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Yağız BK, Göktuğ UU, Sapmaz A, Dinç T, Budak AB, Terzioğlu SG. The impact of comorbidities on mortality in patients with non-traumatic major lower extremity amputation. J Wound Care 2023; 32:805-810. [PMID: 38060412 DOI: 10.12968/jowc.2023.32.12.805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
OBJECTIVE Major lower limb amputation is generally associated with a high risk of early and late-term mortality. In this study, 30-day, one-year and three-year mortality of non-traumatic major lower extremity amputations and comorbidities affecting the mortality rate were investigated. METHOD Patients who underwent a major lower limb amputation secondary to diabetes or peripheral artery disease between the years 2010-2015 were retrospectively evaluated. Additional to patient demographic data and comorbidities, amputation level, survival and mortality time were extracted. Mortality rates after 30 days, one year and three years were analysed. The associations of the survival to different parameters were evaluated with Kaplan-Meier analysis and log rank test, while the impact of the risk factors on mortality was evaluated with the Cox regression test. RESULTS A total of 193 patients were enrolled in the study. Approximately 60% of patients were aged ≥65 years, and 65.8% were male. Below-knee amputation was performed in 64.8% of patients and above-knee amputation in 35.2% of patients. The mean follow-up of patients was 29.48 months (range: 0-101 months). After non-traumatic major lower extremity amputation, 30-day, one-year and three-year mortality were 16.6%, 38.3% and 60.1%, respectively. On Cox regression analysis, age ≥65 years was the only variable that had significant impact on the 30-day mortality (hazard ratio (HR): 3.4; p=0.012), while age ≥65 years (HR: 2.5, p=0.000), diabetes (HR: 2, p=0.006) and renal failure (HR: 2, p=0.001) were found to have significant impacts on three-year mortality. CONCLUSION The findings of this study showed that >50% of patients with non-traumatic major lower limb amputations died within three years. Advanced age, diabetes and renal failure were the risk factors that increased the mortality. The high mortality rates revealed the importance of employing all hard-to-heal wound treatment options before making an amputation decision. Further, prospective studies are needed to determine the effects of primary disease status and timing of amputation on mortality.
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Affiliation(s)
- Betül Keskinkılıç Yağız
- Ministry of Health Samsun Gazi State Hospital, Department of General Surgery, Samsun, Turkey
| | - Ufuk Utku Göktuğ
- Yeditepe University Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
| | - Ali Sapmaz
- Ministry of Health Ankara City Hospital, Department of General Surgery, Ankara, Turkey
| | - Tolga Dinç
- Ministry of Health Ankara City Hospital, Department of General Surgery, Ankara, Turkey
| | - Ali Baran Budak
- Başkent University Faculty of Medicine Alanya Practice and Research Center, Department of Cardiovascular Surgery, Antalya, Turkey
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Imam MS, Almutairi AK, Alhajri AM, Alharby MM, Alanazi MH, Alotaibi AG, Abdelrahim MEA. Effect of hyperbaric oxygen treatment on diabetic foot ulcers: A meta-analysis. Int Wound J 2023; 21:e14427. [PMID: 37795772 PMCID: PMC10828728 DOI: 10.1111/iwj.14427] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/06/2023] Open
Abstract
The meta-analysis aimed to assess the effect of hyperbaric oxygen treatment on diabetic foot ulcers. Using dichotomous or contentious random or fixed effect models, the outcomes of this meta-analysis were examined and the odds ratio (OR) and the mean difference (MD) with 95% confidence intervals (CIs) were computed. 17 examinations from 1992 to 2022 were enrolled for the present meta-analysis, including 7219 people with diabetic foot ulcers. Hyperbaric oxygen treatment had a significantly higher healed ulcer (OR, 14.39; 95% CI, 4.02-51.52, p < 0.001), higher adverse event (OR, 2.14; 95% CI, 1.11-4.11, p = 0.02), lower mortality (OR, 0.22; 95% CI, 0.07-0.71, p = 0.01) and higher ulcer area reduction (MD, 23.39; 95% CI, 11.79-34.99, p < 0.001) compared to standard treatment in patients with diabetic foot ulcers. However, hyperbaric oxygen treatment and standard treatment had no significant difference in amputation (OR, 0.62; 95% CI, 0.22-1.75, p = 0.37), major amputation (OR, 0.59; 95% CI, 0.18-1.92, p = 0.38), minor amputation (OR, 0.64; 95% CI, 0.15-2.66, p = 0.54) and healing time (MD, -0.001; 95% CI, -0.76 to 0.75, p = 0.99) in patients with diabetic foot ulcers. The examined data revealed that hyperbaric oxygen treatment had a significantly higher healed ulcer, adverse event, and ulcer area reduction and lower mortality, however, there was no significant difference in amputation and healing time compared to standard treatment in patients with diabetic foot ulcers. Yet, attention should be paid to its values since most of the selected examinations had a low sample size and some of the comparisons had a low number of selected studies.
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Affiliation(s)
- Mohamed S. Imam
- Pharmacy Practice DepartmentCollege of Pharmacy, Shaqra UniversityShaqraSaudi Arabia
- Clinical Pharmacy DepartmentNational Cancer Institute, Cairo UniversityCairoEgypt
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Wafi A, Kolli V, Azhar B, Poole G, Budge J, Moxey P, Loftus I, Holt P. Amputation of the Unsalvageable Leg in Vascular Patients with Cancer. Vasc Endovascular Surg 2023; 57:697-705. [PMID: 37070430 DOI: 10.1177/15385744231171752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES The aim of this study was to compare outcomes of major lower limb amputation (MLA) in patients with and without cancer and with cancer patients receiving palliation over amputation for their unsalvageable limb. METHODS Cancer patients who underwent a major amputation or palliation between 2013 and 2018 were included. Comparison groups were cancer-MLA (active/managed cancers), non-cancer MLA (historic cancer or no cancer history) and cancer-palliation at presentation with unsalvageable limbs. Prospectively collected data was retrospectively analysed for outcomes including survival, postoperative complications, length of stay, suitability for rehabilitation and discharge destination. RESULTS 262 (cancer and non-cancer) patients underwent MLA and 18 patients with cancer received palliation. Of those amputated, 26 (9.9%) had active or managed cancer, of which 12 were diagnosed in the 6 months before MLA. Cancer-MLA patients presented with more acute ischaemia compared to non-cancer patients. Median survival was significantly different between the cancer-MLA (14.1 [9.5 - 29.5, 95% CI] months), non-cancer MLA (57.7 [45 - 73.6, 95% CI] months) and cancer-palliation (.6 [.4 - 2.3, 95% CI] months) groups, P < .001. A significantly higher proportion of cancer-MLA patients (10/26, 38.5%) were deemed unsuitable for rehabilitation in post-operative assessment compared to non-cancer MLA (21/236, 8.9%) patients, P < .001. There was a variation in destinations of discharge, with a greater proportion of cancer-MLA patients (4/26, 15.4%) going to a nursing home compared to non-cancer MLA (10/236, 4.2%) patients, P = .016. CONCLUSION Cancer is prevalent among vascular amputees, with a large proportion being occult diagnoses. Cancer is associated with poorer outcomes following amputation, but survival remains significantly better compared to palliation in cancer patients presenting with unsalvageable limbs.
