Gender difference in the risk for cardiovascular events or mortality of patients with diabetic foot syndrome

Association of the triglyceride glucose index with sudden cardiac death in the patients with diabetic foot ulcer

BACKGROUND

This study examines the relationship between the TyG index and the risk of sudden cardiac death (SCD) in the patients with diabetic foot ulcer (DFU).

METHODS

688 type 2 diabetes mellitus (T2DM) inpatients with DFU between January 2010 and December 2023 was included in this retrospective study. The 1:1 propensity score matching (PSM) method was applied. The relationship between TyG index and SCD risk was analyzed using the Kaplan-Meier (K-M) survival curve analysis, multivariate Cox proportional hazard regression model, Restricted cubic spline (RCS) model analysis and subgroup analyses.

RESULTS

Over a median follow-up period of 61 months, 38 cases of SCD were recorded. After PSM, 71 pairs of score-matched patients according to TyG index were generated. K-M survival curves revealed higher SCD rates in patients with TyG index ≥9.65. The Cox proportional hazard model, independently associated with the risk of SCD (HR: 75.98; 95 % CI: 9.16 ∼ 630.40; P < 0.001). RCS model showed that SCD risk was non-linearly correlated with gradual increases in TyG index levels. Stratified analyses indicated a consistent relationship between increasing TyG index and SCD risk across all subgroups.

CONCLUSIONS

Elevated TyG index independently confers an increased risk for SCD in individuals with DFU.

Metrics of Gender Differences in Mortality Risk after Diabetic Foot Disease

BACKGROUND

The aim of this study was to clarify any gender differences in the mortality risk of people with DFD since patients with diabetic foot disease (DFD) are at a high risk of mortality and, at the same time, are more likely to be men.

METHODS

From regional administrative sources, the survival probability was retrospectively evaluated by the Kaplan-Meier method and using the Cox proportional-hazards model comparing people with DFD to those without DFD across the years 2011-2018 in Tuscany, Italy. Gender difference in mortality was evaluated by the ratio of hazard ratios (RHR) of men to women after initial DFD hospitalizations (n = 11,529) or in a cohort with prior history of DFD hospitalizations (n = 11,246).

RESULTS

In both cohorts, the survival probability after DFD was lower among women. Compared to those without DFD, after initial DFD hospitalizations, the mortality risk was significantly (18%) higher for men compared to women. This excess risk was particularly high after major amputations but also after ulcers, infections, gangrene, or Charcot, with a lower reduction after revascularization procedures among men. In the cohort that included people with a history of prior DFD hospitalizations, except for the risk of minor amputations being higher for men, there was no gender difference in mortality risk.

CONCLUSIONS

In people with DFD, the overall survival probability was lower among women. Compared to those without DFD after a first DFD hospitalization, men were at higher risk of mortality. This excess risk disappeared in groups with a history of previous DFD hospitalizations containing a greater percentage of women who were older and probably had a longer duration of diabetes and thus becoming, over time, progressively frailer than men.

Healthcare costs of diabetic foot disease in Italy: estimates for event and state costs

OBJECTIVE

This study aimed to estimate healthcare costs of diabetic foot disease (DFD) in a large population-based cohort of people with type-2 diabetes (T2D) in the Tuscany region (Italy).

DATA SOURCES/STUDY SETTING

Administrative healthcare data of Tuscany region, with 2018 as the base year.

STUDY DESIGN

Retrospective study assessing a longitudinal cohort of patients with T2D.

DATA COLLECTION/EXTRACTION METHODS

Using administrative healthcare data, DFD were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes.

METHODS

We examined the annual healthcare costs of these clinical problems in patients with T2D between 2015 and 2018; moreover, we used a generalized linear model to estimate the total healthcare costs.

PRINCIPAL FINDINGS

Between 2015 and 2018, patients with T2D experiencing DFD showed significantly higher average direct costs than patients with T2D without DFD (p < 0.0001). Among patients with T2D experiencing DFD, those who experienced complications either in 2015-2017 and in 2018 incurred the highest incremental costs (incremental cost of € 16,702) followed by those with complications in 2018 only (incremental cost of € 9,536) and from 2015 to 2017 (incremental cost of € 800).

CONCLUSIONS

DFD significantly increase healthcare utilization and costs among patients with TD2. Healthcare costs of DFD among patients with T2D are associated with the timing and frequency of DFD. These findings should increase awareness among policymakers regarding resource reallocation toward preventive strategies among patients with T2D.

