Risk factors for lower extremity amputation in diabetic foot disease categorized by Wagner classification

Predictors of Major Lower Extremity Amputation in Type 2 Diabetic Patients With Diabetic Foot Ulcers: A Cross-Sectional Analytical Study

Introduction Diabetic foot ulcers (DFUs) are a significant complication of diabetes mellitus, often leading to major lower extremity amputation. Identifying predictive factors for amputation can guide interventions to prevent this severe outcome. This study aimed to identify predictors of major lower extremity amputation in type 2 diabetic patients with DFUs. Methodology A cross-sectional analytical study was conducted at the Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India, involving 101 patients with DFUs. The study assessed the association between various clinical and laboratory predictors and the necessity for major lower extremity amputation. Results Significant predictors for amputation included Wagner's grade ≥ 5, absent peripheral pulsation, clinical evidence of infection, and elevated levels of erythrocyte sedimentation rate and C-reactive protein. Conclusion This study highlights the importance of early identification of high-risk patients through detailed clinical assessment and laboratory investigations and underscores the need for aggressive management strategies targeting identified predictors to reduce the risk of major amputation among patients with DFUs.

Prevalence and influencing factors of malnutrition in diabetic patients: A systematic review and meta-analysis

The prevalence of malnutrition in diabetic patients and its influencing factors remain poorly described. We aim to investigate the prevalence of malnutrition and the influencing factors in diabetic patients through meta-analysis. Utilizing search terms, such as diabetes, malnutrition, and prevalence, we systematically searched eight databases, including Embase, PubMed, Web of Science, The Cochrane Library, China Knowledge Resource Integrated Database (CNKI), Wanfang Database, Chinese Biomedical Database (CBM), and VIP Database, from inception to May 4, 2023. The search aimed to identify studies related to the prevalence of malnutrition and its influencing factors in adult patients with diabetes. Cohort studies, case-control studies, and cross-sectional studies that met the inclusion criteria were included in the analysis. Stata 16.0 software was used for meta-analysis. Quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). The study protocol is registered with Prospective Register of Systematic Reviews (PROSPERO), CRD42023443649. A total of 46 studies were included, involving 18 062 patients with ages ranging from 18 to 95 years. The overall malnutrition prevalence was 33% (95% confidence interval [CI]: 0.25-0.40), compared with an at-risk prevalence of 44% (95% CI: 0.34-0.54). Sixteen factors associated with malnutrition in diabetic patients were identified. This meta-analysis provides insights into the prevalence of malnutrition and its risk factors in diabetic patients. Regular nutritional screening for patients with risk factors is essential for early detection and intervention.

The incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers: A meta-analysis

This study analysed the incidence of lower extremity amputation and its associated risk factors in patients with diabetic foot ulcers. This study systematically searched both Chinese and English databases, including CNKI, Wanfang, VIP, PubMed, EMBASE and Web of Science, to identify cohort studies related to lower extremity amputation and associated risk factors in patients with diabetic foot ulcers up to October 2023. The patients were stratified based on whether they underwent lower extremity amputation, and relevant data, including basic information, patient characteristics, complications, comorbidities and pertinent laboratory test data, were extracted from the included studies. The literature quality assessment in this study utilized the Newcastle-Ottawa Scale to screen for high-quality literature, resulting in the inclusion of 16 cohort studies, all of which were of at least moderate quality. Meta-analysis of outcome indicators was conducted using the Stata 14.0 software. The results indicate that the overall amputation rate of lower extremities in patients with diabetic foot ulcers is 31% (0.25, 0.38). Among the 16 variables evaluated, gender (male), smoking history, body mass index (BMI), hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels were found to be correlated with the occurrence of lower extremity amputation in patients with diabetic foot ulcers. However, no significant correlation was observed between age, diabetes type, duration of diabetes, stroke, glycosylated haemoglobin, creatinine and total cholesterol levels and lower extremity amputation in patients with diabetic foot ulcers. This meta-analysis indicates that the overall amputation rate in patients with diabetic foot ulcers is 31%. Factors such as gender (male), smoking history, high BMI, hypertension, cardiovascular disease, kidney disease, white blood cell count, haemoglobin and albumin levels are identified as significant risk factors for lower extremity amputation in diabetic foot ulcer patients. These findings suggest that attention should be focused on these risk factors in patients with diabetic foot ulcers to reduce the risk of lower extremity amputation. Therefore, preventive and intervention measures targeting these risk factors are of significant importance in clinical practice. (Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier [CRD42024497538]).

Predictors of amputation in patients with diabetic foot ulcers: a multi-centre retrospective cohort study

PURPOSE

Investigating risk factors for amputation in patients with diabetic foot ulcer (DFU) and developing a nomogram prediction model.

METHODS

We gathered case data of DFU patients from five medical institutions in Anhui Province, China. Following eligibility criteria, a retrospective case-control study was performed on data from 526 patients.

RESULTS

Among the 526 patients (mean age: 63.32 ± 12.14), 179 were female, and 347 were male; 264 underwent amputation. Univariate analysis identified several predictors for amputation, including Blood type-B, Ambulation, history of amputation (Hx. Of amputation), Bacterial culture-positive, Wagner grade, peripheral arterial disease (PAD), and laboratory parameters (HbA1c, Hb, CRP, ALB, FIB, PLT, Protein). In the multivariate regression, six variables emerged as independent predictors: Blood type-B (OR = 2.332, 95%CI [1.488-3.657], p < 0.001), Hx. Of amputation (2.298 [1.348-3.917], p = 0.002), Bacterial culture-positive (2.490 [1.618-3.830], p <0.001), Wagner 3 (1.787 [1.049-3.046], p = 0.033), Wagner 4-5 (4.272 [2.444-7.468], p <0.001), PAD (1.554 [1.030-2.345], p = 0.036). We developed a nomogram prediction model utilizing the aforementioned independent risk factors. The model demonstrated a favorable predictive ability for amputation risk, as evidenced by its area under the receiver operating characteristics (ROC) curve of 0.756 and the well-fitted corrected nomogram calibration curve.

CONCLUSION

Our findings underscore Blood type-B, Hx. Of amputation, Bacterial culture-positive, Wagner 3-5, and PAD as independent risk factors for amputation in DFU patients. The resultant nomogram exhibits substantial accuracy in predicting amputation occurrence. Timely identification of these risk factors can reduce DFU-related amputation rates.

The risk factors in diabetic foot ulcers and predictive value of prognosis of wound tissue vascular endothelium growth factor

Diabetic foot ulcer (DFU) is a leading cause of high-level amputation in DM patients, with a low wound healing rate and a high incidence of infection. Vascular endothelial growth factor (VEGF) plays an important role in diabetes mellitus (DM) related complications. This study aims to explore the VEGF expression and its predictive value for prognosis in DFU, in order to provide basis for the prevention of DFU related adverse events. We analyzed 502 patients, with 328 in healing group and 174 in non-healing/recurrent group. The general clinical data and laboratory indicators of patients were compared through Spearman correlation analysis, ROC analysis and logistic regression analysis. Finally, the independent risk factors for adverse prognosis in DFU patients were confirmed. Spearman analysis reveals a positive correlation between the DFU healing rate and ABI, VEGF in wound tissue, and positive rate of VEGF expression, and a negative correlation with DM duration, FPG, HbA1c, TC, Scr, BUN, and serum VEGF. Further logistic regression analysis finds that the DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for adverse prognosis in DFU (p < 0.05). DM duration, FPG, HbA1c, ABI, serum VEGF, VEGF in wound tissue, and positive rate of VEGF expression are the independent risk factors for prognosis in DFU patients. Patients with these risk factors should be screened in time, which is of great significance to prevent DFU related adverse events and improve outcomes.

Confronting a New Challenge in Plastic Surgery: MDR Infections in Patients with Chronic Wounds

BACKGROUND

The presence of a wound can be anywhere from non-problematic to life-threatening on a severity spectrum, with bacterial infection and resistance playing a major role in the development of chronicity, delaying wound healing. Wound colonization with multiple organisms and the limited number of effective antibiotics place a heavy burden on the healthcare system, with patients going through multiple surgeries during a prolonged hospitalization time. By analyzing the resistance patterns of pluri-bacterial populations and the approach used in managing complex cases, we aim to improve the protocols applied in caring for chronic wounds in our practice and share our experiences and observations.

METHODS

We designed a retrospective study on 212 diabetic and non-diabetic patients, aiming to evaluate the course of chronic wound treatment in our practice. We focused on the impact that MDR bacteria and diabetes have on surgical outcomes and their role in the healing process.

RESULTS

Patients who received empiric antibiotic therapy before being admitted eventually presented with multiple MDR bacteria compared to those who did not receive antibiotics (p = 0.014). The presence of at least one MDR bacteria in the wound bed was associated with ulcers reaching bone (p = 0.02) and was positively correlated with the number of surgeries performed (p < 0.001). Diabetes played a significant role in surgery-related complications (p = 0.02) and hospitalization time (p < 0.001).