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Affiliation(s)
- Arsalan Wafi
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Vijay Kolli
- Douglas Bader Rehabilitation Unit, Queen Mary's Hospital, London, UK
| | - Bilal Azhar
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Grace Poole
- St George's Medical School, University of London, London, UK
| | - James Budge
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Paul Moxey
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Ian Loftus
- St George's Vascular Institute, St George's University Hospital, London, UK
| | - Peter Holt
- St George's Vascular Institute, St George's University Hospital, London, UK
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Lin YJ, Chang Chien BY, Lee YH. Injectable and thermoresponsive hybrid hydrogel with Antibacterial, Anti-inflammatory, oxygen Transport, and enhanced cell growth activities for improved diabetic wound healing. Eur Polym J 2022. [DOI: 10.1016/j.eurpolymj.2022.111364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abbas ZG, Chockalingam N, Lutale JK, Naemi R. Predicting the risk of amputation and death in patients with diabetic foot ulcer. A long‐term prospective cohort study of patients in Tanzania. Endocrinol Diabetes Metab 2022; 5:e00336. [PMID: 35388642 PMCID: PMC9094473 DOI: 10.1002/edm2.336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/12/2022] [Accepted: 03/20/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Zulfiqarali G. Abbas
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
- Abbas Medical Centre Dar es Salaam Tanzania
| | - Nachiappan Chockalingam
- Centre for Biomechancis and Rehabilitation Technologies, School of Health, Science and Wellbeing Science Centre Staffordshire University Stoke on Trent UK
| | - Janet K. Lutale
- Muhimbili University of Health and Allied Sciences Dar es Salaam Tanzania
| | - Roozbeh Naemi
- Centre for Biomechancis and Rehabilitation Technologies, School of Health, Science and Wellbeing Science Centre Staffordshire University Stoke on Trent UK
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Chitosan/PVA Hetero-Composite Hydrogel Containing Antimicrobials, Perfluorocarbon Nanoemulsions, and Growth Factor-Loaded Nanoparticles as a Multifunctional Dressing for Diabetic Wound Healing: Synthesis, Characterization, and In Vitro/In Vivo Evaluation. Pharmaceutics 2022; 14:pharmaceutics14030537. [PMID: 35335913 PMCID: PMC8951566 DOI: 10.3390/pharmaceutics14030537] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 02/04/2023] Open
Abstract
Diabetic foot ulcers remain one of the most difficult-to-treat complications of diabetes and may seriously threaten the life of patients since it frequently results in limb loss due to amputation, suggesting that an effective therapeutic strategy is still urgently needed. In this study, a chitosan-based heterogeneous composite hydrogel encapsulating perfluorocarbon emulsions, epidermal growth factor (EGF)-loaded chitosan nanoparticles, and polyhexamethylene biguanide (PHMB) named PEENPPCH was developed for diabetic wound healing. The PEENPPCH could sustainably release EGF and PHMB in an ion-rich environment to exert antibacterial effects and promote cell growth for wound repair. In addition, the PEENPPCH can provide anti-inflammatory effects functioned by its main constituent of chitosan. Moreover, the PEENPPCH can proactively offer oxygen delivery through the incorporation of perfluorocarbon and, therefore, is able to alleviate hypoxia conditions on diabetic wounds. These functionalities enabled a markedly enhanced wound healing efficacy on diabetic rats treated with the PEENPPCHs, including thorough re-epithelization, a reduced inflammatory response, faster collagen deposition, and advanced collagen maturation resulting in a 95% of wound closure degree after 15 days that was 12.6% (p < 0.05) higher than the value of the group treated with the commercial dressing HeraDerm. Given the aforementioned advantages, together with the known merits of hydrogels, the developed PEENPPCH is anticipated to be a feasible tool for clinical diabetic wound treatment.
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Lopez-de-Andres A, Jimenez-Garcia R, Hernandez-Barrera V, de Miguel-Diez J, de Miguel-Yanes JM, Omaña-Palanco R, Carabantes-Alarcon D. Trends of Non-Traumatic Lower-Extremity Amputation and Type 2 Diabetes: Spain, 2001-2019. J Clin Med 2022; 11:jcm11051246. [PMID: 35268337 PMCID: PMC8911304 DOI: 10.3390/jcm11051246] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 12/14/2022] Open
Abstract
(1) Background: To examine trends in the incidence (2001–2019), clinical characteristics and in-hospital outcomes following major and minor non-traumatic lower-extremity amputations (LEAs) among people with type 2 diabetes mellitus (T2DM) in Spain, assessing possible sex differences. (2) Methods: Retrospective cohort study using data from the Spanish National Hospital Discharge Database. Joinpoint regression was used to estimate incidence trends, and multivariable logistic regression to estimate factors associated with in-hospital mortality (IHM). (3) Results: LEA was coded in 129,059 patients with T2DM (27.16% in women). Minor LEAs accounted for 59.72% of amputations, and major LEAs comprised 40.28%. The adjusted incidences of minor and major LEAs were higher in men than in women (IRR 3.51; 95%CI 3.46–3.57 and IRR 1.98; 95%CI 1.94–2.01, respectively). In women, joinpoint regression showed that age-adjusted incidence of minor LEAs remained stable over time, and for major LEAs, it decreased from 2006 to 2019. In men, incidences of minor and major LEAs decreased significantly from 2004 to 2019. In-hospital mortality (IHM) increased with age and the presence of comorbidity, such as heart failure (OR 5.11; 95%CI 4.61–5.68, for minor LEAs and OR 2.91; 95%CI 2.71–3.13 for major LEAs). Being a woman was associated with higher IHM after minor and major LEA (OR 1.3; 95%CI 1.17–1.44 and OR 1.18; 95%CI 1.11–1.26, respectively). (4) Conclusions: Our data showed major sex differences indicating decreasing and increasing LEA trends among men and women, respectively; furthermore, women presented significantly higher IHM after minor and major LEA procedures than men.
