signs, probe-to-bone test, and plain X-rays are postulated as the basic tests for clinical diagnosis when DFO is suspected. Diagnosis should be supported by laboratory tests, of which ESR (>70mm/h) has been shown to be most precise. MRI is the most accurate imaging test, especially for differential diagnosis with Charcot foot. Pathogen isolation by bone culture is essential when the patient is treated with ATB only. Medical or surgical treatment should be based on the clinical characteristics of the patient and the lesion. Surgery should always be an option if medical treatment fails.

Complications and revision amputation following trauma-related lower limb loss

INTRODUCTION

Trauma-related amputations are a common cause of limb loss in the United States. Despite the military and public health impact of trauma-related amputations, distributions of various lower limb amputations and the relative frequency of complications and revision amputations have not been well described. We used the National Trauma Data Bank (NTDB) in order to investigate the epidemiology of trauma-related lower extremity amputations among civilians in U.S. trauma centers.

MATERIALS AND METHODS

We conducted a secondary data analysis of the 2011-2012 NTDB research data sets, using means and frequencies to characterize the patient population and describe the distribution of major lower extremity amputations. Multivariable regression models were fit to identify predictors of major post-surgical complications, revision amputation, length of hospitalization, and in-hospital mortality.

RESULTS

A total of 2879 patients underwent a major lower extremity amputation secondary to a trauma-related lower limb injury, representing 0.18% of all NTDB trauma admissions from 2011 to 2012. 80.4% were male and 67.6% were white. The three most frequent definitive amputations preformed included trans-tibial (46%), trans-femoral (37.5%), and through foot (7.6%). The average length of hospitalization for all amputees was 22.7days. Patients with at least one revision amputation stayed in the hospital approximately 5.5days longer than patients not needing a revision amputation. 1204 patients (41.8%) required at least one revision amputation. 27.5% of amputees experienced at least one major post-surgical complication. African Americans experienced a 49% higher major post-surgical complication incidence and stayed, on average, 2.5days longer in the hospital compared to whites. Injury severity score, age, hospital teaching status, presence of a crush injury, fracture location, presence of compartment syndrome, and experiencing a major post-surgical complication were all significant predictors of revision amputation.

CONCLUSION

We report a high rate of complications and revision amputations among trauma-related lower limb amputees, and identify predictors of surgical outcomes that have not been described in the literature including African American race. Compartment syndrome is a significant predictor of major post-surgical complications, revision amputation, and length of hospitalization.

The impact of gender, level of amputation and diabetes on prosthetic fit rates following major lower extremity amputation

BACKGROUND

Diabetes mellitus is a leading cause of major lower extremity amputation.

OBJECTIVE

To examine the influence of gender, level of amputation and diabetes mellitus status on being fit with a prosthetic limb following lower extremity amputation for peripheral arterial disease.

STUDY DESIGN

Retrospective analysis of the Scottish Physiotherapy Amputee Research Group dataset.

RESULTS

Within the cohort with peripheral arterial disease ( n = 1735), 64% were men ( n = 1112) and 48% ( n = 834) had diabetes mellitus. Those with diabetes mellitus were younger than those without: mean 67.5 and 71.1 years, respectively ( p < 0.001). Trans-tibial amputation:trans-femoral amputation ratio was 2.33 in those with diabetes mellitus, and 0.93 in those without. A total of 41% of those with diabetes mellitus were successfully fit with a prosthetic limb compared to 38% of those without diabetes mellitus. Male gender positively predicted fitting with a prosthetic limb at both trans-tibial amputation ( p = 0.001) and trans-femoral amputation ( p = 0.001) levels. Bilateral amputations and increasing age were negative predictors of fitting with a prosthetic limb ( p < 0.001). Diabetes mellitus negatively predicted fitting with a prosthetic limb at trans-femoral amputation level ( p < 0.001). Mortality was 17% for the cohort, 22% when the amputation was at trans-femoral amputation level.

CONCLUSION

Of those with lower extremity amputation as a result of peripheral arterial disease, those with diabetes mellitus were younger, and more had trans-tibial amputation. Although both age and amputation level are good predictors of fitting with a prosthetic limb, successful limb fit rates were no better than those without diabetes mellitus. Clinical relevance This is of clinical relevance to those who are involved in the decision-making process of prosthetic fitting following major amputation for dysvascular and diabetes aetiologies.

A Series of 210 Peripheral Arterial Disease Below-Knee Amputations and Predictors for Subsequent Above-Knee Amputations

Objective: To review patient characteristics and outcomes after peripheral arterial disease (PAD)-related below-knee amputation (BKA), and identify risk factors predicting subsequent above-knee amputation (AKA).

Materials and Methods: A retrospective study of 210 BKAs between May 2008 and December 2015.

Results: The mean age of the study population was 66 years. Most of the patients had cardiovascular comorbidities, and 33% had end-stage renal failure (ESRF); 89% were American Society of Anesthesiologists 3 or 4. Previous ipsilateral lower-limb minor amputation was present in 49% and previous contralateral lower-limb major amputation was present in 20% patients. Limb salvage revascularization via angioplasty prior to BKA was performed in 73%, while 27% had extensive tissue loss that was not suitable for limb salvage. Postoperatively, 20% had BKA wound infection, with 3% requiring further surgical debridement, and 9% (19 patients) required subsequent AKA within 1 month. Overall survival analysis at 1–5 years was 75%, 66%, 64%, 59%, and 58%, respectively. Multivariate analysis showed ESRF (Odds Ratio [OR]=3.85; p=0.01) and preoperative non-ambulatory status (OR=5.58; p=0.01) to be independent risk factors in predicting for subsequent AKA.

Conclusion: Patients with underlying ESRF or preoperative non-ambulatory status may benefit from direct AKA if major amputation is required.

Predictors of in-hospital mortality following major lower extremity amputations in type 2 diabetic patients using artificial neural networks

BACKGROUND

Outcome prediction is important in the clinical decision-making process. Artificial neural networks (ANN) have been used to predict the risk of post-operative events, including survival, and are increasingly being used in complex medical decision making. We aimed to use ANN analysis to estimate predictive factors of in-hospital mortality (IHM) in patients with type 2 diabetes (T2DM) after major lower extremity amputation (LEA) in Spain.

METHODS

We design a retrospective, observational study using ANN models. We used the Spanish National Hospital Discharge Database to select all hospital admissions of major LEA procedure in T2DM patients.

MAIN OUTCOME MEASURES

Predictors of IHM using 4 ANN models: i) with all discharge diagnosis included in the database; ii) with all discharge diagnosis included in the database, excluding infectious diseases; iii) comorbidities included in the Charlson Comorbidities Index; iv) comorbidities included in the Elixhauser Comorbidity Index.