CONCLUSIONS

Proper management of chronic wounds requires a comprehensive, multidisciplinary approach and a thorough understanding of antibiotic usage. To address this need, we have developed and implemented a chronic wound treatment protocol in our clinic, with the goal of discharging patients once their ulcers have been treated and closed. A key summary of the protocol presented is to reduce the incidence of MDR bacteria and improve the patient's quality of life.

Prediction of amputation risk of patients with diabetic foot using classification algorithms: A clinical study from a tertiary center

Diabetic foot ulcers can have vital consequences, such as amputation for patients. The primary purpose of this study is to predict the amputation risk of diabetic foot patients using machine-learning classification algorithms. In this research, 407 patients treated with the diagnosis of diabetic foot between January 2009-September 2019 in Istanbul University Faculty of Medicine in the Department of Undersea and Hyperbaric Medicine were retrospectively evaluated. Principal Component Analysis (PCA) was used to identify the key features associated with the amputation risk in diabetic foot patients within the dataset. Thus, various prediction/classification models were created to predict the "overall" risk of diabetic foot patients. Predictive machine-learning models were created using various algorithms. Additionally to optimize the hyperparameters of the Random Forest Algorithm (RF), experimental use of Bayesian Optimization (BO) has been employed. The sub-dimension data set comprising categorical and numerical values was subjected to a feature selection procedure. Among all the algorithms tested under the defined experimental conditions, the BO-optimized "RF" based on the hybrid approach (PCA-RF-BO) and "Logistic Regression" algorithms demonstrated superior performance with 85% and 90% test accuracies, respectively. In conclusion, our findings would serve as an essential benchmark, offering valuable guidance in reducing such hazards.

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Prevalence of Peripheral Arterial Disease in Diabetic Foot Ulcer Patients and its Impact in Limb Salvage

Diabetic foot ulcer syndrome is a common complication of diabetes mellitus. Three main factors contribute to it: neuropathy, vasculopathy, and infection. This study was conducted to evaluate the prevalence of peripheral arterial disease (PAD) in diabetic foot ulcer patients and its impact on limb salvage as an outcome. This prospective cross-sectional study included 392 cases, who were divided according to the presence of PAD into 2 groups; patients with PAD were labeled as PAD +ve (172 cases) and those without PAD were labeled as PAD -ve (22 cases). All cases were clinically assessed, and routine laboratory examinations were ordered. Moreover, duplex ultrasound was done for suspected cases of having PAD by examination. Computed tomography angiography was ordered for patients who are in need of a revascularization procedure. Cases were managed by debridement and/or revascularization. After that, these cases were assessed clinically and radiologically for vascularity and infection and the possibility for amputation was evaluated. Infection was classified using Wagner Classification System, and revascularization was decided according to the TASC II system. The incidence of PAD in cases with diabetic foot ulcer syndrome was 43.87%. No difference was detected between the 2 groups regarding age and gender (P > .05). The prevalence of smoking, hemodialysis, ischemic heart disease (IHD), and hypertension was more significantly higher in cases with PAD (P < .05). Revascularization procedures were only performed in cases that had documented severe PAD or chronic limb-threatening ischemia in addition to foot ulcer and/or infection. With regard to limb salvage, it was more significantly performed in cases without PAD (82.3% vs 48.3% in PAD cases; P < .001). Male gender, smoking, ankle-brachial pressure index, hemodialysis, IHD, neuropathy, HbA1C, PAD, and high Wagner classification were predictors of limb amputation (P < .05). PAD is associated with worse outcomes in diabetic foot ulcer patients. Not only does it constitute a great number among diabetic foot ulcer patients, but it also has a negative impact on limb salvage.

Adiponectin as a therapeutic target for diabetic foot ulcer

The global burden of diabetic foot ulcers (DFUs) is a significant public health concern, affecting millions of people worldwide. These wounds cause considerable suffering and have a high economic cost. Therefore, there is a need for effective strategies to prevent and treat DFUs. One promising therapeutic approach is the use of adiponectin, a hormone primarily produced and secreted by adipose tissue. Adiponectin has demonstrated anti-inflammatory and anti-atherogenic properties, and researchers have suggested its potential therapeutic applications in the treatment of DFUs. Studies have indicated that adiponectin can inhibit the production of pro-inflammatory cytokines, increase the production of vascular endothelial growth factor, a key mediator of angiogenesis, and inhibit the activation of the intrinsic apoptotic pathway. Additionally, adiponectin has been found to possess antioxidant properties and impact glucose metabolism, the immune system, extracellular matrix remodeling, and nerve function. The objective of this review is to summarize the current state of research on the potential role of adiponectin in the treatment of DFUs and to identify areas where further research is needed in order to fully understand the effects of adiponectin on DFUs and to establish its safety and efficacy as a treatment for DFUs in the clinical setting. This will provide a deeper understanding of the underlying mechanisms of DFUs that can aid in the development of new and more effective treatment strategies.

Distribution of Causative Microorganisms in Diabetic Foot Infections: A Ten-Year Retrospective Study in a Tertiary Care Hospital in Central Malaysia

Diabetes mellitus is a global pandemic, especially in Southeast Asia. Diabetic foot infection (DFI) is a common complication of this condition and causes significant morbidity and mortality in those affected. There is a lack of locally published data on the types of microorganisms and empirical antibiotics being prescribed. This paper highlights the importance of local microorganism culture and antibiotic prescription trends among diabetic foot patients in a tertiary care hospital in central Malaysia. This is a retrospective, cross-sectional study of data taken from January 2010 to December 2019 among 434 patients admitted with diabetic foot infections (DFIs) using the Wagner classification. Patients between the ages of 58 and 68 years old had the highest rate of infection. Pseudomonas Aeruginosa, Proteus spp., and Proteus mirabilis appeared to be the most isolated Gram-negative microorganisms, and Staphylococcus aureus, Streptococcus agalactiae, and MRSA appeared to be the most common Gram-positive microorganisms. The most common empirical antibiotics prescribed were ampicillin/sulbactam, followed by ciprofloxacin and ceftazidime, and the most common therapeutic antibiotics prescribed were ampicillin/sulbactam, ciprofloxacin, and cefuroxime. This study could be immensely pertinent in facilitating future empirical therapy guidelines for treating diabetic foot infections.

Application of extracorporeal shockwave therapy to improve microcirculation in diabetic foot ulcers: A prospective study

Extracorporeal shockwave therapy (ESWT) can induce wound healing by increasing tissue microcirculation. However, studies on the effect of ESWT on enhancing tissue microcirculation in diabetic foot ulcer (DFU), particularly on when the microcirculation increases after ESWT application, are still lacking. Therefore, we aimed to examine the effectiveness of ESWT in promoting microcirculation in DFU patients in a time-dependent manner. We included 50 feet of 25 patients with type 2 diabetes mellitus and Wagner grade I to II DFU in this study. The affected feet were used as the ESWT group and the unaffected contralateral feet were used as the control group. ESWT was performed in 3 sessions per week for a total of 3 weeks. Transcutaneous partial oxygen pressure (TcPO2) was used to evaluate the tissue microcirculation. The TcPO2 level (>43 mm Hg) in the ESWT group was recovered by the 2nd week of treatment, and statistical significance (P < .05) was demonstrated at the same time. From the 2nd week of ESWT, a significant increase in TcPO2 was observed in Wagner grade I and II DFU. These findings imply that the ESWT may improve microcirculation in patients with Wagner grades I to II DFU. However, this impact requires at least 2 weeks or more than 6 sessions. For better comparison, further studies with larger clinical groups and extended period are needed.

Physical Treatment of Diabetic Foot Ulcers—Preliminary Study for Topical Application of Oxygen or Ozone Auxiliary Treatment of Diabetic Foot Ulcers

Diabetes mellitus is one of the most common metabolic diseases in which one of the most serious complications is the diabetic foot ulcer (DFU). The aim of the study was to compare the efficacy of two physical therapeutic methods: topical oxygen therapy and topical ozone therapy in the treatment of DFU with the calculation of the financial costs for both applied physical methods. The study included 85 patients, 47 male (55.2%) and 38 female (44.7%) in age range between 40 and 90 years (mean age: 67.82 ± 12.42 years) with hard to heal diabetic foot ulcers. The mean diabetic foot ulcer duration was 3.6 ± 1.23 years. Patients were randomized into two study groups not significantly different in terms of age, body mass index (BMI) value, and baseline ulcer surface area value, who underwent topical oxygen therapy (group I) and topical ozone therapy (group II), respectively. Both the groups underwent a total of 30 daily treatments lasting 30 minutes, in 2 sessions of 15 treatments with a 14-day break between sessions. Progress in wound healing was evaluated by computerized planimetry and the pain intensity was assessed with use of a VAS scale. After the treatment, the ulcer area in group I decreased by an average of 33.25 ± 10.97% and by an average of 28.67 ± 14.47% in group II $\left(p=0.030\right)$ . On the other hand, the intensity of pain ailments after the treatment was statistically significantly decreased in group I by an average of 57.13 ± 16.24% while in group II by an average of 40.21 ± 14.53% ( $p<0.001$ ). After application of topical oxygen therapy and topical ozone therapy in the treatment of diabetic foot ulcers a statistically significant reduction in the surface area of treated ulcers in objective planimetric assessment was observed, with local oxygen therapy showing only a slight advantage in this regard. Both compared methods also caused a statistically significant reduction in the pain intensity, while local oxygen therapy shows statistically significantly better analgesic effectiveness. Due to the calculated moderate cost, both applied methods appeared to be cost-effective.