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Affiliation(s)
- Ana Lopez-de-Andres
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28007 Madrid, Spain; (A.L.-d.-A.); (R.O.-P.); (D.C.-A.)
| | - Rodrigo Jimenez-Garcia
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28007 Madrid, Spain; (A.L.-d.-A.); (R.O.-P.); (D.C.-A.)
- Correspondence: ; Tel.: +34-91-394-1521
| | - Valentin Hernandez-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcón, 28032 Madrid, Spain;
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28007 Madrid, Spain;
| | - Jose M. de Miguel-Yanes
- Internal Medicine Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Universidad Complutense de Madrid, 28007 Madrid, Spain;
| | - Ricardo Omaña-Palanco
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28007 Madrid, Spain; (A.L.-d.-A.); (R.O.-P.); (D.C.-A.)
| | - David Carabantes-Alarcon
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, IdISSC, 28007 Madrid, Spain; (A.L.-d.-A.); (R.O.-P.); (D.C.-A.)
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The Burden of Diabetes-Related Preventable Hospitalization: 11-Year Trend and Associated Factors in a Region of Southern Italy. Healthcare (Basel) 2021; 9:healthcare9080997. [PMID: 34442134 PMCID: PMC8391579 DOI: 10.3390/healthcare9080997] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 12/23/2022] Open
Abstract
(1) Introduction: Diabetes care is complex and delivered by different care providers in different settings across the healthcare system. Better coordination through all levels of care can lead to better outcomes and fewer hospitalizations. Prevention quality indicators (PQIs) for diabetes allow us to monitor diabetes-related avoidable admissions. The aim of this research is to assess the trend of diabetes-related preventable hospitalizations and associated risk factors in a southern Italian region. (2) Methods: The study considered all hospital admissions performed from 2008 to 2018 in the Abruzzo region, Southern Italy. Data were collected from hospital discharge records. Four different indicators were evaluated as follows: short-term complications (PQI-01), long-term complications (PQI-03), uncontrolled diabetes (PQI-14) and lower-extremity amputations (PQI-16). Joinpoint models were used to evaluate the time trends of standardized rates and the average annual percent change (AAPC). (3) Results: During study period, 8660 DRPH were performed: 1298 among PQI-01, 3217 among PQI-03, 1975 among PQI-14 and 2170 among PQI-16. During the study period, PQI-01and PQI-04 showed decreasing trends. An increasing trend was showed by PQI-16. (4) Conclusions: During an 11-year period, admissions for short-term diabetes complications and for uncontrolled diabetes significantly decreased. The use of standardized tools as PQIs can help the evaluation of healthcare providers in developing preventive strategy.
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Economic Evaluation of Sucrose Octasulfate Dressing for the Treatment of Diabetic Foot Ulcers for Type 2 Diabetes Patients. Can J Diabetes 2021; 46:126-133. [DOI: 10.1016/j.jcjd.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 05/05/2021] [Accepted: 07/01/2021] [Indexed: 11/24/2022]
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Basiri R, Haverstock BD, Petrasek PF, Manji K. Reduction in Diabetes-Related Major Amputation Rates After Implementation of a Multidisciplinary Model: An Evaluation in Alberta, Canada. J Am Podiatr Med Assoc 2021; 111:436244. [PMID: 31674800 DOI: 10.7547/19-137] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetes-related lower limb amputations (LLAs) are a major complication that can be reduced by employing multidisciplinary center frameworks such as the Toe and Flow model (TFM). In this study, we investigate the LLAs reduction efficacy of the TFM compared to the standard of care (SOC) in the Canadian health-care system. METHODS We retrospectively reviewed the anonymized diabetes-related LLA reports (2007-2017) in Calgary and Edmonton metropolitan health zones in Alberta, Canada. Both zones have the same provincial health-care coverage and similar demographics; however, Calgary operates based on the TFM while Edmonton with the provincial SOC. LLAs were divided into minor and major amputation cohorts and evaluated using the chi-square test, linear regression. A lower major LLAs rate was denoted as a sign for higher efficacy of the system. RESULTS Although LLAs numbers remained relatively comparable (Calgary: 2238 and Edmonton: 2410), the Calgary zone had both significantly lower major (45%) and higher minor (42%) amputation incidence rates compared to the Edmonton zone. The increasing trend in minor LLAs and decreasing major LLAs in the Calgary zone were negatively and significantly correlated (r = -0.730, p = 0.011), with no significant correlation in the Edmonton zone. CONCLUSIONS Calgary's decreasing diabetes-related major LLAs and negative correlation in the minor-major LLAs rates compared to its sister zone Edmonton, provides support for the positive impact of the TFM. This investigation includes support for a modernization of the diabetes-related limb preservation practice in Canada by implementing TFMs across the country to combat major LLAs.
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Meshkin DH, Zolper EG, Chang K, Bryant M, Bekeny JC, Evans KK, Attinger CE, Fan KL. Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis. J Foot Ankle Surg 2021; 60:567-576. [PMID: 33509714 DOI: 10.1053/j.jfas.2020.06.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 02/03/2023]
Abstract
Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.
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Affiliation(s)
- Dean H Meshkin
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Elizabeth G Zolper
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Kevin Chang
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Meigan Bryant
- Medical Student, Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- Medical Student, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Christopher E Attinger
- Professor of Plastic Surgery, Department of Plastic and Reconstructive Surgery, Center for Wound Healing, MedStar Georgetown University Hospital, Washington
| | - Kenneth L Fan
- Assistant Professor Plastic Surgery, Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC.
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Aragón-Hernández J, Rojas-Bonilla JM, Murillo-Vargas C. Long-term Mortality of a Cohort of Patients Undergoing Surgical Treatment for Diabetic Foot Infections. An 8-year Follow-up Study. INT J LOW EXTR WOUND 2021; 22:314-320. [PMID: 33909492 DOI: 10.1177/15347346211009425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We analyzed a retrospective cohort of 150 patients with diabetic foot infections (DFIs) who underwent surgical treatment to determine long-term outcomes. The median follow-up of the series was 7.6 years. Cox's proportional hazards model for survival time was performed and hazard ratios (HRs) were estimated. Survival times were plotted using the Kaplan-Meier method. Fifteen patients (10%) required readmission after discharge from the hospital for a recurrence of the infection. Ninety patients (60%) had re-ulcerations. Forty-nine (54.4% of those re-ulcerated) required new admission and 24 of them (26.6% of those re-ulcerated) finally required a new amputation. Overall cumulative survival rates at 1, 5, and 8 years were 95%, 78%, and 64%, respectively. Predictive variables of long-term mortality were insulin treatment (HR: 2.0, 95% CI: 1.1-3.6, P = .01), female sex (HR: 3.1, 95% CI: 1.7-5.3, P<.01) and estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (HR: 2.2, 95% CI: 1.1-4.2, P = .01). In conclusion, patients undergoing surgical treatment for DFIs had a high rate of recurrences and mortality. Women, patients who underwent treatment with insulin, and those with eGFR <60 ml/min/1.73 m2 had a higher risk of long-term mortality.