RESULTS

From 2003 to 2013, 40,857 major LEAs in patients with T2DM were identified with a 10.0% IHM. We found that Elixhauser Comorbidity Index model performed better in terms of sensitivity, specificity and precision than Charlson Comorbidity Index model (0.7634 vs 0.7444; 0.9602 vs 0.9121; 0.9511 vs 0.888, respectively). The area under the ROC curve for Elixhauser comorbidity model was 91.7% (95% CI 90.3-93.0) and for Charlson comorbidity model was 88.9% (95% CI; 87.590.2) p = 0.043. Models including all discharge diagnosis with and without infectious diseases showed worse results. In the Elixhauser Comorbidity Index model the most sensitive parameter was age (variable sensitive ratio [VSR] 1.451) followed by female sex (VSR 1.433), congestive heart failure (VSR 1.341), renal failure (VSR 1.274) and chronic pulmonary disease (VSR 1.266).

CONCLUSIONS

Elixhauser Comorbidity Index is a superior comorbidity risk-adjustment model for major LEA survival prediction in patients with T2DM than Charlson Comorbidity Index model using ANN models. Female sex, congestive heart failure, and renal failure are strong predictors of mortality in these patients.

The amputation prevention initiative

BACKGROUND

The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes.

METHODS

To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490).

RESULTS

The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components.

CONCLUSIONS

These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.

Increasing patient involvement in the diabetic foot pathway: a pilot randomized controlled trial

AIMS

This pilot study aimed to explore whether the use of an intervention to increase shared decision-making (Decision Navigation) increased decision self-efficacy and foot-treatment adherence in patients with a diabetic foot ulcer.

METHODS

Fifty-six patients with a diabetic foot ulcer were randomized to receive Decision Navigation (N = 30) or usual care (N = 26). Primary outcomes included decision self-efficacy, adherence to foot treatment as reported by the participant and adherence to foot treatment as reported by the clinician. Secondary outcomes included foot ulcer healing rate, health-related quality of life, decision conflict and decision regret.

RESULTS

Despite participants rating Decision Navigation as very helpful, mixed analyses of variance revealed no differences in decision self-efficacy or adherence between those receiving Decision Navigation and those receiving usual care. There were no differences between groups with regards to the secondary outcomes, with the exception of decision conflict which increased over time (12 weeks) for those receiving Decision Navigation.

CONCLUSIONS

An intervention that facilitated patient involvement in treatment decisions did not have any impact on decisional confidence or adherence to foot treatment. This does not provide support for the suggestion that personalized care can improve health-related outcomes at this progressed stage of the patient's disease trajectory. We suggest that the diabetic foot population may benefit from interventions aimed at increasing motivation to engage with care pathways, centred on challenging personal controllability beliefs.

Diabetes Is Associated With Decreased Limb Survival in Patients With Critical Limb Ischemia: Pooled Data From Two Randomized Controlled Trials

OBJECTIVE

Although never assessed prospectively, diabetes mellitus (DM) is assumed to negatively affect the outcomes of critical limb ischemia (CLI). DM was highly prevalent in two recently conducted randomized controlled trials in CLI patients, the PADI (Percutaneous Transluminal Balloon Angioplasty [PTA] and Drug Eluting Stents for Infrapopliteal Lesions in Critical Limb Ischemia) and JUVENTAS (Rejuvenating Endothelial Progenitor Cells via Transcutaneous Intra-Arterial Supplementation) trials. To determine the implications of DM in a population of patients with infrapopliteal CLI, clinical outcomes were compared in patients with and without DM.

RESEARCH DESIGN AND METHODS

Individual data from patients with CLI (Rutherford category ≥4) were pooled. Patients were considered to have DM when this diagnosis was reported in the hospital electronic medical records. Rates of major amputation (above ankle level) and major events (major amputation or death) were compared between CLI patients with and without DM. Hazard ratios (HRs) were calculated.

RESULTS

Of a total of 281 patients, DM was present in 49.1%. The major amputation rate at 5 years of follow-up was higher in patients with DM than in patients without DM (34.1% vs. 20.4%, P = 0.015). The major event and death rate did not differ. The unadjusted HR of DM for the major amputation risk was 1.87 (95% CI 1.12-3.12). Model factors with significant HRs in the multivariate analysis were baseline Rutherford category (HR 1.95; 95% CI 1.24-3.06) and ankle-brachial index (ABI) >1.4 (HR 2.78; 95% CI 1.37-5.64).

CONCLUSIONS

CLI patients with DM are at a significantly higher risk of major amputation than CLI patients without DM. This increased risk is associated with a higher prevalence of baseline ABI >1.4 and more severe ischemia at initial presentation in patients with DM.

Long-term mortality after lower-limb amputation

BACKGROUND

Mortality after amputation is known to be extremely high and is associated with a number of patient features. We wished to calculate this mortality after first-time lower-limb amputation and investigate whether any population or treatment factors are associated with worse mortality.

OBJECTIVE

To follow up individuals after lower limb amputation and ascertain the mortality rate as well as population or treatment features associated with mortality.

STUDY DESIGN

A prospective cohort study.

METHODS

Prospective lower-limb amputations over 1 year (N = 105) at a Regional Rehabilitation Centre were followed up for 3 years.

RESULTS

After 3 years, 35 individuals in the cohort had died, representing a mortality of 33%. On initial univariate analysis, those who died were more likely to have diabetes mellitus (χ(2) = 7.16, df = 1, p = 0.007) and less likely to have been fitted with a prosthesis (χ(2) = 5.84, df = 1, p = 0.016). There was no association with age, gender, level of amputation, social isolation, significant medical co-morbidity other than diabetes or presence of mood disorders. A multi-variable logistic regression (backward step) confirmed that diabetes (odds ratio = 3.04, confidence intervals = 1.25-7.40, p = 0.014) and absence of prosthesis-fitting (odds ratio = 2.60, confidence interval = 1.16-6.25, p = 0.028) were independent predictors of mortality.

CONCLUSION

Mortality after amputation is extremely high and is increased in individuals with diabetes or in those who are not fitted with a prosthesis after amputation.

CLINICAL RELEVANCE

The link between diabetes and mortality after amputation has been noted by others, but this is the first study to find an effect from prosthetic limb-wearing. This requires further investigation to ascertain why the wearing of a prosthetic limb, confers an independent survival benefit that is not related to the presence of medical co-morbidity.