Clinical characteristics and risk factors of lower extremity amputation in the diabetic inpatients with foot ulcers

OBJECTIVES

To analyze clinical characteristics of the diabetic inpatients with foot ulcers and explore the risk factors of lower extremity amputation (LEA) in West China Hospital of Sichuan University.

METHODS

A retrospective analysis was performed based on the clinical data of the patients with diabetic foot ulcer (DFU) hospitalized in West China Hospital of Sichuan University from January 1, 2012 to December 31, 2020. The DFU patients were divided into three groups: non-amputation, minor amputation, and major amputation groups. The ordinal logistic regression analysis was used to identify the risk factors for LEA.

RESULTS

992 diabetic patients (622 males and 370 females) with DFU were hospitalized in the Diabetic Foot Care Center of Sichuan University. Among them, 72 (7.3%) (55 minor amputations and 17 major amputations) cases experienced amputation, and 21(2.1%) refused amputation. Excluding the patients who refused amputation, the mean age and duration of diabetes of and HbA1c the 971 patients with DFU, were 65.1 ± 12.3 years old, 11.1 ± 7.6 years, and 8.6 ± 2.3% respectively. The patients in the major amputation group were older and had longer course of diabetes for a longer period of time than those in the non-amputation and minor amputation groups. Compared with the non-amputation patients (55.1%), more patients with amputation (minor amputation (63.5%) and major amputation (88.2%)) suffered from peripheral arterial disease (P=0.019). The amputated patients had statistically lower hemoglobin, serum albumin and ankle brachial index (ABI), but higher white blood cell, platelet counts, fibrinogen and C-reactive protein levels. The patients with amputation had a higher incidence of osteomyelitis (P = 0.006), foot gangrene (P < 0.001), and a history of prior amputations (P < 0.001) than those without amputation. Furthermore, a history of prior amputation (odds ratio 10.194; 95% CI, 2.646-39.279; P=0.001), foot gangrene (odds ratio 6.466; 95% CI, 1.576-26.539; P=0.010) and ABI (odds ratio 0.791; 95% CI, 0.639-0.980; P = 0.032) were significantly associated with LEAs.

CONCLUSIONS

The DFU inpatients with amputation were older with long duration of diabetes, poorly glycemic control, malnutrition, PAD, severe foot ulcers with infection. A history of prior amputation, foot gangrene and a low ABI level were the independent predictors of LEA. Multidisciplinary intervention for DFU is essential to avoid amputation of the diabetic patients with foot ulcer.

Predictive factors and nomogram to evaluate the risk of below-ankle re-amputation in patients with diabetic foot

BACKGROUND

Diabetes mellitus, as the most common metabolic disease, is common worldwide and represents a crucial global health concern. The purpose of this research was to investigate the related risk factors and to develop a re-amputation risk nomogram in diabetic patients who have undergone an amputation.

METHODS

A observational analysis was performed on 459 patients who have underwent amputation for diabetic foot from January 2014 through December 2019 at the First Affiliated Hospital of Wenzhou Medical University. The least absolute shrinkage and selection operator regression and stepwise regression methods were implemented to determine risk selection for the re-amputation risk model, and the predictive nomogram was established with these features. Calibration curve, receiver operating characteristic curve, and decision curve analysis of this re-amputation nomogram were assessed.

RESULTS

Predictors contained in this predictive model included smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI) and C-reactive protein (CRP). Good discrimination with a C-index of 0.725 (95% CI, 0.6624-0.7876) and good calibration were displayed with this predictive model. The decision curve analysis showed that this re-amputation nomogram predicting risk adds more benefit than none strategy if the threshold probability of a patient was >6% and <59%.

CONCLUSIONS

This novel re-amputation nomogram incorporating smoking, glycated hemoglobin A1c (HbA1c), ankle-brachial index (ABI), C-reactive protein (CRP), and smoking could be easily used to predict individual re-amputation risk prediction in diabetic foot patients who have undergone an amputation. In the future, further analysis and external testing will be needed as much as possible to reconfirm that this new Nomogram can accurately predict the risk of toe re-amputation.

Local Hyperbaric Oxygen Therapy in the Treatment of Diabetic Foot Ulcers

Background: Diabetes mellitus is one of the most common metabolic diseases. The most serious complication of diabetes is diabetic foot ulcer, which affects several million people around the world each year. In recent years, increasingly modern methods of physical medicine including hyperbaric oxygen therapy have been used often in the complex therapy of this complication. Methods: This study included 45 patients, 24 male (53.3%) and 21 female (46.6%), whose age was between 49 and 83 years (mean age: 66.7 ± 8.8 years) with diabetes lasting for 1.5-18 years, who underwent local hyperbaric oxygen therapy at the pressure of 2.5 ATA (30 exposures for 30 min each) due to diabetic foot ulcers. The progress in wound healing before and after the end of therapy was evaluated by computerized planimetry, and the pain intensity was assessed with the use of a VAS. Results: The analysis of results showed a statistically significant reduction in the wound surface area after the treatment, from 8.54 ± 3.34 cm to 4.23 ± 3.23 cm² (p = 0.000001). In 5 patients (11.1%), the wounds were healed completely. In 25 patients (55.5%), the topical state of the wound surface was significantly decreased by 50% on average. There was also a significant reduction in the perceived pain on the VAS in all examined patients from 4.64 ± 1.68 points before treatment to 1.51 ± 0.92 points after treatment (p = 0.000001). Conclusions: The application of local HBO therapy in the treatment of diabetic foot ulcers accelerates the ulcer healing process, as judged in objective planimetric assessment, and reduces the intensity of perceived pain ailments.

Predicting Amputation in Patients With Diabetic Foot Ulcers: A Systematic Review

Foot ulcers are a leading cause of morbidity in diabetics. One of the known complications of diabetic foot ulcers is lower limb amputation which makes it a major socioeconomic problem. Currently, there's a lack of knowledge on the predictors of amputations in diabetics with foot ulcers. We performed a systematic review of studies that identified risk factors of amputation in patients with diabetic foot ulcers. This systematic review aims to identify the predictors of amputation in order to optimize the management strategy and care plan. Medline database was searched and inclusion criteria were implemented for the selection of studies. The risk factors extracted were part of four categories: (i) history and physical examination, (ii) ulcer characteristics, (iii) lab results, and (iv) co-morbidities. The data extracted were in the form of odds ratios, 95% confidence intervals, and predictive values. The mean values with standard deviations of the included risk factors were recorded, and the incidence of risk factors among the amputation groups was identified or calculated when the data were sufficient. Seven articles were selected reporting on 3481 patients. This review identified peripheral arterial disease, neuropathy, high Wagner's grade, osteomyelitis, postprandial glucose level, white cell count, c-reactive protein, erythrocyte sedimentation rate, low hemoglobin, and albumin as the most significant predictors of amputation.

Hyperbaric oxygen therapy as an adjunct to the standard wound care for the treatment of diabetic foot ulcers in Indian patients: a cost utility analysis

BACKGROUND

Diabetic foot ulcer (DFU) is a common complication of diabetes. Hyperbaric oxygen therapy (HBOT) is an adjunct treatment that expedites the healing of DFU.

AIM

To evaluate the cost-utility of using standard wound care (SWC) plus HBOT as compared to SWC alone for the treatment of DFU from a societal perspective in the Indian context.

METHOD

A Markov decision analysis model comparing SWC with and without HBOT was developed. Data for the model were derived from relevant literature and secondary data from India. The main outcome measures were minor and major lower extremity amputations (LEA) averted, incremental quality-adjusted-life-years (QALY) gained, incremental costs, incremental cost-effectiveness ratio (ICER) per amputation averted and ICER per QALY gained. Sensitivity and threshold analyses were also done.

RESULT

HBOT, when added to SWC, lowered the proportion of minor LEA and major LEA among patients with DFU by 6.1% and 4.2%, respectively. The discounted ICER was INR 193,939 [95% CI: 186,745-203,753] or US$ 2,621 [95% CI: 2,524-2,753] per QALY gained.

CONCLUSION

SWC plus HBOT is not cost-effective in India. Additional information is required on patient experiences with adjunctive HBOT, if it were to be adopted as the standard of care in India.

An explainable machine learning model for predicting in-hospital amputation rate of patients with diabetic foot ulcer

Diabetic foot ulcer (DFU) is one of the most serious and alarming diabetic complications, which often leads to high amputation rates in diabetic patients. Machine learning is a part of the field of artificial intelligence, which can automatically learn models from data and better inform clinical decision-making. We aimed to develop an accurate and explainable prediction model to estimate the risk of in-hospital amputation in patients with DFU. A total of 618 hospitalised patients with DFU were included in this study. The patients were divided into non-amputation, minor amputation or major amputation group. Light Gradient Boosting Machine (LightGBM) and 5-fold cross-validation tools were used to construct a multi-class classification model to predict the three outcomes of interest. In addition, we used the SHapley Additive exPlanations (SHAP) algorithm to interpret the predictions of the model. Our area under the receiver-operating-characteristic curve (AUC) demonstrated a 0.90, 0.85 and 0.86 predictive ability for non-amputation, minor amputation and major amputation outcomes, respectively. Taken together, our data demonstrated that the developed explainable machine learning model provided accurate estimates of the amputation rate in patients with DFU during hospitalisation. Besides, the model could inform individualised analyses of the patients' risk factors.