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Chiang N, Wang J, Marie N, Wu A, Ravindra R, Robinson D. Evaluation of Clinical Outcomes Following Minor Amputations in Australia - An Important Consideration for Timing of Revascularisation. Ann Vasc Surg 2021; 76:389-398. [PMID: 33905853 DOI: 10.1016/j.avsg.2021.03.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/06/2021] [Accepted: 03/30/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Vascular patients with tissue loss requiring minor amputations could be an early sign of a terminal event. The long-term outcomes and timing of revascularisation for these patients are not well-studied. The aim of this study was to determine the clinical outcomes following minor amputations. Primary outcomes were functional status, limb loss, and mortality. Secondary outcomes compared immediate and delayed revascularisation. METHODS A retrospective analysis of 200 vascular patients who required minor amputations at Austin Hospital, Melbourne was performed over 5 years. Demographics, details of revascularisation, functional status, and clinical outcomes such as recurrent tissue loss, limb loss and death were recorded. RESULTS Of the entire cohort requiring minor amputations, 118 (59%) patients underwent revascularisation. 111 (94%) revascularisation procedures were performed within 90 days of minor amputation. Over all 5-year limb preservation was 89.9%. Patients who required revascularisation were not statistically significantly more at risk for limb loss at 5 years [13.6% vs. 6.6%; P=0.08]. Limb salvage at 1 year was not different between groups revascularized before and after amputation [89.5% vs. 90.9%; P=0.70]. Over all 5-year mortality rate was 50%. In the diabetic subset, those who had revascularisation after minor amputation had a greater 5-year mortality [67.9% vs. 50%; P=0.03]. A scoring system based on risk factors was developed but was not reliable based on the study data. CONCLUSIONS The data from this study suggest that patients with diabetes who undergo revascularisation after minor amputation have worse outcomes than those revascularised prior to minor amputation. A predictive model applied at presentation could help detect high-risk patients but requires further work.
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Affiliation(s)
- Nathaniel Chiang
- Department of Vascular Surgery, Austin Health, Melbourne Victoria Australia
| | - Judy Wang
- Department of Vascular Surgery, Austin Health, Melbourne Victoria Australia.
| | - Natalie Marie
- Department of Vascular Surgery, Austin Health, Melbourne Victoria Australia
| | - Angela Wu
- Department of Vascular Surgery, Austin Health, Melbourne Victoria Australia
| | - Raevin Ravindra
- Department of Vascular Surgery, Austin Health, Melbourne Victoria Australia
| | - Domenic Robinson
- Department of Vascular Surgery, Austin Health, Melbourne Victoria Australia
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Patoulias D, Papadopoulos C, Doumas M. Updated meta-analysis assessing the risk of amputation with sodium-glucose co-transporter-2 inhibitors in the hallmark cardiovascular and renal outcome trials. Diabetes Obes Metab 2021; 23:1063-1065. [PMID: 33319468 DOI: 10.1111/dom.14297] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/07/2020] [Accepted: 12/09/2020] [Indexed: 01/15/2023]
Affiliation(s)
- Dimitrios Patoulias
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
| | - Christodoulos Papadopoulos
- Third Department of Cardiology, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
| | - Michael Doumas
- Second Propedeutic Department of Internal Medicine, Aristotle University of Thessaloniki, General Hospital "Hippokration", Thessaloniki, Greece
- Veterans Affairs Medical Center, George Washington University, Washington, District of Columbia, USA
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15
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Gunn LH, Vamos EP, Majeed A, Normahani P, Jaffer U, Molina G, Valabhji J, McKay AJ. Associations between attainment of incentivized primary care indicators and incident lower limb amputation among those with type 2 diabetes: a population-based historical cohort study. BMJ Open Diabetes Res Care 2021; 9:9/1/e002069. [PMID: 33903115 PMCID: PMC8076942 DOI: 10.1136/bmjdrc-2020-002069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/18/2021] [Accepted: 04/03/2021] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION England has invested considerably in diabetes care through such programs as the Quality and Outcomes Framework (QOF) and National Diabetes Audit (NDA). Associations between program indicators and clinical endpoints, such as amputation, remain unclear. We examined associations between primary care indicators and incident lower limb amputation. RESEARCH DESIGN AND METHODS This population-based retrospective cohort study, spanning 2010-2017, was comprised of adults in England with type 2 diabetes and no history of lower limb amputation. Exposures at baseline (2010-2011) were attainment of QOF glycated hemoglobin (HbA1c), blood pressure and total cholesterol indicators, and number of NDA processes completed. Propensity score matching was performed and multivariable Cox proportional hazards models, adjusting for disease-related, comorbidity, lifestyle, and sociodemographic factors, were fitted using matched samples for each exposure. RESULTS 83 688 individuals from 330 English primary care practices were included. Mean follow-up was 3.9 (SD 2.0) years, and 521 (0.6%) minor or major amputations were observed (1.62 per 1000 person-years). HbA1c and cholesterol indicator attainment were associated with considerably lower risks of minor or major amputation (adjusted HRs; 95% CIs) 0.61 (0.49 to 0.74; p<0.0001) and 0.67 (0.53 to 0.86; p=0.0017), respectively). No evidence of association between blood pressure indicator attainment and amputation was observed (adjusted HR 0.88 (0.73 to 1.06; p=0.1891)). Substantially lower amputation rates were observed among those completing a greater number of NDA care processes (adjusted HRs 0.45 (0.24 to 0.83; p=0.0106), 0.67 (0.47 to 0.97; p=0.0319), and 0.38 (0.20 to 0.70; p=0.0022) for comparisons of 4-6 vs 0-3, 7-9 vs 0-3, and 7-9 vs 4-6 processes, respectively). Results for major-only amputations were similar for HbA1c and blood pressure, though cholesterol indicator attainment was non-significant. CONCLUSIONS Comprehensive primary care-based secondary prevention may offer considerable protection against diabetes-related amputation. This has important implications for diabetes management and medical decision-making for patients, as well as type 2 diabetes quality improvement programs.