Presentations of major peripheral arterial disease and risk of major outcomes in patients with type 2 diabetes: results from the ADVANCE-ON study

Background

Peripheral arterial disease (PAD) is known to be associated with high cardiovascular risk, but the individual impact of PAD presentations on risk of macrovascular and microvascular events has not been reliably compared in patients with type 2 diabetes. We aimed to evaluate the impact of major PAD, and its different presentations, on the 10-year risk of death, major macrovascular events, and major clinical microvascular events in these patients.

Methods

Participants in the action in diabetes and vascular disease: PreterAx and DiamicroN modified-release controlled evaluation (ADVANCE) trial and the ADVANCE-ON post-trial study were followed for a median of 5.0 (in-trial), 5.4 (post-trial), and 9.9 (overall) years. Major PAD at baseline was subdivided into lower-extremity chronic ulceration or amputation secondary to vascular disease and history of peripheral revascularization by angioplasty or surgery.

Results

Among 11,140 participants, 516 (4.6 %) had major PAD at baseline: 300 (2.7 %) had lower-extremity ulceration or amputation alone, 190 (1.7 %) had peripheral revascularization alone, and 26 (0.2 %) had both presentations. All-cause mortality, major macrovascular events, and major clinical microvascular events occurred in 2265 (20.3 %), 2166 (19.4 %), and 807 (7.2 %) participants, respectively. Compared to those without PAD, patients with major PAD had increased rates of all-cause mortality (HR 1.35, 95 % CI 1.15–1.60, p = 0.0004), and major macrovascular events (1.47 [1.23–1.75], p < 0.0001), after multiple adjustments for region of origin, cardiovascular risk factors and treatments, peripheral neuropathy markers, and randomized treatments. We have also observed a trend toward an association of baseline PAD with risk of major clinical microvascular events [1.31 (0.96–1.78), p = 0.09]. These associations were comparable for patients with a lower-extremity ulceration or amputation and for those with a history of peripheral revascularization. Furthermore, the risk of retinal photocoagulation or blindness, but not renal events, increased in patients with lower-extremity ulceration or amputation [1.53 (1.01–2.30), p = 0.04].

Conclusions

Lower-extremity ulceration or amputation, and peripheral revascularization both increased the risks of death and cardiovascular events, but only lower-extremity ulceration or amputation increased the risk of severe retinopathy in patients with type 2 diabetes. Screening for major PAD and its management remain crucial for cardiovascular prevention in patients with type 2 diabetes (ClinicalTrials.gov number, NCT00949286).

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-016-0446-x) contains supplementary material, which is available to authorized users.

Neuropathic Minimally Invasive Surgeries (NEMESIS):: Percutaneous Diabetic Foot Surgery and Reconstruction

Patients with peripheral neuropathy associated with ulceration are the nemesis of the orthopedic foot and ankle surgeon. Diabetic foot syndrome is the leading cause of peripheral neuropathy, and its prevalence continues to increase at an alarming rate. Poor wound healing, nonunion, infection, and risk of amputation contribute to the understandable caution toward this patient group. Significant metalwork is required to hold these technically challenging deformities. Neuropathic Minimally Invasive Surgeries is an addition to the toolbox of management of the diabetic foot. It may potentially reduce the risk associated with large wounds and bony correction in this patient group.

Diabetes-related lower extremity amputations in Singapore

Background:

Lower extremity amputation (LEA) is defined as the complete loss in the transverse anatomical plane of any part of the lower limb. The objective of this study is to look at the trend and mortality trend of LEA performed in diabetes patients from 2008 to 2013.

Methods:

All patients age 15 and above with diabetes mellitus who had undergone LEAs (both major and minor) in Tan Tock Seng Hospital, Singapore from 1 January 2008 to 31 December 2013 were included. The outcomes of interest were deaths from all causes within 30 days and within 1 year.

Results:

Major LEA rate has increased from 11.0 per 100,000 population in 2008 to 13.3 per 100,000 population in 2013. The 30-day mortality rate ranges from 6.0% to 11.1% and the 1-year mortality rate ranges from 24.3% to 30.6%. Minor LEA rate has increased from 10.8 per 100,000 population in 2008 to 13.9 per 100,000 population in 2013. The 30-day mortality rate ranges from 1.5% to 3.7% and the 1-year mortality rate ranges from 9.7% to 18.3%.

Conclusions:

The trends in major and minor LEA are increasing. The 30-day and 1-year mortality for both major and minor LEA are comparable to figures reported worldwide. There is a need to re-look at preventive strategies to reduce LEA in diabetes patients in Singapore.

A Canadian population-based description of the indications for lower-extremity amputations and outcomes

BACKGROUND

To our knowledge, there have been no previously published reports characterizing lower-extremity amputations in Canada. The objective of this study was to describe the indications and outcomes of lower-extremity amputations in the Canadian population.

METHODS

We performed a retrospective cohort study of all adult patients who underwent lower-extremity amputation in Canada between 2006 and 2009. Patients were identified from the Canadian Institute for Health Information's Discharge Abstract Database, which includes all hospital admissions across Canada with the exception of the province of Quebec. Pediatric, trauma, and outpatients were excluded.

RESULTS

During the study period, 5342 patients underwent lower-extremity amputations in 207 Canadian hospitals. The mean age was 67 ± 13 years, and 68% were men. Amputations were most frequently indicated after admission for diabetic complications (81%), cardiovascular disease (6%), or cancer (3%). In total, 65% of patients were discharged to another inpatient or long-term care facility, and 26% were discharged home with or without extra support. Most patients were diabetic (96%) and most (65%) required a below-knee amputation. Predictors of prolonged (> 7 d) hospital stay included amputation performed by a general surgeon; cardiovascular risk factors, such as diabetes, hypertension, ischemic heart disease, congestive heart failure, or hyperlipidemia; and undergoing the amputation in the provinces of Newfoundland and Labrador, New Brunswick, or British Columbia.

CONCLUSION

There is variability in the delivery of lower-extremity amputations and postoperative hospital discharges among surgical specialists and regions across Canada. Future work is needed to investigate the reasons for this variability and to develop initiatives to shorten postoperative hospital stays.

Survival evaluation of the patients with diabetic major lower-extremity amputations

PURPOSE

The purpose of this study was to evaluate the survival after major lower-limb amputation, at a level either below (BKA) or above (AKA) the knee, in diabetic patients.

METHODS

A total of 140 diabetic patients who underwent major lower-limb amputation during the period of 2001-2011 were enrolled in the study. The patients were grouped as below-knee and above-knee amputations. The differences in survival by age, gender, amputation level and revision surgery were investigated. The clinical follow-up periods and the results of the patients with major lower-limb amputation were retrospectively assessed.