Predicting the risk of amputation and death in patients with diabetic foot ulcer. A long-term prospective cohort study of patients in Tanzania

INTRODUCTION

This prospective cohort study aimed to identify the characteristics of patients with diabetic foot ulcer who are at higher risk of amputation and at increased risk of death.

METHODS

About 103(M/F:60/43) participants, with active foot ulcer at baseline, participated in this study and followed for 22 years till death or lost to follow-up. Ten clinical measures were collected at baseline. During the follow-up of 4.2 ± 5.4 years, 22(M/F:14/8) participants had an amputation and 50(M/F:32/18) participants passed away during 5.5 ± 5.8 years follow-up period.

RESULTS

Cox Proportional Hazard regression (HR[95%CI]) indicated neuropathy (6.415[1.119-36.778]); peripheral arterial disease (PAD) (9.741[1.932- 49.109]); current smoking (16.148[1.658-157.308]); diabetes type- 1 (3.228[1.151-9.048]) and longer delay attending appointment after ulcer (1.013[1.003-1.023]) were significantly (p < .05) associated with increased risk of amputation. In addition, death was significantly associated with the risk of amputation (3.458[1.243-9.621]). Three parameters (HR[95%CI]) including neuropathy (3.058[1.297-7.210]); PAD (5.069[2.113-12.160]); amputation history (3.689[1.306-10.423]) and retinopathy (2.389[1.227-4.653]) were all significantly associated with increased risk of death. Kaplan-Meier survival analyses indicates that the time to amputation in years for participants who eventually died was significantly shorter (11.122 ± 1.507) vs those who stayed alive (15.427 ± 1.370).

CONCLUSION

Neuropathy and PAD were the only two characteristics that increased both the risk of amputation and death. Amputation showed to contribute to an increased risk of death and those participants who eventually died had a higher risk of amputation. Delay in attending appointments after ulceration is shown to increase the risk of amputation. In addition, the participants with PAD showed a significantly shorter time to both amputation and death while neuropathy was only associated with decreased time to death. Amputation history and death during follow-up decrease the time to death and amputation respectively.

Quality of life in diabetic foot ulcer, grade 3: associated demographic factors

Abstract

Introduction: Patients with diabetic foot ulcer grade 3 experience some limitations that adversely affect their quality of life (QoL).

Aim: The aim of the study was to explore demographic characteristics associated with the quality of life of diabetic foot ulcer patients, grade 3.

Materials and methods: The present study recruited 120 diabetic foot ulcer patients. Data collected by completion of SF-36 Health Survey (SF-36).

Results: Of the 120 participants, 65.8% were men and 73% were more than 60 years of age. Patients showed moderate to high levels of quality of life in social functionality, energy/fatigue, emotional well-being, and physical pain (medians: 50, 60, 72, and 67.5, respectively) and poor levels in physical functioning, role physical, and role emotional (medians: 22, 0 and 0, respectively). In addition, patients had moderate levels of quality of life in general health (median: 48.5). It was observed that physical functioning was significantly associated with place of residence (p=0.005). Moreover, physical role was significantly associated with age (p=0.020) and occupation (p=0.018), while emotional role was significantly associated with age (p=0.012), marital status (p=0.016), and occupation (p=0.012). Energy/fatigue was significantly associated with age (p=0.026), marital status (p=0.018), and occupation (p=0.009). Emotional well-being was significantly associated with gender (p=0.009), level of education (p=0.001), and occupation (p=0.007). Social functionality was significantly associated with marital status (p=0.001) while pain was significantly associated with education level (p=0.010). General health was significantly associated with marital status (p=0.037), and place of residence (p=0.024).

Conclusions: The findings of the present study may adequately inform stakeholders in the field of diabetic foot ulcer grade 3 when planning effective care.

CT-Angiography-Based Outcome Prediction on Diabetic Foot Ulcer Patients: A Statistical Learning Approach

The purpose of our study is to predict the occurrence and prognosis of diabetic foot ulcers (DFUs) by clinical and lower extremity computed tomography angiography (CTA) data of patients using the artificial neural networks (ANN) model. DFU is a common complication of diabetes that severely affects the quality of life of patients, leading to amputation and even death. There are a lack of valid predictive techniques for the prognosis of DFU. In clinical practice, the use of scales alone has a large subjective component, leading to significant bias and heterogeneity. Currently, there is a lack of evidence-based support for patients to develop clinical strategies before reaching end-stage outcomes. The present study provides a novel technical tool for predicting the prognosis of DFU. After screening the data, 203 patients with diabetic foot ulcers (DFUs) were analyzed and divided into two subgroups based on their Wagner Score (138 patients in the low Wagner Score group and 65 patients in the high Wagner Score group). Based on clinical and lower extremity CTA data, 10 predictive factors were selected for inclusion in the model. The total dataset was randomly divided into the training sample, testing sample and holdout sample in ratio of 3:1:1. After the training sample and testing sample developing the ANN model, the holdout sample was utilized to assess the accuracy of the model. ANN model analysis shows that the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC) of the overall ANN model were 92.3%, 93.5%, 87.0%, 94.2% and 0.955, respectively. We observed that the proposed model performed superbly on the prediction of DFU with a 91.6% accuracy. Evaluated with the holdout sample, the model accuracy, sensitivity, specificity, PPV and NPV were 88.9%, 90.0%, 88.5%, 75.0% and 95.8%, respectively. By contrast, the logistic regression model was inferior to the ANN model. The ANN model can accurately and reliably predict the occurrence and prognosis of a DFU according to clinical and lower extremity CTA data. We provided clinicians with a novel technical tool to develop clinical strategies before end-stage outcomes.

Hyperbaric oxygen therapy: when pressure is good for diabetic foot ulcers

The diabetic foot ulcer (DFU) as a common complication of diabetes. Even with adequate treatment, up to 35% of these ulcers do not heal. This is due to the effect of aging, repeated ischemia-reperfusion (IR) injury, bacterial colonisation of the wound and chronic hypoxia. All wound-healing processes are highly dependent on oxygen, so hyperbaric oxygen therapy (HBOT) can be employed to improve wound healing and correct the four pathophysiological factors for chronic wounds. It is, in fact, internationally recognised as a treatment option for non-healing DFUs. Several trials and systematic reviews have been performed on its efficacy, which show a positive trend towards increased wound healing and reduced amputation risk. Some controversy exists due to contradictory results in these studies, which may be due to grouping patients with and without peripheral arterial occlusive disease (PAOD) together. Side effects are usually mild and transient, and the treatment is considered safe.

The reliability of the Wagner Scale for evaluation the diabetic wounds: A literature review

BACKGROUND AND AIMS

Classification of wound severity is important in medical care decisions specially in diabetic patients. The Wagner Scale provides a structure to determine the severity of a wound by examining its depth and extent. The adequate reliability of this instrument, like other instruments for measuring health status, is important. So, the aim of this review is to report evidence on the reliability of the Wagner scale.

METHOD

A comprehensive search was performed in databases. Observational studies that assessed the reliability of the Wagner scale, with statistical measures, were included. Methodological quality of studies was evaluated with the COSMIN checklist. Finally, we report the reliability measurements, narratively.

RESULTS

We assessed 7 studies. In all studies 1873 subjects participated. Methodological quality was good only in one study. In two studies used of weighted kappa (Inter Observer Reliability) that reliability was in median level in both studies. The relation between Wagner score and amputation were report in two studies that measured by X²_trend and regression analysis. In four measurements, reported the correlation between Wagner with ulcer healing by X²_trend, Log Rank, Kaplan-Meier, and inter quartile range.

CONCLUSION

It can be confirmed that the reliability of the Wagner scale is appropriate and this tool is recommended to evaluate the severity of the wounds specially in diabetic patients. It should also be noted that the user of the scale must be trained. In future studies, it is recommended to use appropriate methodology and complete reports for the reliability of Wagner scale.