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Affiliation(s)
- Laura H Gunn
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
- School of Data Science, University of North Carolina at Charlotte, Charlotte, North Carolina, USA
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Eszter P Vamos
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Pasha Normahani
- Imperial Vascular Unit, Imperial College London NHS Healthcare Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Usman Jaffer
- Imperial Vascular Unit, Imperial College London NHS Healthcare Trust, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - German Molina
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Jonathan Valabhji
- Division of Metabolism, Digestion & Reproduction, Faculty of Medicine, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, St. Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
- NHS England and NHS Improvement, London, UK
| | - Ailsa J McKay
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Efficacy of hyperbaric oxygen therapy for diabetic foot ulcer, a systematic review and meta-analysis of controlled clinical trials. Sci Rep 2021; 11:2189. [PMID: 33500533 PMCID: PMC7838311 DOI: 10.1038/s41598-021-81886-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 12/21/2020] [Indexed: 01/30/2023] Open
Abstract
Studies have suggested that hyperbaric oxygen therapy (HBOT) is effective in the healing of diabetic foot ulcer (DFU); however, there is a lack of consensus. Therefore, to assess the efficacy of HBOT on diabetic foot ulcer among diabetic patients, controlled clinical trials were searched through PubMed, EMBASE, Clinical key, Ovid Discovery, ERMED, Clinical Trials.gov databases for randomized controlled trials (RCTs) and other sources until 15 September 2020. Studies that evaluated the effect of HBOT on diabetic foot ulcer, complete healing, amputation, adverse events, ulcer reduction area, and mortality rate were included. Of 1984 study records screened, 14 studies (768 participants) including twelve RCTs, and two CCTs were included as per inclusion criteria. The results with pooled analysis have shown that HBOT was significantly effective in complete healing of diabetic foot ulcer (OR = 0.29; 95% CI 0.14-0.61; I2 = 62%) and reduction of major amputation (RR = 0.60; 95% CI 0.39-0.92; I2 = 24%). Although, it was not effective for minor amputations (RR = 0.82; 95% CI 0.34-1.97; I2 = 79%); however, less adverse events were reported in standard treatment group (RR = 1.68; 95% CI 1.07-2.65; I2 = 0%). Nevertheless, reduction in mean percentage of ulcer area and mortality rate did not differ in HBOT and control groups. This review provides an evidence that hyperbaric oxygen therapy is effective as an adjunct treatment measure for the diabetes foot ulcers. These findings could be generalized cautiously by considering methodological flaws within all studies.
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Chen W, Chen K, Xu Z, Hu Y, Liu Y, Liu W, Hu X, Ye T, Hong J, Zhu H, Shen F. Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio Predict Mortality in Patients with Diabetic Foot Ulcers Undergoing Amputations. Diabetes Metab Syndr Obes 2021; 14:821-829. [PMID: 33658817 PMCID: PMC7917326 DOI: 10.2147/dmso.s284583] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/23/2021] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Elevated platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) are associated with poor outcomes in various diseases. The objectives of this study were to explore the utility of PLR and NLR in predicting all-cause mortality in patients with diabetic foot ulcers (DFU) undergoing amputations. PATIENTS AND METHODS A retrospective observational study was performed that included a total of 348 DFU patients undergoing amputations. The primary end-point was all-cause death. According to the PLR and NLR cut-off values, patients were divided into two groups and Kaplan-Meier survival curves were constructed. Multivariable Cox regression was conducted to test the independent predictors of mortality in the study cohort. RESULTS All-cause mortality was significantly higher in patients with a high PLR/NLR compared to those with a low PLR/NLR. In the low NLR group, the overall survival (OS) rates at 1, 3, and 5 years after amputation were 96.8%, 84% and 80.1%, respectively (p=0.001). In the high NLR group the corresponding OS rates at 1, 3, and 5 years were 85.2%, 58.6% and 23.9% (p<0.001). According to the multivariate analysis, age (HR 1.074, 95% CI 1.045-1.104, p<0.001), Wagner classification (HR 2.274, 95% CI 1.351-3.828, p=0.002), PLR (HR 1.794, 95% CI 1.014-3.174, p=0.045), NLR (HR 2.029, 95% CI 1.177-3.499, p=0.011), creatinine (HR 1.003, 95% CI 1.001-1.004, p<0.001) and direct bilirubin (HR 1.154, 95% CI 1.081-1.232, p<0.001) were independent predictors of mortality following amputation. CONCLUSION Postoperative PLR and NLR values may be reliable predictive biomarkers of mortality in patients following amputation for DFU. Considering the high mortality in those patients, the patients with elevated PLR/NLR should be given more intensive in clinical practice.
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Affiliation(s)
- Wenwen Chen
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Kun Chen
- Department of Thoracic Surgery, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Zhixiao Xu
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Yepeng Hu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Yiying Liu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Wenyue Liu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Xiang Hu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Tingting Ye
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Jing Hong
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Hong Zhu
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
| | - Feixia Shen
- Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China
- Correspondence: Feixia Shen Department of Endocrinology and Metabolism, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People’s Republic of China Email
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18
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Álvaro-Afonso FJ, García-Álvarez Y, Lázaro-Martínez JL, Kakagia D, Papanas N. Advances in Dermoepidermal Skin Substitutes for Diabetic Foot Ulcers. Curr Vasc Pharmacol 2020; 18:182-192. [PMID: 30963977 DOI: 10.2174/1570161117666190408170144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/11/2018] [Accepted: 12/21/2018] [Indexed: 11/22/2022]
Abstract
Diabetic foot ulcers (DFUs) are one of the major complications of diabetes, representing a leading cause of hospitalisation and non-traumatic lower limb amputations. Multidisciplinary management, patient education, glucose control, debridement, off-loading, infection control, and adequate perfusion are the mainstays of standard care. Despite all these, at least 30% of DFUs fail to heal within 20 weeks. Therefore, dermoepidermal skin substitutes (DSS) have been used as a new therapeutic adjunct for DFUs. This brief review outlines the recent advances in DSS for the treatment of DFUs. PubMed and Cochrane databases were systematically searched in May to July 2018 for systematic reviews published after 2013 and for randomised controlled trials (RCTs). A retrospective evaluation of 28 RCTs was performed. Rates of complete wound closure and time to healing were examined for 17 commonly available DSS. Healing rates after 12 weeks and time to complete closure in DFUs are heterogeneous among the 28 RCT. The best healing rates at 12 weeks were accomplished with dermal cellular substitutes (Epifix®, 100% and Amnioband®, 85%) and with dermal acellular substitutes (Allopatch®, 80% and Hyalograft®, 78.8%). Based on these studies, DSS used in conjunction with standard care appear to improve the healing rates of DFUs, as compared with standard care alone. Nonetheless, new studies with more homogeneous samples are needed to ascertain the role of ulcer size, duration, depth and/or type in the efficacy of DSS. Moreover, future RCTs should include patients with severe comorbidities, in order to be more representative of clinical reality.