The Weakness of the Strong Sex: Differences Between Men and Women Affected by Diabetic Foot Disease

We aimed to analyze sex-related differences in clinical outcomes among patients with diabetic foot disease (DFD) managed in a third-level referral center. We retrospectively analyzed data of admissions performed in our department between 2011 and 2015 for DFD. We collected demographic and clinical data, procedures performed during the admission, and short- and long-term outcomes in terms of healing rate and healing time, major amputation, and mortality rates during the follow-up. We focused on differences between genders and tried to figure out if sex could be considered a predictive factor. We collected data from 1237 admission performed in 842 patients (615 men [73%] and 227 women [27%]; age: 68.6 ± 27.9 years; diabetes duration: 16.4 ± 13.4 years; body mass index: 28.2 ± 6.4 kg/m²; hemoglobin A1c 7.9 ± 1.9%). Men showed a higher prevalence of comorbidities and previous ulcers or revascularization procedures. Men had a significantly higher healing rate compared with women (85.4% vs 63.2%, P < .001), but a longer healing time (124 ± 27 days vs 87 ± 14 days, P = .02). Major amputation did not differ between groups, while mortality rate was significantly higher in men (24.5% vs 16.1%, P = .02). In Cox's regression analysis, male sex was a positive predictive factor for healing and a negative one for time to heal and mortality. The difference in mortality was confirmed by a Kaplan-Meier analysis (log rank test: P = .03). DFD represents a severe disease and a strong marker of mortality affecting more severely on clinical outcomes and survival on men.

Sex differences in diabetic foot ulcer severity and outcome in Belgium

BACKGROUND

Sex differences are increasingly recognized to play an important role in the epidemiology, treatment and outcomes of many diseases. This study aims to describe differences between sexes in patient characteristics, ulcer severity and outcome after 6 months in individuals with a diabetic foot ulcer (DFU).

METHODS

A total of 1,771 patients with moderate to severe DFU participated in a national prospective, multicenter cohort study. Data were collected on demographics, medical history, current DFU and outcome. For data analysis, a Generalized Estimating Equation model and an adjusted Cox proportional hazards regression were used.

RESULTS

The vast majority of patients included were male (72%). Ulcers in men were deeper, more frequently displaying probe to bone, and more frequently deeply infected. Twice as many men presented with systemic infection as women. Men demonstrated a higher prevalence of previous lower limb revascularization, while women presented more frequently with renal insufficiency. Smoking was more common in men than in women. No differences in presentation delay were observed. In the Cox regression analysis, women had a 26% higher chance of healing without major amputation as a first event (hazard ratio 1.258 (95% confidence interval 1.048-1.509)).

CONCLUSIONS

Men presented with more severe DFU than women, although no increase in presentation delay was observed. Moreover, female sex was significantly associated with a higher probability of ulcer healing as a first event. Among many possible contributing factors, a worse vascular state associated with a higher rate of (previous) smoking in men stands out.

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

AIMS

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

DATA SYNTHESIS

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

CONCLUSION

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

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

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

Alterations in pro- and anti-inflammatory mediators are involved in microvascular dysfunction in postmenopausal women with type 2 diabetes mellitus

Evidence has shown that women with type 2 diabetes mellitus (T2DM) have a greater risk of cardiovascular complications compared with men, but this sex difference is not clearly understood. This study assessed the microvascular function and circulatory biomarkers in postmenopausal women (PMW) with T2DM compared with diabetic men and their non-diabetic counterparts. Sixty participants were divided into nondiabetic PMW, PMW with T2DM, non-diabetic men, and diabetic men. Microvascular function was assessed using non-invasive equipment (EndoPAT^®) and reported as reactive hyperemia index (RHI). Anthropometric and cardiovascular parameters were also measured. Two-way ANOVA was performed using sex (women or men) and T2DM (non-diabetic and diabetic) as the two factors. RHI impairment (1.97±0.14) was detected in diabetic PMW compared with women without T2DM (2.5±0.13) accompanied by lower adiponectin levels (T2DM: 9.3±1.2 and CTL: 13.8±1.8 ug/mL, P<0.05). An increase in the Nε-carboxymethyllysine (CML), nitrate/nitrite, and C-reactive protein (CRP) levels were observed in diabetic PMW compared to the other groups. Although a poor glycemia control was seen in diabetic men, neither RHI nor circulatory biomarkers were affected by T2DM. Multiple linear regression stratified by sex and T2DM identified some variables with RHI only in PMW with T2DM: HbA1c (P=0.003), body mass index (P=0.029), CML (P=0.032), and CRP (P=0.006). Diabetic PMW were more susceptible to the deleterious effects of hyperglycemia than men, showing microvascular dysfunction with high levels of pro-inflammatory mediators (CML and CRP) and a lower adiponectin concentration.

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

BACKGROUND

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background and Aims

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

Methods

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

Results

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

Conclusions

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

The effects of auricular acupuncture on vascular parameters on the risk factors for diabetic foot: A randomized clinical trial

AIMS AND OBJECTIVES

To evaluate the effects of auricular acupuncture on vascular parameters on the risk factors for Diabetic Foot.