Clinical validation of an artificial intelligence-enabled wound imaging mobile application in diabetic foot ulcers

There is a lifetime risk of 15% to 25% of development of diabetic foot ulcers (DFUs) in patients with diabetes mellitus. DFUs need to be followed up on and assessed for development of complications and/or resolution, which was traditionally performed using manual measurement. Our study aims to compare the intra- and inter-rater reliability of an artificial intelligence-enabled wound imaging mobile application (CARES4WOUNDS [C4W] system, Tetsuyu, Singapore) with traditional measurement. This is a prospective cross-sectional study on 28 patients with DFUs from June 2020 to January 2021. The main wound parameters assessed were length and width. For traditional manual measurement, area was calculated by overlaying traced wound on graphical paper. Intra- and inter-rater reliability was analysed using intra-class correlation statistics. A value of <0.5, 0.5-0.75, 0.75-0.9, and >0.9 indicates poor, moderate, good, and excellent reliability, respectively. Seventy-five wound episodes from 28 patients were collected and a total of 547 wound images were analysed in this study. The median wound area during the first clinic consultation and all wound episodes was 3.75 cm2 (interquartile range [IQR] 1.40-16.50) and 3.10 cm2 (IQR 0.60-14.84), respectively. There is excellent intra-rater reliability of C4W on three different image captures of the same wound (intra-rater reliability ranging 0.933-0.994). There is also excellent inter-rater reliability between three C4W devices for length (0.947), width (0.923), and area (0.965). Good inter-rater reliability for length, width, and area (range 0.825-0.934) was obtained between wound nurse measurement and each of the C4W devices. In conclusion, we obtained good inter-rater and intra-rater reliability of C4W measurements against traditional wound measurement. The C4W is a useful adjunct in monitoring DFU wound progress.

Relationship Between Neutrophil/Albumin Ratio and Early Mortality After Major Lower Extremity Amputation

Introduction Diabetic foot infection is a condition that affects the patient's life, may cause limb loss, and has a high mortality. Too many parameters were used for predicting early mortality but the gold standard method wasn't described. Neutrophil lymphocyte ratio (NLR) is universally accepted as a predictive value for amputation-free survival and mortality. NLR increases due to inflammation-induced neutrophilia and lymphopenia related to cortisol-induced stress. Increasing in the neutrophil albumin ratio is expected due to decreasing albumin levels because albumin is a negative acute-phase reactant. The aim of this study is to investigate the sensitivity and value of the neutrophil albumin ratio (NAR) for early mortality after major lower extremity amputation (LEA). Methods  Following the approval of the ethics committee, 87 patients who underwent major LEA between May 2018 and May 2020 were analyzed for the study. White blood cell (WBC), neutrophil, lymphocyte, C-reactive protein (CRP), creatinine, albumin, platelet, and hemoglobin values on the day prior to surgery were recorded. NLR was calculated as the ratio of neutrophil count to lymphocyte count, NAR as the ratio of neutrophil count to albumin value, CRP/albumin ratio (CAR) as the ratio of CRP value to albumin value, and platelet lymphocyte ratio (PLR) as the ratio of platelet count to lymphocyte count. Each parameter was also recorded in the postoperative second week. Results Of the patients included in the study, 52 were men (59.8%) and 35 were women (40.2%). It was determined that 29 of 87 patients (33.3%) died within the first year. The relationship between post-operative NAR value and early mortality is examined. The area under the curve was calculated as 0.873. When the cut-off value was applied as 0.265, the sensitivity was found as 88% and specificity as 76%. Conclusions Higher neutrophil/albumin ratio after lower extremity amputation was associated with early mortality after extremity amputation. This parameter can help predict mortality. The cut-off value was determined as 0.265, the sensitivity was found as 88%, and specificity as 76%.

Urine Albumin-Creatinine ratio is associated with prognosis in patients with diabetic foot osteomyelitis

AIMS

We aimed to explore the association between albuminuria and clinical outcomes in patients with diabetic foot osteomyelitis (DFO).

METHODS

This is an observational retrospective study and a total of 202 inpatients with DFO were eligible for inclusion in our study. Based on urine albumin-creatinine ratio (UACR), the patients were divided into three groups: normoalbuminuria group, microalbuminuria group and macroalbuminuria group. The data collected include demographics data, laboratory data, clinical diagnostic data, diabetic foot examination and clinical visit data. The association was then evaluated between albuminuria and all-cause mortality, major cardiovascular adverse events (MACE) and mixed endpoint events.

RESULTS

The mean age was 60.3 years, 62.9% were male and 45.05% were urinary protein-positive. The incidence rates of all-cause mortality, MACE and mixed endpoint events related to elevated UACR were significantly increased in patients with DFO (all P for trend < 0.01). After adjusting for confounders, compared with normoalbuminuria group, the risk of all-cause mortality, MACE and mixed endpoint events in the microalbuminuria group increased by 81.8%, 135.4% and 136.4%, respectively. The risk of all-cause mortality, MACE and mixed endpoint events in the macroalbuminuria group increased by 246.2%, 145.1% and 252.3%, respectively. The population attributable risk percentage (PAR%) suggested that 50.16% of all-cause mortality, 47.85% of MACE and 59.11% of mixed endpoint events could be attributed to the elevated UACR. Meanwhile, compared with normoalbuminuria, those with microalbuminuria or macroalbuminuria have lower apoA1 and ABI, higher SCr and higher incidence rate of CHD, hindfoot infection and severe infection (all P < 0.05).

CONCLUSIONS

In patients with DFO, the UACR level is associated with all-cause mortality, MACE and mixed endpoint events and elevated UACR levels increase the risk of all-cause mortality, MACE and mixed endpoint events.

Hyperbaric oxygen therapy for chronic diabetic foot ulcers: An overview of systematic reviews

OBJECTIVES

Hyperbaric oxygen therapy in the treatment of diabetic foot ulcer has been widely used in medical practice, but its clinical effect is not clear. The purpose of this overview of systematic reviews is to evaluate the clinical evidence of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers.

METHODS

PubMed, Cochrane Library, Web of Knowledge, Embase, MEDLINE, Chinese National Knowledge Infrastructure Database, the Chongqing VIP Database, Chinese Biomedical Database, and Wanfang Database were searched in 1st December 2020. Systematic reviews (SRs) evaluating the effects of Hyperbaric oxygen therapy in people with diabetic foot ulcer were included. Methodological quality of the included SRs was assessed using the AMSTAR-2 tool. The quality of evidence of the primary studies was assessed using GRADE. The integrity of the included SRs was assessed using PRISMA. The bias risk of each SR was assessed using ROBIS evaluation tool.

RESULTS

Eleven SRs/MAs met all inclusion criteria. According to the results of the AMSTAR-2, only 1 included review were rated critically as being of high quality, 6 included review were rated critically as being of medium quality. With PRISMA, the reporting checklist was relatively complete, but some reporting weaknesses remained in the topics of the protocol and registration, search strategy, and additional analyses. Based on the ROBIS tool, only five SRs/MAs had a low risk of bias. With the GRADE system, no high-quality evidence was found, and only 13 outcomes provided moderate-quality evidence.

CONCLUSIONS

There is limited clinical evidence to support hyperbaric oxygen therapy in the treatment of diabetic foot ulcers, it is not recommended to routinely apply hyperbaric oxygen therapy to all patients with diabetic foot ulcers, especially those with non-ischemic diabetic foot ulcers. Hyperbaric oxygen therapy has certain potential to promote ulcer healing and reduce amputation rate in patients with ischemic diabetic foot ulcers, but due to the low quality and small quantity of the SRs/MAs supporting these results, high-quality studies with rigorous study designs and larger samples are needed before widespread recommendations can be made.

Risk factors associated with lower extremity amputation in Sudanese individuals with diabetes: The need for improvement in primary health care system

Background:

Lower extremity amputation (LEA) in individuals with diabetes is a serious health issue with a considerable physical and social burden. The aim of this study was to assess the prevalence and risk factors associated with LEA in diabetic foot ulcer (DFU) patients.

Materials and Methods:

This was a cross-sectional health facility-based study that recruited 315 diabetes individuals with foot ulcers from the diabetes center in Khartoum, Sudan. Direct interviewing of subjects was used to obtain data, using a standardized validated questionnaire. Chi-square and logistic regression analysis were used in data analysis.

Results:

69.5% of the diabetic participants were aged 50 years old or more, and 71.1% were males. Most of the subjects (48.2%) were diabetics for a duration of >10 years, while more than one third (37.5%) of them were diabetic for 5–10 years. The majority (89.5%) had type 2 DM, while only 10.5% were type 1 DM. Two hundred forty-five patients had a left lower foot ulcer; 55.1% of the patients' ulcers were present in the toes, while 21.6% were in the foot sole. The overall prevalence of lower limb amputation was 17.1%. Individuals with diabetes patients with LEA had a higher incidence of hypertension (P = 0.000), retinopathy (P = 0.000), nephropathy (P = 0.002), ulcer size >2.5 cm (P = 0.000), and neuropathy (P = 0.000) through Chi-square analysis. Furthermore, logistic regression analysis showed that amputation was significantly associated with retinopathy (P = 0.000), size of ulcer (P = 0.000), and neuropathy (P = 0.016).

Conclusion:

The overall prevalence of LEA was 17.1%. The primary risks factors associated with amputation were presence of neuropathy and ulcer size >2.5 cm. Presence of retinopathy predispose diabetic individuals to amputation. Amputation is associated with disability and psychological problems; therefore, there is an urgent need for more improvement in preventative measures and primary health care system in low resource setting country like Sudan in order to decrease diabetes complications, especially patient's education about diabetes management by primary care physicians.

Development of Predictive Nomograms for Clinical Use to Quantify the Risk of Amputation in Patients with Diabetic Foot Ulcer

OBJECTIVE

To determine the novel proposed nomogram model accuracy in the prediction of the lower-extremity amputations (LEA) risk in diabetic foot ulcer (DFU).