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Affiliation(s)
- Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, Complutense University of Madrid, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Yolanda García-Álvarez
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, Complutense University of Madrid, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Jose Luis Lázaro-Martínez
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, Complutense University of Madrid, Instituto de Investigacion Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Despoina Kakagia
- Department of Plastic Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Rathnayake A, Saboo A, Malabu UH, Falhammar H. Lower extremity amputations and long-term outcomes in diabetic foot ulcers: A systematic review. World J Diabetes 2020; 11:391-399. [PMID: 32994867 PMCID: PMC7503503 DOI: 10.4239/wjd.v11.i9.391] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/06/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Diabetes mellitus causes a large majority of non-traumatic major and minor amputations globally. Patients with diabetes are clinically complex with a multifactorial association between diabetic foot ulcers (DFU) and subsequent lower extremity amputations (LEA). Few studies show the long-term outcomes within the cohort of DFU-associated LEA.
AIM To highlight the long-term outcomes of LEA as a result of DFU.
METHODS PubMed/MEDLINE and Google Scholar were searched for key terms, “diabetes”, “foot ulcers”, “amputations” and “outcomes”. Outcomes such as mortality, re-amputation, re-ulceration and functional impact were recorded. Peer-reviewed studies with adult patients who had DFU, subsequent amputation and follow up of at least 1 year were included. Non-English language articles or studies involving children were excluded.
RESULTS A total of 22 publications with a total of 2334 patients were selected against the inclusion criteria for review. The weighted mean of re-amputation was 20.14%, 29.63% and 45.72% at 1, 3 and 5 years respectively. The weighted mean of mortality at 1, 3 and 5 years were 13.62%, 30.25% and 50.55% respectively with significantly higher rates associated with major amputation, re-amputation and ischemic cardiomyopathy.
CONCLUSION Previous LEA, level of the LEA and patient comorbidities were significant risk factors contributing to re-ulceration, re-amputation, mortality and depreciated functional status.
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Affiliation(s)
- Ayeshmanthe Rathnayake
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
| | - Apoorva Saboo
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
| | - Usman H Malabu
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
- Department of Medicine, Townsville University Hospital, Townsville 4814, Queensland, Australia
- School of Medicine and Dentistry, James Cook University, Townsville 4811, Queensland, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm 17176, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm 17176, Sweden
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20
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West J, Wetherhold J, Schulz S, Valerio I. A Novel Use of Next-Generation Closed Incision Negative Pressure Wound Therapy After Major Limb Amputation and Amputation Revision. Cureus 2020; 12:e10393. [PMID: 33062513 PMCID: PMC7550024 DOI: 10.7759/cureus.10393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report our experience with next-generation incisional negative pressure wound therapy (iNPWT) applied after major limb amputation or amputation revision. In this high-risk patient population, the need for reliable post-operative soft tissue management is imperative. In both cases reported, healing was uncomplicated. Using the next generation iNPWT in this unique way optimizes the post-operative residual limb by improved incision healing, residual limb edema reduction, and reduced risk of surgical site infection (SSI). This is the first case report of its kind reporting a novel use of next-generation iNPWT, and it demonstrates a need to examine this particular use further.
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Affiliation(s)
- Julie West
- Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Julia Wetherhold
- Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Steven Schulz
- Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Ian Valerio
- Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, USA
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21
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Yammine K, Hayek F, Assi C. A meta-analysis of mortality after minor amputation among patients with diabetes and/or peripheral vascular disease. J Vasc Surg 2020; 72:2197-2207. [PMID: 32835790 DOI: 10.1016/j.jvs.2020.07.086] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 07/06/2020] [Indexed: 01/17/2023]
Abstract
OBJECTIVE Foot complications in patients with diabetes or peripheral artery disease (PAD) are serious events in the life of these patients that often lead to amputations and mortality. No evidence synthesis has been reported on the mortality rates after minor lower extremity amputation; thus, a quantitative evidence synthesis was needed. METHODS A systematic literature search was performed to identify studies that had reported the survival or mortality rates after a minor LEA. The studies were required to include one or more of the following primary outcomes: mortality rate at 30 days, 1 year, 3 years, 5 years, 6 to 7 years, or 8 to 9 years. The secondary outcomes were the mortality rates according to the anatomic location of the amputation in the foot and the independent risk factors for mortality. RESULTS A total of 28 studies with 17,325 subjects fulfilled the inclusion criteria. The meta-analytical results of the mortality rates were as follows: 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years, 51.3% at 6 to 7 years, and 58.5% at 8 to 9 years. From these studies of diabetic patients, age was the most consistent independent risk factor, followed by chronic kidney disease, PAD, and coronary artery disease. One study of patients with PAD had reported diabetes as an independent risk factor for mortality. The subgroup analysis of the four studies reporting the outcomes of patients with PAD showed greater 3- and 5-year mortality rates compared with the overall and "diabetic" results. CONCLUSIONS Mortality after minor amputation for patients with diabetes and/or PAD was found to be very high. Compared with the reported cancer data, survival was worse than that for many cancers. Just as in the case of major amputations, minor amputations should be considered a pivotal event in the life of these patients.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Division of Vascular Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon.
| | - Fady Hayek
- Division of Vascular Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon; Diabetic Foot Clinic, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, LAU Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
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22
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Álvaro-Afonso FJ, Sanz-Corbalán I, Lázaro-Martínez JL, Kakagia D, Papanas N. Adipose-Derived Mesenchymal Stem Cells in the Treatment of Diabetic Foot Ulcers: A Review of Preclinical and Clinical Studies. Angiology 2020; 71:853-863. [PMID: 32723090 DOI: 10.1177/0003319720939467] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review provides an outline of the use of adipose-derived mesenchymal stem cells (AMSCs) in the treatment of diabetic foot ulcers (DFUs). A systematic search of PubMed and the Cochrane database was performed on October 2, 2019. Eighteen studies were identified (14 preclinical and 4 clinical). Studies in animal models have demonstrated that AMSCs enhance diabetic wound healing, accelerate granulation tissue formation, and increase reepithelialization and neovascularization. Only 1 randomized control trial has been published so far. Patients (n = 25) with DFUs were treated using an allogeneic AMSC directly on the wound bed as a primary dressing, and improvements were found in complete wound closure in the treatment group (n = 16). Three clinical studies showed that autologous AMSC might be a safe alternative to achieve therapeutic angiogenesis in patients with diabetes and peripheral arterial disease. Based on the available evidence, AMSCs hold promise in the treatment of DFUs. However, this evidence requires confirmation by well-designed trials. Additional studies are also required to understand some issues regarding this treatment for DFUs. For example, the potential application of autologous or allogeneic AMSCs in different types of DFUs, optimal dose/infusion schedules, safety evaluations, and cost-effectiveness.