METHODS

Randomized and masked clinical trial. The sample was composed of 44 individuals with type 2 Diabetes Mellitus and they were randomly assigned to two groups: intervention (n = 22), which received five sessions of auricular acupuncture, and control (n = 22), which did not receive the therapy. Three evaluations were performed: before the intervention; one day after the last acupuncture session and 15 days after the second evaluation. For this, the subject's characterization instrument, the Ankle-Brachial Index measurement, and thermography were used. For data analysis, Mann-Whitney, Wilcoxon, Wilcoxon signed-rank, Fisher's Exact and Chi-Square tests were used.

RESULTS

Auriculotherapy provided results in the Ankle-Brachial Index Test, as well as in thermography, which showed significant temperature improvement.

CONCLUSIONS

The technique proved to be efficient in improving circulatory conditions and plantar temperature.

Risk factors in acute diabetic foot syndrome: analysis of 75 consecutive patients referred to a tertiary center in Modena, Italy

Aim: Diabetic foot syndrome (DFS) is a complication of diabetes in which the presence of infections, ulceration and/or destruction of deep tissue associated with neuropathy, peripheral atherosclerosis and comorbidity affect the prognosis, the need for limb amputation and quality of life. Purpose of the present study is to report the features of patients with acute DFS admitted to our Diabetic Foot Unit tertiary Center in 2019. Methods: In all patients admitted, the approach was performed through a multidisciplinary team (Diabetic Foot Care Team) and described in a specific diagnostic-therapeutic-assistance program. Criteria of inclusion were presence of sepsis and/or suspected osteomyelitis and/or critical limb ischemia. Clinical features and interventions performed were registered. Primary endpoints were mortality and amputation (major, minor). Secondary endpoints were length of hospitalization, type of revascularization and duration of antibiotic therapy. Results: Among 75 consecutive patients (mean age 70.9 years) enrolled, prevalence of acute DFS was higher among men (M/F 3:1). Poor glycemic control [mean hemoglobin A1c (HbA1c) 67.9 ± 22.3 mmol/mol], long duration of diabetes (mean 19 ± 16.3 years), high low-density lipoprotein-cholesterol (mean 89.5 ± 45.1 mg/ dL) and obesity (mean Body Mass Index 30.2 ± 7.6 kg/m2) were common. Diabetes-related complications as peripheral arterial disease (PAD) (76%), ischemic heart disease (48%), retinopathy (40.5%), hepatic steatosis (50%), heart failure (17.8%) were present. During hospitalization, 21 subjects (28.4%) underwent lower limb amputations (overall rate of major amputation 4%), and 41.3% underwent percutaneous angioplasty. Long period of hospitalization (18.4 ± 7.9 days) and prolonged antibiotic therapy (23.9 ± 15.9 days) were observed. Major amputation was associated with C-reactive protein > 6.5 mg/dL (P = 0.03), osteomyelitis (P = 0.001), prior insulin therapy (P = 0.015). Conclusions: Male sex, co-morbidity, PAD, systemic inflammation and poor glycemic control are major features of acute hospitalized DFS. An approach through a multidisciplinary team is recommended in order to treat vascular and extra-vascular complications aimed at reducing mortality and at improving quality of life.

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

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

Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer

Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.

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

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

Mortality in Asian Indians with Charcot's neuroarthropathy: a nested cohort prospective study

AIMS

We studied mortality in individuals of diabetes with or without Charcot neuroarthropathy (CN).

METHODS

People attending diabetic foot care facility with CN of foot (Cohort 1) were prospectively evaluated. Details pertaining to the duration of diabetes, microvascular and macrovascular complications, foot ulcer, amputation and mortality outcomes were recorded and compared with those without foot complications (Cohort 2) by multivariate logistic regression.

RESULTS

Data for 260 individuals of diabetes with CN and 520 individuals without CN were analysed. Mean age at presentation with CN was 55.8 ± 9.1 years, and duration of diabetes was 12.9 ± 7.8 years. 39.8% individuals with CN had foot ulcer, and 15.3% had amputation. People with CN were younger (55 ± 9.1 vs. 59.9 ± 8.1 years, p < 0.001) and had higher prevalence of microvascular complications. A total of 39 (15%) individuals with CN and 50 (9.8%) (p = 0.03) individuals without CN died during median follow-up of 40(24-51) months. People with CN had 2.7 times (OR 2.72, 95% CI 1.4-5.2, p = 0.003) increased mortality risk when matched for potential confounders. Prevalent CAD and low eGFR predicted higher mortality in people with CN.

CONCLUSIONS

People with Charcot neuroarthropathy have almost three times increased risk of mortality despite being younger at presentation.