METHODS AND MATERIALS

In this retrospective study, data of 125 patients with diabetic foot ulcer who met the research criteria in Zhongnan Hospital of Wuhan University from January 2015 to December 2019 were collected by filling in the clinical investigation case report form. Firstly, univariate analysis was used to find the primary predictive factors of amputation in patients with diabetic foot ulcer. Secondly, single factor and multiple factor logistic regression analysis were employed to screen the independent influencing factors of amputation introducing the primary predictive factors selected from the univariate analysis. Thirdly, the independent influencing factors were applied to build a prediction model of amputation risk in patients with diabetic foot ulcer by using R4.3; then, the nomogram was established according to the selected variables visually. Finally, the performance of the prediction model was evaluated and verified by receiver working characteristic (ROC) curve, corrected calibration curve, and clinical decision curve.

RESULTS

7 primary predictive factors were selected by univariate analysis from 21 variables, including the course of diabetes, peripheral angiopathy of diabetic (PAD), glycosylated hemoglobin A1c (HbA1c), white blood cells (WBC), albumin (ALB), blood uric acid (BUA), and fibrinogen (FIB); single factor logistic regression analysis showed that albumin was a protective factor for amputation in patients with diabetic foot ulcer, and the other six factors were risk factors. Multivariate logical regression analysis illustrated that only five factors (the course of diabetes, PAD, HbA1c, WBC, and FIB) were independent risk factors for amputation in patients with diabetic foot ulcer. According to the area under curve (AUC) of ROC was 0.876 and corrected calibration curve of the nomogram displayed good fitting ability, the model established by these 5 independent risk factors exhibited good ability to predict the risk of amputation. The decision analysis curve (DCA) indicated that the nomogram model was more practical and accurate when the risk threshold was between 6% and 91%.

CONCLUSION

Our novel proposed nomogram showed that the course of diabetes, PAD, HbA1c, WBC, and FIB are the independent risk factors of amputation in patients with DFU. This prediction model was well developed and behaved a great accurate value for LEA so as to provide a useful tool for screening LEA risk and preventing DFU from developing into amputation.

Assessment of diabetic foot ulcers based on pictorial material: an interobserver study

OBJECTIVE

The frequent change in clinicians, and the emerging use of photographic documentation in wound management, could require a more diverse treatment of patients due to poor interobserver agreement. The aim of this study was to assess the interobserver agreement of a commonly used classification system for diabetic foot ulcers (DFUs), the Meggitt-Wagner classification, and to compare the agreement on classification with the agreement in treatment recommendations.

METHOD

An interobserver study was conducted based on a questionnaire linked to 30 photographs of DFUs. Different groups of observers were tested to investigate whether there was a difference between professions or level of education: experienced orthopaedic wound care doctors (n=7); nurses specialised in wound care (n=8) and untrained nurses assigned to a diabetic wound care training course (n=23). Krippendorff's alpha was used to calculate interobserver agreement, and an agreement of >0.67 was defined as substantial.

RESULTS

The Krippendorff's alpha value for interobserver agreement on the Meggitt-Wagner classification was 0.52 for the doctors group, 0.67 for the specialised nurses and 0.61 for the untrained nurses. The corresponding values regarding agreement on recommendation of surgical revision of the wound were 0.35, 0.22 and 0.15, respectively. The choice of dressing type or antibiotic treatment had even lower interobserver agreement.

CONCLUSIONS

The interobserver agreement on the Meggitt-Wagner classification was substantial in the specialised nurse group, but the evaluation and treatment of DFUs should not be exclusively based on pictorial materials.

Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis

PURPOSE

A considerable number of diabetic foot ulcer (DFU) patients require amputation every year, which worsens their quality of life, aggravates the social burden, and shortens their life expectancy. Considering these negative effects, it is important to explore the relative risk factors affecting amputation in DFU patients.

METHODS

The PubMed, SCIE and Embase databases were comprehensively searched for prospective or retrospective studies published before October 31, 2019. All English language studies involving DFU patients were included, and RevMan 5.3 software was used to analyse the data.

RESULTS

This meta-analysis includes 21 studies involving 6505 participants, including 2006 patients who required a lower limb amputation. The following variables were associated with an increased risk of amputation: male sex (odds ratios (OR) = 1.30, 95% confidence interval (CI) = 1.16~1.46, P<0.00001), smoking history (OR = 1.19, 95% CI = 1.04~1.35, P = 0.009), a history of foot ulcers (OR = 2.48, 95% CI = 2.00~3.07, P<0.00001), osteomyelitis (OR = 3.70, 95% CI = 3.02~4.53, P<0.00001), gangrene (OR = 10.90, 95% CI = 5.73~20.8, P<0.00001), a lower body mass index (mean difference IV (MD) = -0.88, 95% CI = -1.30~-0.47, P<0.0001), and a higher white blood cell count (MD = 2.42, 95% CI = 2.02~2.82, P<0.00001). However, age (MD = 1.24, 95% CI = -0.45~2.93, P = 0.15), type of diabetes (OR = 0.96, 95% CI = 0.61~1.52, P = 0.86), hypertension (OR = 1.19, 95% CI = 0.96~1.47, P = 0.12), and HbA1c level (MD = 0.02, 95% CI = -0.28~0.33, P = 0.87) were not associated with amputation in patients with DFU.

CONCLUSIONS

Our meta-analysis identified several risk factors for amputation in DFU patients, including the male sex, a smoking history, a history of foot ulcers, osteomyelitis, gangrene, a lower body mass index, and a higher white blood cell count. Once gangrene occurs, the risk of amputation rapidly increases.

Outcomes of Diabetic Foot Ulcers in a Tertiary Referral Interdisciplinary Clinic: A Retrospective Canadian Study

OBJECTIVES

The objectives of this work were to evaluate demographic data, healing rate, recurrence rate, amputation rate and death rate of patients with diabetic foot ulcers (DFUs) treated in a Québec outpatient diabetic foot ulcer multidisciplinary clinic. Another objective was to determine factors associated with higher ulcer recurrence.

METHODS

We conducted a retrospective cohort study of adults with diabetes with a DFU referred to a Québec City diabetic foot clinic between December 1, 2013 and May 1, 2019. The primary outcome was recurrence rate at 6 months after first ulcer healing. We also evaluated the recurrence rate at 12 months, mean and median time for ulcer healing, mean and median time before recurrence after first ulcer healing, amputation rate, mortality rate and factors associated with DFU recurrence.

RESULTS

Of the 85 patients included in the study, 26 (37.1%) and 36 (54.4%) had DFU recurrence at 6 months and 12 months, respectively, after first ulcer healing. Mean healing time from first consultation in the ulcer clinic was 19.64±21.02 weeks. Of the patients, 36.9% patients underwent lower limb amputation and 30.6% died during follow up. Both previous history of a DFU before first consultation and amputation after first DFU consultation were statistically significant risk factors for DFU recurrence at 12 months.

CONCLUSIONS

DFU recurrence was significantly higher in patients with a past history of DFU before the first one evaluated in the diabetic foot clinic and a previous history of amputation. Thus, systematic follow up should be done specifically with these patients.

Risk factors affecting amputation in diabetic foot

Background

A diabetic foot is the most common cause of non-traumatic lower extremity amputations (LEA). The study seeks to assess the risk factors of amputation in patients with diabetic foot ulcers (DFU).

Methods

The study was conducted on 351 patients with DFUs from January 2010 to December 2018. Their demographic characteristics, disease history, laboratory data, ankle-brachial index, Wagner classification, osteomyelitis, sarcopenia index, and ulcer sizes were considered as variables to predict outcome. A chi-square test and multivariate logistic regression analysis were performed to test the relationship of the data gathered. Additionally, the subjects were divided into two groups based on their amputation surgery.

Results

Out of the 351 subjects, 170 required LEA. The mean age of the subjects was 61 years and the mean duration of diabetes was 15 years; there was no significant difference between the two groups in terms of these averages. Osteomyelitis (hazard ratio [HR], 6.164; 95% confidence interval [CI], 3.561−10.671), lesion on percutaneous transluminal angioplasty (HR, 2.494; 95% CI, 1.087−5.721), estimated glomerular filtration rate (eGFR; HR, 0.99; 95% CI, 0.981−0.999), ulcer size (HR, 1.247; 95% CI, 1.107−1.405), and forefoot ulcer location (HR, 2.475; 95% CI, 0.224−0.73) were associated with risk of amputation.

Conclusion

Osteomyelitis, peripheral artery disease, chronic kidney disease, ulcer size, and forefoot ulcer location were risk factors for amputation in diabetic foot patients. Further investigation would contribute to the establishment of a diabetic foot risk stratification system for Koreans, allowing for optimal individualized treatment.