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Affiliation(s)
- Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, 16734Complutense University of Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Irene Sanz-Corbalán
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, 16734Complutense University of Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, University Podiatric Clinic, Edificio Facultad de Medicina, 16734Complutense University of Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Despoina Kakagia
- Department of Plastic Surgery, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
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23
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Soo BP, Rajbhandari S, Egun A, Ranasinghe U, Lahart IM, Pappachan JM. Survival at 10 years following lower extremity amputations in patients with diabetic foot disease. Endocrine 2020; 69:100-106. [PMID: 32281048 DOI: 10.1007/s12020-020-02292-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 03/27/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Amputations are associated with markedly reduced long-term survival in patients with diabetic foot disease. However, there is paucity of long-term survival data in published literature. METHODS We searched the electronic case records and laboratory details of patients who underwent amputations between 1997 and 2006 to obtain at least 10 years of follow up data after the surgery to assess the survival rates and possible risk factors reducing survival in the year 2016. Amputation level below ankle was considered as minor and above ankle as major amputations. RESULTS Of the 233 cases (159 males; median age 68 years), 161 had major amputations. Of the 72 cases who had minor amputations initially, 63 needed a further amputation or contralateral amputation on follow up. One hundred seventy-seven patients (76%) were not alive after 10 years of follow up. The survival rates at 1, 3, 5, 7, and ≥10 years were 64%, 50%, 40%, 34%, and 24%, respectively. Maximum number of deaths occurred within 4 months of amputations. There was no difference between survival rates following major or minor amputations and among males or females. The only statistically significant parameter affecting lower survival rate was age ≥70 years, with each additional year of age increasing the hazard by a factor of 1.039 (95% CI: 1.024-1.054) or 3.9% (2.4-5.4%). CONCLUSIONS Five-year and 10-year survival rates were 40% and 24%, respectively, following diabetic foot amputations. Higher age ≥70 years was associated with lower survival rate compared with younger age groups after lower extremity amputations.
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Affiliation(s)
- Bernard Pac Soo
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Satyan Rajbhandari
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Ansy Egun
- Department of Vascular Surgery, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, PR2 9HT, UK
| | - Ushank Ranasinghe
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Ian M Lahart
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | - Joseph M Pappachan
- Department of Endocrinology and Metabolism, Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK.
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Cascini S, Agabiti N, Davoli M, Uccioli L, Meloni M, Giurato L, Marino C, Bargagli AM. Survival and factors predicting mortality after major and minor lower-extremity amputations among patients with diabetes: a population-based study using health information systems. BMJ Open Diabetes Res Care 2020; 8:8/1/e001355. [PMID: 32690575 PMCID: PMC7371030 DOI: 10.1136/bmjdrc-2020-001355] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/01/2020] [Accepted: 06/16/2020] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION The aim of the study was to identify the sociodemographic and clinical factors associated with death after the first lower-extremity amputation (LEA), minor and major separately, using data from regional health administrative databases. RESEARCH DESIGN AND METHODS We carried out a population-based cohort study including patients with diabetes residing in the Lazio region and undergoing a primary amputation in the period 2012-2015. Each individual was followed up for at least 2 years. Kaplan-Meier analysis was used to evaluate long-term survival; Cox proportional regression models were applied to identify factors associated with all-cause mortality. RESULTS The cohort included 1053 patients, 72% were male, 63% aged ≥65 years, and 519 (49%) died by the end of follow-up. Mortality rates at 1 and 4 years were, respectively, 33% and 65% for major LEA and 18% and 45% for minor LEA. Significant risk factors for mortality were age ≥65, diabetes-related cardiovascular complications, and chronic renal disease for patients with minor LEA, and age ≥75 years, chronic renal disease and antidepressant drug consumption for subjects with major LEA. CONCLUSIONS The present study confirms the high mortality rates described in patients with diabetes after non-traumatic LEA. It shows differences between minor and major LEA in terms of mortality rates and related risk factors. The study highlights the role of depression as specific risk factor for death in patients with diabetes after major LEA and suggests including its definition and management in strategies to reduce the high mortality rate observed in this group of patients.
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Affiliation(s)
- Silvia Cascini
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Luigi Uccioli
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Lazio, Italy
| | - Marco Meloni
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Lazio, Italy
| | - Laura Giurato
- Department of Internal Medicine, University of Rome Tor Vergata, Rome, Lazio, Italy
| | - Claudia Marino
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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25
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Otsuka T, Arai M, Sugimura K, Sakai M, Nishizawa Y, Suzuki Y, Okamoto H, Kuroiwa M. Preoperative sepsis is a predictive factor for 30-day mortality after major lower limb amputation among patients with arteriosclerosis obliterans and diabetes. J Orthop Sci 2020; 25:441-445. [PMID: 31227298 DOI: 10.1016/j.jos.2019.05.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/13/2019] [Accepted: 05/26/2019] [Indexed: 02/09/2023]
Abstract
BACKGROUND While many patients with lower limb ischemia also have severe infections, few studies have investigated whether the presence of preoperative sepsis affects patient prognosis following lower limb amputation (LLA). Therefore, we investigated the factors (including sepsis as defined in SEPSIS-3) that contribute to the acute mortality rate in patients who underwent LLA due to arteriosclerosis obliterans (ASO) or diabetes mellitus (DM). METHODS In this retrospective, single-center, 10-year chart review study, 122 adult patients who underwent LLA due to ASO and/or DM were identified from 56,438 surgery cases. Patient characteristics, including co-morbidities, surgical conditions, the presence/absence of sepsis, and acute physiological condition after surgery, were investigated in patients who died within 30 days of LLA and those who survived. Univariate analysis between groups was performed using the chi-square test. Comparisons of age and American Society of Anesthesiologists-Physical Status classification between groups were performed using the Mann-Whitney U test. Risk factors for 30-day mortality after LLA were examined using stepwise logistic regression (backward elimination). Statistical results were considered significant at P < 0.05. RESULTS Eight cases of mortality (6.6%) were found; we identified the causes as sepsis, myocardial infarction, fatal arrhythmia, and mesenteric artery occlusive disease in 5 (62.5%), 1 (12.5%), 1 (12.5%), and 1 (12.5%) cases, respectively. Using univariate analysis, we identified that age (≥74), delirium, sepsis, intensive care unit admission, non-DM (ASO only), hemodialysis, and acute kidney injury were significantly higher in the mortality group. In logistic regression analysis, non-DM (odds ratio [OR]: 35.2, 95% confidence interval [CI]: 2.8-432) and sepsis (OR: 80.7, 95% CI: 6.7-959) were potential risk factors for 30-day mortality. CONCLUSIONS This study suggests that cases resulting in amputation due to ASO pathology alone might have poor prognosis and that preoperative sepsis can increase perioperative mortality; hence, the decision to amputate must be considered before the development of sepsis.