RESULTS

The mean follow-up period was 24.87 months (range 0.06-120 months). The mortality rate of series was 32.8 % for 1 year and 70 % for 5 years. One-year mortality rate was 24.6 % and 5-year mortality rate was 66.3 % in below-knee group, 1-year mortality rate was 43.3 % and 5-year mortality rate was 83.3 % in above-knee group. The difference between mortality rates of these groups was significant (p: 0.019). There was no statistically significant difference according to age and gender (p: 0.543 and 0.568). The previous minor amputations were found to have no effect on mortality (p: 0.471).

CONCLUSION

Routine utilization of diabetes follow-up, screening and treatment programs with a multidisciplinary approach might be mandatory to handle early multisystem involvement-prevent major amputation, and increase survival rate in diabetic patients.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Bridging the Gap between Theory and Practice in Integrated Care: The Case of the Diabetic Foot Pathway in Tuscany

INTRODUCTION AND BACKGROUND

As diabetic foot (DF) care benefits from integration, monitoring geographic variations in lower limb Major Amputation rate enables to highlight potential lack of Integrated Care. In Tuscany (Italy), these DF outcomes were good on average but they varied within the region. In order to stimulate an improvement process towards integration, the project aimed to shift health professionals' focus on the geographic variation issue, promote the Population Medicine approach, and engage professionals in a community of practice.

METHOD

Three strategies were thus carried out: the use of a transparent performance evaluation system based on benchmarking; the use of patient stories and benchmarking analyses on outcomes, service utilization and costs that cross-checked delivery- and population-based perspectives; the establishment of a stable community of professionals to discuss data and practices.

RESULTS

The project enabled professionals to shift their focus on geographic variation and to a joint accountability on outcomes and costs for the entire patient pathways. Organizational best practices and gaps in integration were identified and improvement actions towards Integrated Care were implemented.

CONCLUSION AND DISCUSSION

For the specific category of care pathways whose geographic variation is related to a lack of Integrated Care, a comprehensive strategy to improve outcomes and reduce equity gaps by diffusing integration should be carried out.

Mortality After Nontraumatic Major Amputation Among Patients With Diabetes and Peripheral Vascular Disease: A Systematic Review

High mortality rates have been reported after major amputations of a lower limb secondary to diabetes and peripheral vascular disease. However, the mortality rates have varied across studies. A systematic review of the 5-year mortality after nontraumatic major amputations of the lower extremity was conducted. A data search was performed of Medline using OVID, CINHAL, and Cochrane, 365 abstracts were screened, and 79 full text articles were assessed for eligibility. After review, 31 studies met the inclusion and exclusion criteria. Overall, the 5-year mortality rate was very high among patients with any amputation (major and minor combined), ranging from 53% to 100%, and in patients with major amputations, ranging from 52% to 80%. Mortality after below-the-knee amputation ranged from 40% to 82% and after above-the-knee amputation from 40% to 90%. The risk factors for increased mortality included age, renal disease, proximal amputation, and peripheral vascular disease. Although our previous systematic review of the 5-year mortality after ulceration had much lower rates of death, additional studies are warranted to determine whether amputation hastens death or is a marker for underlying disease severity.

Lower-extremity amputation as a marker for renal and cardiovascular events and mortality in patients with long standing type 1 diabetes

Background

We evaluated the risks of renal and cardiovascular complications, and mortality associated with lower extremity amputation (LEA) in patients with type 1 diabetes.

Methods

We studied two cohorts of people with long standing type 1 diabetes: GENEDIAB (n = 456) and GENESIS (n = 611). Subsets of the cohorts (n = 260, n = 544) were followed for 9 and 5 years, respectively. Outcomes were the incidence of end stage renal disease (ESRD), myocardial infarction, stroke and mortality during follow-up. Analyses were performed in pooled cohorts.

Results

The prevalence of LEA at baseline was 9.3 % (n = 99). A positive history of LEA was associated with the baseline prevalence of established (OR 4.50, 95 % CI 2.33–8.91, p < 0.0001) and advanced diabetic nephropathy (OR 5.50, 95 % CI 2.89–10.78, p < 0.0001), ESRD (OR 2.86, 95 % CI 1.43–5.50, p = 0.004), myocardial infarction (OR 3.25, 95 % CI 1.68–6.15, p = 0.0006) and stroke (OR 3.88, 95 % CI 1.67–8.72, p = 0.002, adjusted for sex, age, and cohort membership). A positive history of LEA at baseline was associated with the incidence during follow-up of ESRD (HR 2.69, 95 % CI 1.17–6.20, p = 0.02), and myocardial infarction (HR 3.53, 95 % CI 1.79–6.97, p = 0.0001). History of LEA was also associated with increased risk for all-cause (HR 3.55, 95 % CI 2.05–6.16, p < 0.0001), cardiovascular (HR 3.30, 95 % CI 1.36–8.02, p = 0.008), infectious disease (HR 5.18, 95 % CI 1.13–23.84, p = 0.03) and other-cause mortality (HR 2.81, 95 % CI 1.09–7.26, p = 0.03). History of LEA at baseline was associated with a 40 % reduction in the duration of survival in the subset of patients who died during follow-up. Population attributable risk of the history of LEA at baseline for total mortality during follow-up was 0.31.

Conclusions

Patients with LEA have a higher risk of ESRD, myocardial infarction and cardiovascular and non-cardiovascular mortality. Our results highlight the importance of LEA as a key-predictor for major vascular events and premature death in type 1 diabetic patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-015-0322-0) contains supplementary material, which is available to authorized users.

Nanomaterials as a game changer in the management and treatment of diabetic foot ulcers

Nanoengineered biomaterials have tremendously improved the range of tools utilized for the control of as well as acceleration of healing of diabetic foot ulcers (DFU) over the last few decades.

When and how to audit a diabetic foot service

Quality improvement depends on data collection and audit of clinical services to inform clinical improvements. Various steps in the care of the diabetic foot can be used to audit a service but need defined audit standards. A diabetes foot service should have risk stratification system in place that should compare to the population-based figures of 76% having low-risk feet, 17% moderate risk and 7% being at high risk of ulceration. Resources can then be directed towards those with high-risk feet. Prevalence of foot ulceration needs to be audited. Community-based studies give an audit standard of around 2%, with 2 to 9% having had an ulcer at some stage in the past. Amputation rates should be easier to measure, and the best results are reported to be around 1.5-3 per 1000 people with diabetes. This is a useful benchmark figure, and the rate has been shown to decrease by approximately a third over the last 15 years in some centres. Ulceration rates and ulcer healing rates are the ultimate outcome audit measure as they are always undesirable, whilst occasionally for defined individuals, an amputation can be a good outcome. In addition to clinical outcomes, processes of care can be audited such as provision of clinical services, time from new ulcer to be seen by health care professional, inpatient foot care or use of antibiotics. Measurement of clinical services can be a challenge in the diabetic foot, but it is essential if clinical services and patient outcomes are to be improved.