Diabetic foot ulcer classifications: A critical review

Classification and scoring systems can help both clinical management and audit outcomes of routine care. The aim of this study was to assess published systems of diabetic foot ulcers (DFUs) to determine which should be recommended for a given clinical purpose. Published classifications had to have been validated in populations of > 75% people with diabetes and a foot ulcer. Each study was assessed for internal and external validity and reliability. Eight key factors associated with failure to heal were identified from large clinical series and each classification was scored on the number of these key factors included. Classifications were then arranged according to their proposed purpose into one or more of four groups: (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) aid clinical management decision making for an individual case, and (d) audit to compare outcome in different populations. Thirty-seven classification systems were identified of which 18 were excluded for not being validated in a population of >75% DFUs. The included 19 classifications had different purposes and were derived from different populations. Only six were developed in multicentre studies, just 13 were externally validated, and very few had evaluated reliability.Classifications varied in the number (4 - 30), and definition of individual items and the diagnostic tools required. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalization, limb amputation, mortality, and cost. Despite the limitations, there was sufficient evidence to make recommendations on the use of particular classifications for the indications listed above.

Hyperbaric oxygen therapy for nonischemic diabetic ulcers: A systematic review

Diabetic foot ulcers are a common complication of diabetes, which affects 25% of patients and may ultimately lead to amputation of affected limbs. Research suggests hyperbaric oxygen therapy improves healing of these ulcers. However, this has not been reflected in previous reviews, possibly because they did not differentiate between patients with and without peripheral arterial occlusive disease. Therefore, we performed a systematic review of published literature in the MEDLINE, Embase, and Cochrane CENTRAL databases on nonischemic diabetic foot ulcers with outcome measures including complete ulcer healing, amputation rate (major and minor), and mortality. Seven studies were included, of which two were randomized clinical trials. Two studies found no difference in major amputation rate, whereas one large retrospective study found 2% more major amputations in the hyperbaric oxygen group. However, this study did not correct for baseline differences. Two studies showed no significant difference in minor amputation rate. Five studies reporting on complete wound healing showed no significant differences. In conclusion, the current evidence suggests that hyperbaric oxygen therapy does not accelerate wound healing and does not prevent major or minor amputations in patients with a diabetic foot ulcer without peripheral arterial occlusive disease. Based on the available evidence, routine clinical use of this therapy cannot be recommended. However, the available research for this specific subgroup of patients is scarce, and physicians should counsel patients on expected risks and benefits. Additional research, focusing especially on patient selection criteria, is needed to better identify patients that might profit from this therapy modality.

Amino acids and wound healing in people with limb-threatening diabetic foot ulcers

BACKGROUND

Amino acids are associated with wound healing in traumatic wounds and burns, although their effects on healing in patients with diabetic foot ulcers (DFUs) are limited. This study aimed to evaluate and identify specific amino acids associated with healing outcomes of patients with DFUs.

METHODS

Sixty-two out of 85 patients who completed the in-hospital treatment for limb-threatening DFUs were enrolled. All ulcers had epithelialization without clinical evidence of infection at discharge. The patients and their families were instructed on foot-care techniques and committed to regular follow-up for 1 year. Baseline characteristics, PEDIS wound classification, laboratory data and serum amino acid levels were used to analyze their predictive power.

RESULTS

Fifty-seven patients completed the study in which 38 had healed and 19 had unhealed ulcers. The unhealed group had higher incidence of coronary artery disease and larger wound size. Most patients received endovascular therapy (81.6% healed group; 78.9% unhealed group) before enrollment. Following adjustments for clinical factors, the serum levels of arginine (326.4 μmol/L vs. 245.0 μmol/L, P = 0.045), isoleucine (166.7 μmol/L vs. 130.1 μmol/L, P = 0.019), leucine (325.8 μmol/L vs. 248.9 μmol/L, P = 0.039), and threonine (186.7 μmol/L vs. 152.0 μmol/L, P = 0.019) were significantly higher in the healed group.

CONCLUSIONS

The amino acids associated with wound healing in DFUs differ from those reported for traditional traumatic wounds. These findings affirm the necessity for future large-scaled studies for the application of these amino acids in DFU healing, either as prognostic predictors or supplemented regimens.

Diabetic Foot Infection Presenting Systemic Inflammatory Response Syndrome: A Unique Disorder of Systemic Reaction from Infection of the Most Distal Body

Diabetic foot infection (DFI) is a major complication of diabetic foot that lead to nontraumatic lower-extremity amputation (LEA). Such distal infection of the body having systemic inflammatory response syndrome (SIRS) is rarely reported. Consecutive patients treated for limb-threatening DFI in a major diabetic foot center in Taiwan were analyzed between the years 2014 to 2017. Clinical factors, laboratory data, perfusion, extent, depth, infection and sensation (PEDIS) wound score in 519 subjects with grade 3 DFI and 203 presenting SIRS (28.1%) were compared. Major LEA and in-hospital mortality were defined as poor prognosis. Patients presenting SIRS had poor prognosis compared with those with grade 3 DFI (14.3% versus 6.6% for major LEA and 6.4% versus 3.5% for in-hospital mortality). Age, wound size, and HbA1c were independent risk factors favoring SIRS presentation. Perfusion grade 3 (odds ratio 3.37, p = 0.044) and history of major adverse cardiac events (OR 2.41, p = 0.036) were the independent factors for poor prognosis in treating patients with DFI presenting SIRS. SIRS when presented in patients with DFI is not only limb- but life-threatening as well. Clinicians should be aware of the clinical factors that are prone to develop and those affecting the prognosis in treating patients with limb-threatening foot infections.

Diabetes-related kidney, eye, and foot disease in Taiwan: An analysis of nationwide data from 2005 to 2014

BACKGROUND/PURPOSE

Patients with diabetes have a higher risk of developing chronic complications and cause a huge burden to the public health care system as well as on patients and their families. We studied these diabetic complications about kidney, eye and peripheral vascular diseases to understand their prevalence and distributions in a national survey.

METHODS

We analyzed diabetic complications using National-Health-Insurance claims filed from 2005 to 2014. We used this database to evaluate their developments of kidney, eye, and peripheral vascular diseases according to the International-Classification-of-Diseases, Ninth Revision using clinical modification diagnosis codes.

RESULTS

The prevalence of diabetic kidney disease (DKD) significantly increased from 10.49% to 17.92% from 2005 to 2014. The prevalence rate of diabetic foot significantly decreased from 1.34% to 1.05% from 2005 to 2014, and the rate of severe infection also significantly decreased from 50.69% to 45.85%. The amputation rate significantly decreased from 24.91% to 17.47% among all patients with diabetic foot.

CONCLUSION

In this study, the trends in DKD and dialysis prevalence were similar to those of the 2012 report. The rate of increase in dialysis prevalence is lower in this study than in the 2012 report. The prevalence of diabetic foot, severe infection, and amputation in this report exhibited significantly decreasing trends. This improvement may be attributable to care from multidisciplinary teams. We should dedicate more resources to our prevention program of DKD and retinopathy to further improve outcomes in the future.

Predictors of lower extremity amputation in patients with diabetic foot ulcer: findings from MEDFUN, a multi-center observational study

Background

Lower extremity amputation (LEA) is a potential sequelae of diabetic foot ulceration (DFU) and is associated with huge morbidly and mortality. Low and middle income countries are currently at the greatest risk of diabetes-related complications and deaths. We sought to identify demographic, clinical and laboratory variables that significantly predict LEA in patients hospitalized for DFU.

Methods

The Multi-center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study conducted between March 2016 and April 2017 in six tertiary healthcare institutions. We prospectively followed 336 diabetic patients hospitalized for DFU and managed by a multidisciplinary team until discharge or death. Demographic and diabetes-related information and ulcer characteristics were documented. Patients were evaluated for neuropathy, peripheral arterial disease (PAD) and medical co-morbidities while relevant laboratory and imaging tests were performed. The study end-points were ulcer healing, LEA, duration of hospitalization and mortality. Here we present data on amputation.

Results

One hundred and nineteen subjects (35.4%) underwent LEA during the follow-up period. Univariate predictors of LEA were ulcer duration more than 1 month prior to hospitalization (P <  0.001), PAD (P <  0.001), Wagner grade ≥ 4 (P <  0.001), wound infection (P 0.041), Proteinuria (P 0.021), leucocytosis (P 0.001) and osteomyelitis (P <  0.001). On multivariate regression, only three variables emerged as significant independent predictors of LEA and these include: ulcer duration more than 1 month (O.R. 10.3, 95% C.I. 4.055–26.132), PAD (O.R. 2.8, 95% C.I. 1.520–5.110) and presence of osteomyelitis (O.R. 5.6, 95% C.I. 2.930–10.776). Age, gender, diabetes type and duration, neuropathy, glycemic control and anemia did not predict LEA in the studied population.

Conclusion

We identified duration of ulcer greater than 1 month, PAD, Wagner grade 4 or higher, proteinuria, leucocytosis, wound infection and osteomyelitis as the significant predictors of LEA in patients hospitalized for DFU. Prompt attention to these risk factors may reduce amputation rate among these patients.

The Significant Association between Polymicrobial Diabetic Foot Infection and Its Severity and Outcomes

Background

Foot infection is a major complication of diabetes mellitus (DM) and its agents are usually polymicrobial. This study aims to describe the agent and determine the association between polymicrobial infections and the severity of diabetic foot infections (DFI) and their outcomes.