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Affiliation(s)
- Tomohisa Otsuka
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan.
| | - Masayasu Arai
- Division of Intensive Care Medicine, Department of Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
| | - Kosuke Sugimura
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
| | - Mayuko Sakai
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
| | - Yoshiyuki Nishizawa
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
| | - Yutato Suzuki
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
| | - Hirotsugu Okamoto
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
| | - Masayuki Kuroiwa
- Department of Anesthesiology, Kitastao University, School of Medicine, 1-15-1, Kitasato, Minamiku, Sagamihara, Kanagawa, 2520374, Japan
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26
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López-de-Andrés A, Jiménez-García R, Esteban-Vasallo MD, Hernández-Barrera V, Aragon-Sánchez J, Jiménez-Trujillo I, de Miguel-Diez J, Palomar-Gallego MA, Romero-Maroto M, Perez-Farinos N. Time Trends in the Incidence of Long-Term Mortality in T2DM Patients Who Have Undergone a Lower Extremity Amputation. Results of a Descriptive and Retrospective Cohort Study. J Clin Med 2019; 8:jcm8101597. [PMID: 31581755 PMCID: PMC6832955 DOI: 10.3390/jcm8101597] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 01/22/2023] Open
Abstract
(1) Background: The aims of this study were to examine the incidence of lower extremity amputations (LEAs) among patients with type 2 diabetes mellitus (T2DM) and to compare the mortality risk of diabetic individuals who underwent LEA with age and sex-matched diabetic individuals without LEA. (2) Methods: We performed a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients. Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure (HR 1.75; 95% CI 1.65–1.87). Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk.
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Affiliation(s)
- Ana López-de-Andrés
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Rodrigo Jiménez-García
- Department of Public Health & Maternal and Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain.
| | | | - Valentin Hernández-Barrera
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier Aragon-Sánchez
- Department of Surgery, Diabetic Foot Unit, La Paloma Hospital, 35005 Las Palmas de Gran Canaria, Spain.
| | - Isabel Jiménez-Trujillo
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Javier de Miguel-Diez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), 28009 Madrid, Spain.
| | - Maria A Palomar-Gallego
- Basic Science Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Martin Romero-Maroto
- Medical Department, Health Sciences Faculty, Rey Juan Carlos University, 28922 Madrid, Spain.
| | - Napoleón Perez-Farinos
- Department of Public Health and Psychiatry, Faculty of Medicine, Universidad de Malaga, 29071 Malaga, Spain.
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Zayan NE, West JM, Schulz SA, Jordan SW, Valerio IL. Incisional Negative Pressure Wound Therapy: An Effective Tool for Major Limb Amputation and Amputation Revision Site Closure. Adv Wound Care (New Rochelle) 2019; 8:368-373. [PMID: 31346491 DOI: 10.1089/wound.2018.0935] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/20/2019] [Indexed: 12/17/2022] Open
Abstract
Objective: To evaluate our institutional experience of incisional negative pressure wound therapy (iNPWT) applied immediately after major limb amputation closure or amputation revision closure. Approach: A retrospective review was performed on 25 patients who underwent major limb amputation or amputation revision and had iNPWT placed intraoperatively upon incision closure. Results: Twenty-one patients underwent lower extremity amputation and four underwent upper extremity amputation. Seventeen were primary amputations and eight were amputation revisions. No patients developed dehiscence, seroma, or hematoma. One patient developed a surgical site infection (4%) that was treated with oral antibiotics. The average time to eligibility for prosthetic fitting for lower extremity amputations was 6.3 weeks. Innovation: Amputee patients have increased wound healing demands that can impact prosthetic wear and ambulation status. Stump incisions are located at the distal end of their extremities and often are in areas that have had prior surgical procedures performed. Thus, blood supply to the incision site may not be optimal. iNPWT is an effective incision management technique to promote healing and decrease postoperative complications in this patient population, which can lead to increased mortality. Conclusion: iNPWT is an effective technique of minimizing wound complications in the amputee and should be considered in this high-risk patient population.
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Affiliation(s)
- Nichole E. Zayan
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Julie M. West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven A. Schulz
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Sumanas W. Jordan
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Division of Plastic Surgery, Northwestern University, Chicago, Illinois
| | - Ian L. Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Vadiveloo T, Jeffcoate W, Donnan PT, Colhoun HC, McGurnaghan S, Wild S, McCrimmon R, Leese GP. Amputation-free survival in 17,353 people at high risk for foot ulceration in diabetes: a national observational study. Diabetologia 2018; 61:2590-2597. [PMID: 30171278 PMCID: PMC6223842 DOI: 10.1007/s00125-018-4723-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/30/2018] [Indexed: 12/25/2022]
Abstract
AIMS/HYPOTHESIS Our aim was to investigate amputation-free survival in people at high risk for foot ulceration in diabetes ('high-risk foot'), and to compare different subcategories of high-risk foot. METHODS Overall, 17,353 people with diabetes and high-risk foot from January 2008 to December 2011 were identified from the Scotland-wide diabetes register (Scottish Care Information-Diabetes: N = 247,278). Participants were followed-up for up to 2 years from baseline and were categorised into three groups: (1) those with no previous ulcer, (2) those with an active ulcer or (3) those with a healed previous ulcer. Participants with prior minor or major amputation were excluded. Accelerated failure time models were used to compare amputation-free survival up to 2 years between the three exposure groups. RESULTS The 2 year amputation-free survival rate in all people with diabetes with high-risk foot was 84.5%. In this study group, 270 people (10.0%) had an amputation and 2424 (90.0%) died during the 2 year follow-up period. People who had active and healed previous ulcers at baseline had significantly lower 2 year amputation-free survival compared with those who had no previous ulcer (both p < 0.0001). The percentage of people who died within 2 years for those with healed ulcer, active ulcer or no baseline ulcer was 22.8%, 16% and 12.1%, respectively. CONCLUSIONS/INTERPRETATION In people judged to be at high risk of foot ulceration, the risk of death was up to nine times the risk of amputation. Death rates were higher for people with diabetes who had healed ulcers than for those with active ulcers. However, people with active ulcers had the highest risk of amputation.
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Affiliation(s)
- Thenmalar Vadiveloo
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | | | - Peter T Donnan
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Helen C Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Sarah Wild
- Usher Institute for Public Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Rory McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Graham P Leese
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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