The status of application and physiotherapy-rehabilitation of prosthetics in Turkey

[Purpose] The aim of this study was to determine the frequency of prosthetic applications and to appraise the importance of amputee rehabilitation in Turkey. [Subjects and Methods] Questionnaires were administered to owners or employees of 36 institutions and the obtained data were evaluated. [Results] While 75% of institutions had no physiotherapist, 25% had 1 or 2 physiotherapists; there were 4 or fewer technicians in 86.1%, and the majority of employees were out of profession in almost all institutions. A total of 83.3% of institutions reported falls, 75% reported complications, 58.3% of them occasionally noted the need of repair; 55.6% of institutions made preprosthetic assessments, 63.9% used gait analysis, and 50% performed prosthetic rehabilitation frequently. [Conclusion] The results of this study reveal the need for more physiotherapists in these centers, the utilization of standardized-objective assessment methods, and development of rehabilitation processes for successful prosthetic applications and amputee rehabilitation in Turkey.

Diabetes, lower-extremity amputation, and death

OBJECTIVE

The goal of the study was to determine whether complications of diabetes well-known to be associated with death such as cardiovascular disease and renal failure fully explain the higher rate of death in those who have undergone a lower-extremity amputation (LEA).

RESEARCH DESIGN AND METHODS

This was a longitudinal cohort study of patients cared for in the Health Improvement Network. Our primary exposure was LEA and outcome was all-cause death. Our "risk factor variables" included a history of cardiovascular disease (a history of myocardial infarctions, cerebrovascular accident, and peripheral vascular disease/arterial insufficiency), Charlson index, and a history of chronic kidney disease. We estimated the effect of LEA on death using Cox proportional hazards models.

RESULTS

The hazard ratio (HR) for death after an LEA was 3.02 (95% CI 2.90, 3.14). The fully adjusted (all risk factor variables) LEA HR was diminished only by ∼22% to 2.37 (2.27, 2.48). Furthermore, LEA had an area under the receiver operating curve (AUC) of 0.51, which is poorly predictive, and the fully adjusted model had an AUC of 0.77, which is better but not strongly predictive. Sensitivity analysis revealed that it is unlikely that there exists an unmeasured confounder that can fully explain the association of LEA with death.

CONCLUSIONS

Individuals with diabetes and an LEA are more likely to die at any given point in time than those who have diabetes but no LEA. While some of this variation can be explained by known complications of diabetes, there remains a large amount of unexplained variation.

The Association between Pre-existing Diabetes Mellitus and Pressure Ulcers in Patients Following Surgery: A Meta-analysis

Uncertainty exists about the role of diabetes in the development of surgery-related pressure ulcers. Therefore, we conducted a meta-analysis to explore the association between pre-existing diabetes mellitus and pressure ulcers among patients after surgery. Summary odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random effects models. Thirteen eligible studies of 2367 patients in total and 12053 controls were included in the final analysis. Compared with patients without diabetes, the pooled odds ratio (OR) of the incidence of pressure ulcers in diabetic patients was 1.74 [95% confidence interval (CI) = 1.40–2.15, I²= 51.1%]. Estimates by type of surgery suggested similar results in cardiac surgery [OR = 2.00, 95% CI = 1.42–2.82, I²= 0%], in general surgery [OR = 1.75, 95% CI = 1.42–2.15, I²= 0%], and in major lower limb amputations [OR = 1.65, 95% CI = 1.01–2.68, I²= 0%] for diabetic patients versus non-diabetic controls. We did not find an increased incidence of pressure ulcers in diabetic patients undergoing hip surgery compared with non-diabetic controls [OR = 1.46, 95% CI = 0.62–3.47, I²= 93.1%]. The excess risk of pressure ulcers associated with pre-existing diabetes was significantly higher in patients undergoing surgery, specifically in patients receiving cardiac surgery. Further studies should be conducted to examine these associations in other types of surgery.

Survival of diabetes patients with major amputation is comparable to malignant disease

INTRODUCTION

Almost all studies on diabetic foot syndrome focused on prevention of amputation and did not investigate long-term prognosis and survival of patients as a primary outcome parameter.

METHODS

We did a retrospective cohort study including 314 patients who had diabetic foot syndrome and underwent amputation between December 1995 and January 2001.

RESULTS

A total of 48% of patients received minor amputation (group I), 15% only major amputation (group II) and 36% initially underwent a minor amputation that was followed by a major amputation (group III). Statistically significant differences were observed in comparison of the median survival of group I to group II (51 vs. 40 months; p = 0.016) and of group II to group III (40 vs. 55 months; p = 0.003).

DISCUSSION

The prognosis of patients with major amputation due to diabetic foot syndrome is comparable to patients with malignant diseases. Vascular interventions did not improve the individual prognosis of patients.

Masquelet Technique for Midfoot Reconstruction Following Osteomyelitis in Charcot Diabetic Neuropathy: A Case Report

CASE

We describe a case of ulcerative midfoot osteomyelitis in a patient with Charcot diabetic neuropathy. After debridement, an extensive osseous defect led to staged reconstruction in an attempt to salvage the foot. We describe the presentation, the treatment, and the technical points of this challenging case.

CONCLUSION

We reconstructed the midfoot defect with use of the induced-membrane Masquelet technique, successfully reestablishing a stable, well-aligned, plantigrade, ulcer-free foot.

Impairment of Wound Healing in Patients With Type 2 Diabetes Mellitus Influences Circulating MicroRNA Patterns via Inflammatory Cytokines

OBJECTIVE

MicroRNAs (miRNA/miR) are stably present in body fluids and are increasingly explored as disease biomarkers. Here, we investigated influence of impaired wound healing on the plasma miRNA signature and their functional importance in patients with type 2 diabetes mellitus.

APPROACH AND RESULTS

miRNA array profiling identified 41 miRNAs significantly deregulated in diabetic controls when compared with patients with diabetes mellitus-associated peripheral arterial disease and chronic wounds. Quantitative real-time polymerase chain reaction validation confirmed decrease in circulating miR-191 and miR-200b levels in type 2 diabetic versus healthy controls. This was reverted in diabetic subjects with associated peripheral arterial disease and chronic wounds, who also exhibited higher circulating C-reactive protein and proinflammatory cytokine levels compared with diabetic controls. miR-191 and miR-200b were significantly correlated with C-reactive protein or cytokine levels in patients with diabetes mellitus. Indeed, proinflammatory stress increased endothelial- or platelet-derived secretion of miR-191 or miR-200b. In addition, dermal cells took up endothelial-derived miR-191 leading to downregulation of the miR-191 target zonula occludens-1. Altered miR-191 expression influenced angiogenesis and migratory capacities of diabetic dermal endothelial cells or fibroblasts, respectively, partly via its target zonula occludens-1.