Methods

This retrospective cohort study was conducted during one year and it involved 104 patients. Their records were reviewed and assessed. The causative agents and its sensitivity pattern were noted. The results were presented as descriptive statistic and analysed.

Results

A total of 133 microorganisms were isolated with 1.28 microorganisms per lesion. The microorganism isolated were 62% (n = 83) GN (Gram-negative) and 38% (n = 50) GP (Gram-positive). GN microorganisms include Pseudomonas spp (28%), Proteus spp (11%), Klebsiella spp (8%) and E. coli (4%). Staphylococcus aureus (54%) was predominant among GP, followed by Group B Streptococci (26%) and Enterococcus spp (6%). Thirty patients (28.8%) had polymicrobial infections. The association between the quantity of microorganisms and severity of DFI was significant. Among severe DFI cases, 77.8% with polymicrobial microorganisms underwent amputation compared to 33.3% with monomicrobial infection.

Conclusion

GN microorganisms were predominantly isolated from DFIs and remained sensitive to widely used agents. Polymicrobial infections were associated with DFI severity.

A meta-analysis of the relationship between foot local characteristics and major lower extremity amputation in diabetic foot patients

OBJECTIVE

To clarify and quantify risk factors among local characteristics of the foot for major amputation in diabetic foot patients.

METHODS

Articles published before January 2018 on PubMed and Embase were conducted observational studies about risk factors for major amputation in patients with diabetic foot were retrieved and systematically reviewed by using Stata 12.0 statistical software.

RESULTS

A total of 4668 major amputees and 65 831 controls were reported in 18 observational studies. Across the studies, the overall odds ratios (ORs) and 95% confidence intervals (CIs) of significant risk factors are ulcer reaching bone (OR, 11.796; 95% CI, 6.905-20.152), gangrene (OR, 6.487; 95% CI, 4.088-10.293), hindfoot position (OR, 3.913; 95% CI, 2.254-6.795), decreased ankle-brachial index (ABI) (OR, 2.522; 95% CI, 1.805-3.523), infection (OR, 2.516; 95% CI, 1.708-3.706), peripheral arterial disease (PAD) (OR, 2.114; 95% CI, 1.326-3.372). While there is no significant difference in the size of the ulcer, neuropathy, Charcot foot, osteomyelitis and intermittent claudication (OR, 1.15; 95% CI, 0.85-1.54).

CONCLUSION

Factors among local characteristics of the foot associated with major amputation in patients with diabetic foot are the ulcer reaching bone, gangrene, hindfoot position, decreased ABI, infection, and PAD, a negative risk factor for the risk of amputation. Further studies are required to provide more details of foot local characteristics.

Artificial neural networks in the selection of shoe lasts for people with mild diabetes

This research addressed the selection of shoe lasts for footwear design to help relieve the pain associated with diabetic neuropathy and foot ulcers. A reverse engineering (RE) technique was used to convert point clouds corresponding to scanned shoe lasts and diabetic foot data into stereo lithograph (STL) meshes. A slicing algorithm was developed and was used to find relevant girth features of diabetic foot and the shoe lasts. An artificial neural network, termed self-organizing map (SOM), classified 60 sets of shoe lasts into similar groups. Foot shapes of three mild diabetic patients were entered into the SOM feature categories to match with suitable shoe lasts. By conducting expert questionnaire analysis of the characteristic girths featured data with analytic hierarchy process (AHP), the weights of the girths were obtained. Grey relational analysis (GRA) was then used to calculate the correlation between foot girth and the corresponding range of shoe lasts. The most suitable shoe last for each patient with a mild diabetic foot can be determined by calculating the relative fitness function for each patient. By correlating diabetic foot with suitable shoe lasts, this study demonstrated an effective strategy for designing shoes for patients with mild diabetes, which can then be manufactured to meet customized requirements.

Nationwide trends in the epidemiology of diabetic foot complications and lower-extremity amputation over an 8-year period

OBJECTIVE

To study the prevalence and trends of lower extremity complications of diabetes over an 8-year period in a single nation.

RESEARCH DESIGN AND METHODS

Nationwide data for people with type 2 diabetes (T2D) and diabetic foot complications (DFCs) were analyzed over an 8-year period (2007-2014) from National Health Insurance Research Database using the International Classification of Diseases, Ninth Revision disease coding. The DFCs were defined as ulcers, infections, gangrene, and hospitalization for peripheral arterial disease (PAD). Trends of patient characteristics, foot presentation, and the execution of major procedures were studied, including lower-extremity amputations (LEAs).

RESULTS

Along with the T2D population increasing over time, the absolute number of people with DFCs increased by 33.4%, but retained a prevalence of around 2% per year. The annual incident of LEAs decreased from 2.85 to 2.06 per 1000 T2D population (p=0.001) with the major LEA proportion decreasing from 56.2% to 47.4% (p<0.001).The mean age of patients increased from 65.3 to 66.3 years and most of the associated comorbidities of diabetes were increased. For example, end-stage renal disease increased from 4.9% to 7.7% (p=0.008). The incidence of gangrene on presentation decreased from 14.7% to 11.3% (p<0.001) with a concomitant increase in vascular interventions (6.2% to 19.5%, p<0.001).

CONCLUSIONS

DFCs remain a sustained major medical problem. These nationwide long-term data suggest trends toward older people with greater comorbidities such as PAD and renal disease. Nevertheless, promising trends of reducing gangrene on presentation paired with increases in vascular interventions support continued vigilance and rapid, coordinated interdisciplinary diabetic foot care.

Factors associated with amputation among patients with diabetic foot ulcers in a Saudi population

OBJECTIVES

A prospective study was conducted at the Armed Forces Hospital, Dhahran, Saudi Arabia, between January 2015 and December 2016 to identify the risk factors associated with amputation among diabetic foot ulcers DFUs patients.

RESULTS

In total, 82 patients were recruited. Fifty-five of the patients were males (67.07%), the mean (SD) age of the participants was 60 (± 11.4) years, the mean duration of diabetes was 8.5 (± 3.7) years, and the mean haemoglobin A1c was 4.8 (± 2.8)%. In Univariate analysis, older age and high white blood cell count (WBC) were factors associated with amputation (OR = 1.1, 95% CI = 1-1.1, P = 0.012; and OR = 383, 95% CI = 7.9-18,665, P = 0.003, respectively). On the other hand, an ischaemic ulcer was half as likely as a neuropathic ulcer to lead to amputation (OR = 0.5, 95% CI = 0.3-0.9, P = 0.036), and a higher Wagner's grade was found to be protective against amputation OR = 14.5, 95% CI = 4.3-49.4, P < 0.001. In conclusion, the current study showed that although a number of factors have been described to complicate diabetic ulcers by different researchers, none of those factors were identified in our study apart from older age and high WBC.

Inter-observer agreement of the Wagner, University of Texas and PEDIS classification systems for the diabetic foot syndrome

BACKGROUND

The aim of this cohort study was to assess the inter-observer agreement of three diabetic foot classification systems: the Wagner, the University of Texas and the PEDIS.

METHODS

We included 250 consecutive patients diagnosed of diabetic foot syndrome in 2009-2013. Wound scores were recorded at admission and a reevaluation was performed simultaneously or 24h later by a different evaluator. Demographical, laboratory data and associated risk factors were obtained from the patients' medical records.

RESULTS

The Kappa coefficient showed a moderate inter-observer agreement between the first evaluation and the reevaluation for Wagner scale (Kappa=0.55; 95% CI: 0.507-0.593), University of Texas scale (Kappa=0.513; 95% CI: 0.463-0.563) and for PEDIS scale (Kappa=0.574; 95% CI: 0.522-0.626).

CONCLUSIONS

This moderate agreement shows that these scales should not be used alone for management decisions regarding diabetic foot syndrome and should, therefore, be integrated with other clinical data to ensure an adequate handover.

Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene

Background

Infectious gangrene of the foot is a serious complication of diabetes that usually leads to a certain level of lower-extremity amputation (LEA). Nevertheless, the long-term survival and factors associated with mortality in such patients have yet to be elucidated.

Methods

A total of 157 patients with type 2 diabetes who received treatment for infectious foot gangrene at a major diabetic foot center in Taiwan from 2002 to 2009 were enrolled, of whom 90 had major LEAs (above the ankle) and 67 had minor LEAs (below the ankle). Clinical data during treatment were used for the analysis of survival and LEA, and survival was tracked after treatment until December 2012.

Results

Of the 157 patients, 109 died, with a median survival time of 3.12 years and 5-year survival rate of 40%. Age [hazard ratio 1.04 (95% confidence interval 1.01–1.06)], and major LEA [1.80 (1.05–3.09)] were independent factors associated with mortality. Patients with minor LEAs had a better median survival than those with major LEAs (5.5 and 1.9 years, respectively, P < 0.01). An abnormal ankle-brachial index was an independent risk factor [odds ratio 3.12 (95% CI 1.18–8.24)] for a poor outcome (major LEA) after adjusting for age, smoking status, hypertension, major adverse cardiac events, and renal function.

Conclusions

Efforts to limit amputations below the ankle resulted in better survival of patients with infectious foot gangrene. An abnormal ankle-brachial index may guide physicians to make appropriate decisions with regards to the amputation level.