CONCLUSIONS

This study reports that (1) inflammation underlying nonhealing wounds in patients with type 2 diabetes mellitus influences plasma miRNA concentrations and (2) miR-191 modulates cellular migration and angiogenesis via paracrine regulation of zonula occludens-1 to delay the tissue repair process.

Initial experience with ticagrelor in patients with critical limb ischemia and high on-clopidogrel platelet reactivity undergoing complex peripheral endovascular procedures

PURPOSE

To investigate the safety and efficacy of ticagrelor in patients with critical limb ischemia (CLI) and high on-clopidogrel platelet reactivity (HCPR) undergoing complex, limb-salvage, peripheral endovascular procedures (PEP).

MATERIALS AND METHODS

The study included consecutive patients with HCPR undergoing PEP for CLI. HCPR was defined as platelet reaction units (PRU) >234 as assessed by the VerifyNow P2Y12 assay. Patients with HCPR were prescribed ticagrelor, 180/90 mg twice daily, and aspirin, 100 mg daily, for 6 months and ticagrelor, 180/90 mg twice daily, thereafter. Primary safety outcome was total major bleeding, and primary efficacy outcome was the composite of cardiovascular death and major amputation. Secondary outcomes included the level of platelet inhibition achieved and target limb revascularization (TLR)-free survival rate.

RESULTS

In total, 37 CLI patients with 40 limbs were investigated. Mean follow-up period was 11.3 ± 5.0 months (range 6-21). The mean treated lesion length was 229.2 ± 71.4 mm in the femoropopliteal axis and 179.3 ± 83.9 mm in the infrapopliteal arteries. No major or minor bleeding was detected. There were four periprocedural minor adverse events (10.8%), and in two cases (5.6%) ticagrelor was discontinued. In all patients, ticagrelor achieved platelet inhibition lower than the cut-off value. Mean PRU during clopidogrel therapy was 308.4 ± 41.8 (range 257-422) versus 67.0 ± 52.8 (range 2-189) when switched to ticagrelor; p < 0.0001. Kaplan-Meier estimated primary efficacy outcome and TLR-free survival rates were 92.0 and 67.3% at 12 months, respectively.

CONCLUSION

In this series of CLI patients with HCPR undergoing complex PEP, initial experience with ticagrelor was proven safe and efficient because it resulted in sufficient platelet inhibition and satisfactory clinical results without major complications.

Honey: a potential therapeutic agent for managing diabetic wounds

Diabetic wounds are unlike typical wounds in that they are slower to heal, making treatment with conventional topical medications an uphill process. Among several different alternative therapies, honey is an effective choice because it provides comparatively rapid wound healing. Although honey has been used as an alternative medicine for wound healing since ancient times, the application of honey to diabetic wounds has only recently been revived. Because honey has some unique natural features as a wound healer, it works even more effectively on diabetic wounds than on normal wounds. In addition, honey is known as an "all in one" remedy for diabetic wound healing because it can combat many microorganisms that are involved in the wound process and because it possesses antioxidant activity and controls inflammation. In this review, the potential role of honey's antibacterial activity on diabetic wound-related microorganisms and honey's clinical effectiveness in treating diabetic wounds based on the most recent studies is described. Additionally, ways in which honey can be used as a safer, faster, and effective healing agent for diabetic wounds in comparison with other synthetic medications in terms of microbial resistance and treatment costs are also described to support its traditional claims.

Mesenchymal stem cells ameliorate impaired wound healing through enhancing keratinocyte functions in diabetic foot ulcerations on the plantar skin of rats

AIMS/HYPOTHESIS

Although the initial healing stage involves a re-epithelialization in humans, diabetic foot ulceration (DFU) has been investigated using rodent models with wounds on the thigh skin, in which a wound contraction is initiated. In this study, we established a rodent model of DFU on the plantar skin and evaluated the therapeutic efficacy of bone-marrow-derived mesenchymal stem cells (BM-MSCs) in this model.

METHODS

The wounds made on the hind paws or thighs of streptozotocin induced diabetic or control rats were treated with BM-MSCs. Expression levels of phosphorylated focal adhesion kinase (pFAK), matrix metaroprotease (MMP)-2, EGF, and IGF-1, were evaluated in human keratinocytes, which were cultured in conditioned media of BM-MSCs (MSC-CM) with high glucose levels.

RESULTS

Re-epithelialization initiated the healing process on the plantar, but not on the thigh, skin. The therapy utilizing BM-MSCs ameliorated the delayed healing in diabetic rats. In the keratinocytes cultured with MSC-CM, the decreased pFAK levels in the high glucose condition were restored, and the MMP2, EGF, and IGF-1 levels increased.

CONCLUSIONS/INTERPRETATION

Our study established a novel rat DFU model. The impaired healing process in diabetic rats was ameliorated by transplantation of BM-MSCs. This amelioration might be accounted for by the modification of keratinocyte functions.

Clinical outcomes of toe amputation in patients with type 2 diabetes in Tianjin, China

The aim of this study is to determine the predictors for reulceration, reamputation and mortality in patients with diabetes following toe amputation, and the impact of activities of daily living on clinical outcomes. This prospective cohort study included 245 patients who had undergone toe amputation (202 healing and 43 non-healing) and was followed for a 5-year period. Data regarding new foot ulceration, reamputation and mortality were recorded, and the patients' activities of daily living were evaluated. The rate of wound healing was 82·4%. The rate of follow-up in the healed group was 91·6%. In years 1, 3 and 5, the cumulative incidence of patients who developed a new foot ulcer was 27·3%, 57·2% and 76·4%, respectively, leading to reamputation in 12·5%, 22·3% and 47·1%, respectively. The cumulative mortality was 5·8%, 15·1% and 32·7% at 1, 3 and 5 years, respectively. Multivariate analysis showed that GHbA1c > 9% (75 mmol/mol) was identified as an independent predictor of impaired wound healing, reulceration and reamputation. An age of >70 years was identified as an independent predictor of reamputation, mortality and impairment of activities of daily living. Despite a satisfactory initial healing rate after the first toe amputation, with the extension course after the toe amputation, the long-term outcomes are not optimistic. In developing countries like China, taking measures to prevent reulceration and reamputation is very important for patients with diabetic foot minor amputations, especially following toe amputation.

Diabetic foot ulcers treated with hyperbaric oxygen therapy: a review of the literature

Hyperbaric oxygen therapy (HBO) has been used as an adjunct for healing diabetic foot ulcers (DFUs) for decades. However, its use remains controversial. A literature search was conducted to locate clinical studies and assess the available evidence. Ten prospective and seven retrospective studies evaluating HBO for DFUs were located. These were reviewed and the outcomes were discussed. One study reported no difference in outcomes between patients receiving hyperbaric oxygen and the control group. However, their regime differed from all other studies in that the patients received hyperbaric oxygen twice rather than once daily. Reduced amputation rates and improved healing were the most common outcomes observed.

High serum C-reactive protein level predicts mortality in patients with stage 3 chronic kidney disease or higher and diabetic foot infections

Background

Diabetic patients are predisposed to foot infections because of vascular insufficiency and peripheral neuropathy. Diabetic foot infection is a common cause of mortality and lower extremity amputations (LEAs) in patients with chronic kidney disease (CKD). We evaluated the risk factors for mortality and LEAs in patients with stage 3 CKD or higher with diabetic foot infections.

Methods

We retrospectively evaluated a cohort of 105 CKD patients with diabetic foot infections between July 1998 and December 2011. We reviewed their demographic characteristics and laboratory parameters to evaluate the risk factors for mortality and amputations at 24 weeks after diagnosis of a diabetic foot infection.

Results

The mortality of the 105 enrolled CKD patients was 21% at 24 weeks after the diagnosis of a diabetic foot infection. Cox proportional regression analyses revealed that age 60 years or older [odds ratio (OR) 3.03, 95% confidence interval (CI) = 1.02-9.02, P = 0.047] and initial serum C-reactive protein (CRP) level ≥ 3 mg/dL (OR 3.97, 95% CI = 1.17-13.43, P = 0.027) were independent risk factors for mortality at 24 weeks. Twenty-four patients (23%) underwent LEAs. On Cox proportional regression analyses, peripheral vascular disease (OR=4.49, 95% CI=1.98–10.17, P=0.01) and cerebrovascular accident (OR 2.42, 95% CI=1.09–5.39, P=0.03) were independently associated with LEAs.

Conclusion

This study showed that age and serum CRP level, were independent risk factors for mortality at 24 weeks in patients with stage 3–5 CKD with diabetic foot infections. Peripheral vascular disease and cerebrovascular accident were significantly associated with LEAs.

Impact of critical limb ischemia on long-term cardiac mortality in diabetic patients undergoing percutaneous coronary revascularization

OBJECTIVE

Development of critical limb ischemia (CLI) has been reported as an independent predictor of cardiac mortality in diabetic patients. We aimed to determine whether CLI, managed in a structured setting of close collaboration between different vascular specialists and treated with early endovascular intervention, has any impact on long-term cardiac mortality of diabetic patients initially presenting with symptomatic coronary artery disease (CAD).

RESEARCH DESIGN AND METHODS

We designed a prospective observational study of 764 consecutive diabetic patients undergoing percutaneous coronary intervention (PCI) in whom development of CLI was assessed by a dedicated diabetic foot clinic. Cardiac mortality at 4-year follow-up was the primary end point of the study.

RESULTS

Among the 764 patients, 111 (14%) developed CLI (PCI-CLI group) and underwent revascularization of 145 limbs, with procedural success in 140 (96%). PCI-CLI patients at baseline had lower left ventricular ejection fraction (51 ± 11% vs. 53 ± 10%, P = 0.008), higher prevalence of dialysis (7% vs. 0.3%, P < 0.0001), and longer diabetes duration (13 ± 8 vs. 11 ± 7 years, P = 0.02) compared with PCI-only patients. At 4-year follow-up, cardiac mortality occurred in 10 (9%) PCI-CLI patients vs. 42 (6%) PCI-only patients (P = 0.2). Time-dependent Cox regression model for cardiac death revealed that CLI was not associated with an increased risk of cardiac mortality (hazard ratio 1.08 [95% CI 0.89-3.85]; P = 0.1).

CONCLUSIONS

The development of promptly assessed and aggressively treated CLI was not significantly associated with increased risk of long-term cardiac mortality in diabetic patients initially presenting with symptomatic CAD.

High mortality risks after major lower extremity amputation in Medicare patients with peripheral artery disease

BACKGROUND

Little is known regarding the contemporary outcomes of older patients with peripheral artery disease (PAD) undergoing major lower extremity (LE) amputation in the United States. We sought to characterize clinical outcomes and factors associated with outcomes after LE amputation in patients with PAD.

METHODS

Using data from the Centers for Medicare and Medicaid Services from January 1, 2000, to December 31, 2008, we examined the national patterns of mortality after major LE amputation among patients 65 years or older with PAD. Cox proportional hazards models were used to investigate the association between clinical variables, comorbid conditions, year of index amputation, geographic variation, and major LE amputation.

RESULTS

Among 186,338 older patients with identified PAD who underwent major LE amputation, the mortality rate was 13.5% at 30 days, 48.3% at 1 year, and 70.9% at 3 years. Age per 5-year increase (hazard ratio [HR] 1.29, 95% CI 1.29-1.29), history of heart failure (HR 1.71, 95% CI 1.71-1.72), renal disease (HR 1.84. 95% CI 1.83-1.85), cancer (HR 1.71, 95% CI 1.70-1.72), and chronic obstructive pulmonary disease (HR 1.33, 95% CI, 1.32-1.33) were all independently associated with death after major LE amputation. Subjects who underwent above knee amputation had a statistically higher hazard of death when compared with subjects who underwent LE amputation at more distal locations (HR with above the knee amputation 1.31, 95% CI 1.25-1.36).

CONCLUSIONS

Older patients with PAD undergoing major LE amputation still face a slightly high mortality risk, with almost half of all patients with PAD dying within a year of major LE amputation.

Preoperative medical treatment in patients undergoing diabetic foot surgery with a Wagner Grade-3 or higher ulcer: a retrospective analysis of 52 patients

Diabetic foot ulcers (DFU) are one of the most important complications in people with diabetes mellitus. The present study was aimed to retrospectively review the efficacy of at least 1-week medical treatment before any surgical intervention in patients with Grade-3 and higher DFU according to Wagner's classification. A total of 52 patients (36 males and 16 females) hospitalized and treated between June 2006 and February 2009 and had initially received therapeutic treatment (local wound care, antibiotic therapy and blood glucose regulation) for a period of at least 1 week were included in the study. The level of amputation, rates of reulceration and mortality in both groups were recorded in the following period of 2 years. Group 1 (did not respond to preoperative medical intervention) included 16 patients where a surgical debridement, flap or skin graft surgery was performed in 2 (12.5%) patients, major amputation was performed in another 2 (12.5%) patients and minor amputation was performed in the remaining 12 (75%) patients. Of 36 patients in Group 2 (did respond to preoperative medical intervention), 5 (13.9%) patients underwent the surgical debridement, flap or skin graft surgery, 8 (22.2%) patients had a major amputation and the remaining 23 (63.9%) patients lead to a minor amputation. The ulcer recurrence and mortality rates were obtained as 2 (12.5%) and 2 (12.5%) in Group 1 and 2 (5.6%) and 1 (2.8%) in Group 2, respectively. Despite the lower rates of ulcer recurrence and mortality in patients having adequate responses to initial treatment before surgical procedures were performed, no statistically significant difference was observed between the 2 groups. In addition, there was no statistically significant difference between the levels of amputation in both groups.

Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs

AIMS

To estimate the current and future economic burdens of Type 1 and Type 2 diabetes in the UK.

METHODS

A top-down approach was used to estimate costs for 2010/2011 from aggregated data sets and literature. Prevalence and population data were used to project costs for 2035/2036. Direct health costs were estimated from data on diagnosis, lifestyle interventions, ongoing treatment and management, and complications. Indirect costs were estimated from data on mortality, sickness, presenteeism (potential loss of productivity among people who remain in work) and informal care.

RESULTS

Diabetes cost approximately £ 23.7bn in the UK in 2010/2011: £ 9.8bn in direct costs (£1bn for Type 1 diabetes and £ 8.8bn for Type 2 diabetes) and £ 13.9bn in indirect costs (£ 0.9bn and £ 13bn). In real terms, the 2035/2036 cost is estimated at £ 39.8bn: £ 16.9bn in direct costs (£ 1.8bn for Type 1 diabetes and £ 15.1bn for Type 2 diabetes) and £ 22.9bn in indirect costs (£ 2.4bn and £ 20.5bn). Sensitivity analysis applied to the direct costs produced a range of costs: between £ 7.9bn and £ 11.7bn in 2010/2011 and between £ 13.8bn and £20bn in 2035/2036. Diabetes currently accounts for approximately 10% of the total health resource expenditure and is projected to account for around 17% in 2035/2036.

CONCLUSIONS

Type 1 and Type 2 diabetes are prominent diseases in the UK and are a significant economic burden. Data differentiating between the costs of Type 1 and Type 2 diabetes are sparse. Complications related to the diseases account for a substantial proportion of the direct health costs. As prevalence increases, the cost of treating complications will grow if current care regimes are maintained.

Non traumatic lower extremity amputations in younger patients: an 11-year retrospective study

The purpose of this study was to assess morbidity and mortality in patients undergoing non traumatic lower extremity amputations ≤65 years to identify the specific needs of these younger patients. A retrospective study was conducted to determine the demographics, comorbidity and mortality with below-knee amputations and above-knee amputations from 1998 to 2008. A total of 203 amputations were performed on 176 patients who were ≤65 years. Major comorbidities and associated physical findings were peripheral vascular disease, diabetes, pain, gangrene, hypertension, ulcer, local wound infection and hypercholesterolemia. Compared to patients who were not deceased post-amputation, those deceased had a higher prevalence of diabetes, renal failure, coronary artery disease (CAD) and sepsis. Significant predictors of mortality were renal failure (hazard ratio [HR] = 4·19; 95% CI 1·96-8·93), CAD (HR = 3·33; 95% CI 1·42-7·81) and amputation site (above-knee) (HR = 3·26; 95% CI 1·51-7·04). This study showed that younger patients may benefit from an interdisciplinary approach in treating local foot ulcers aggressively and optimising their cardiovascular, renal and diabetic risk factors.

Risk factors for lower extremity amputation among patients with diabetes in Singapore

BACKGROUND

Among other risk factors, renal disease and ethnicity have been associated with diabetic lower extremity amputation (LEA) in Western populations. However, little is known about risk factors for LEA among Asian patients.

OBJECTIVE

The objective was to assess the proportion of hospitalized patients with diabetes who have a LEA among all hospital patients with diabetes mellitus (DM) and to investigate risk factors for diabetic LEA (especially renal disease and ethnicity) using hospital discharge database.

METHOD

A retrospective study of hospital discharge database (2004-2009) was performed to identify patients with DM, LEA and renal disease using the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Australian Modification codes.

RESULTS

Of 44 917 hospitalized patients with DM during the 6 years, 7312 (16.3%) patients had renal disease, and 1457 (3.2%) patients had LEA. DM patients with renal disease had significant higher rates of LEA (7.1%) compared to DM patients without renal disease (2.5%, P < .001). The differences were present for foot (2.7% vs. 1.2%), ankle or leg (2.8% vs. 0.9%), and knee or above amputation (1.6% vs. 0.4%, all P<.001). Malays had the highest rate of diabetic LEA (5.1%), followed by Indians (3.0%), Chinese (3.0%), and others (2.3%, P < .001). In logistic regression analyses, renal disease and ethnicity were significant predictors of diabetic LEA (renal disease: odds ratio 3.2, 95% confidence interval 2.8-3.6; ethnicity: odds ratio, 1.6, Malays vs. Chinese, P < .001; 1.0, Indians vs. Chinese, P = .784) after adjustment for age, gender, and year of discharge.

CONCLUSION

DM patients with renal disease and Malay ethnicity had higher rates of LEA in this Asian patient population. Malay patients with DM and diabetic patients with renal disease should be considered as high-risk groups for LEA and therefore screened and monitored systematically.

Lower extremity amputations--a review of global variability in incidence

AIM

To quantify global variation in the incidence of lower extremity amputations in light of the rising prevalence of diabetes mellitus.

METHODS

An electronic search was performed using the EMBASE and MEDLINE databases from 1989 until 2010 for incidence of lower extremity amputation. The literature review conformed to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards.

RESULTS

Incidence of all forms of lower extremity amputation ranges from 46.1 to 9600 per 10(5) in the population with diabetes compared with 5.8-31 per 10(5) in the total population. Major amputation ranges from 5.6 to 600 per 10(5) in the population with diabetes and from 3.6 to 68.4 per 10(5) in the total population. Significant reductions in incidence of lower extremity amputation have been shown in specific at-risk populations after the introduction of specialist diabetic foot clinics.

CONCLUSION

Significant global variation exists in the incidence of lower extremity amputation. Ethnicity and social deprivation play a significant role but it is the role of diabetes and its complications that is most profound. Lower extremity amputation reporting methods demonstrate significant variation with no single standard upon which to benchmark care. Effective standardized reporting methods of major, minor and at-risk populations are needed in order to quantify and monitor the growing multidisciplinary team effect on lower extremity amputation rates globally.