Twenty years with diabetes and amputations: a retrospective population-based cohort study

Understanding the Impact of Diabetic Peripheral Neuropathy and Neuropathic Pain on Quality of Life and Mental Health in 6,960 People With Diabetes

OBJECTIVE

Diabetic peripheral neuropathy (DPN) and neuropathic pain impacts quality of life (QoL) and mental health negatively. This cross-sectional survey study aimed to 1) elucidate the associations between painful and painless DPN and QoL, mental health, and socioeconomic factors, 2) assess the prevalence of sensory pain descriptors, and 3) evaluate the association between descriptors and the above factors.

RESEARCH DESIGN AND METHODS

Participants were grouped into people with (n = 1,601) and without (n = 5,359) DPN based on the Michigan Neuropathy Screening Instrument questionnaire. Participants with DPN were subsequently divided into people with (n = 1,085) and without (n = 516) concomitant neuropathic pain based on the modified Douleur Neuropathique en 4 Questions-interview.

RESULTS

The study showed diminished QoL (36-item Short Form Health Survey [SF-36]: 55.1 [interquartile range 36.7, 73.6], 82.2 [63.6, 90.9]) and poorer mental health (Hospital Anxiety and Depression Scale, subscale for anxiety [HADS-A]: 5.00 [2, 9], 2.00 [1, 5]; HADS-subscale for depression [HADS-D]: 4.00 [1, 8], 1.00 [0, 3]) in participants with DPN compared with participants without DPN. The addition of pain diminished QoL (SF-36: 50.7 [34.8, 69.8]) and mental health (HADS-A: 6 [3, 10], HADS-D: 4 [1, 8]) further. The most prevalent pain descriptor in participants with painful DPN were burning pain (73%), while the most prevalent sensory descriptor was pins-and-needles (93%). An interesting finding is the high prevalence of itch (44%). Weak associations with mental health and QoL were present for cold pain, electric pain, and itch.

CONCLUSIONS

An increased focus on differences in QoL, mental health, and pain phenotypes is of importance to move the field forward toward more interdisciplinary, personalized treatment.

Trends in Peripheral Artery Disease, Lower-Extremity Revascularization, and Lower-Extremity Amputation in Incident Type 2 Diabetes: A Danish Population-Based Cohort Study

OBJECTIVE

To examine trends in peripheral artery disease (PAD), lower-extremity (LE) revascularization, and LE amputation in patients with incident type 2 diabetes.

RESEARCH DESIGN AND METHODS

This cohort study included patients in Denmark diagnosed with type 2 diabetes in 1996-2015 and followed until 2020. Patients were age and sex matched with as many as three general population individuals. Outcomes comprised 5-year cumulative incidences of first-time PAD, LE revascularization, and LE amputation. Age- and sex-adjusted hazard ratios (aHRs) were computed using Cox regression.

RESULTS

The cohort comprised 349,454 patients with incident type 2 diabetes (53% male; median age 62 years) and 1,025,054 general population individuals. Among patients with diabetes, decreases in 5-year cumulative incidence of PAD (from 6.2 to 3.4%; aHR 0.55 [95% CI 0.52-0.57]), LE revascularization (from 0.8 to 0.6%; aHR 0.80 [95% CI 0.71-0.90]), and LE amputation (from 1.0 to 0.4%; aHR 0.45 [95% CI 0.40-0.51]) occurred from 1996-2000 to 2011-2015. LE amputation decreased at all amputation levels (hip/thigh, knee/lower leg, and ankle/foot/toe) during the study period. In the general population, 5-year cumulative incidence remained stable (1.2-1.5% for PAD, ∼0.4% for LE revascularization, and ∼0.2% for LE amputation). However, the relative rates of all outcomes were two- to threefold higher in patients with diabetes than matched individuals in 2011-2015.

CONCLUSIONS

In recent decades, the cumulative incidence of LE complications substantially decreased in patients with incident type 2 diabetes while remaining stable in the general population.

External validation of the DIAFORA system to predict lower-extremity amputations in a prospective Danish cohort

AIM

A diabetes-related foot ulcer (DFU) is a major risk factor for lower-extremity amputation (LEA). To help clinicians predict the risk of LEA in people with DFU, the Diabetic Foot Risk Assessment (DIAFORA) system was developed but has never been externally validated.

METHODS

In this study, 317 people presenting with a new DFU were included. At baseline, participants were grouped into three groups based on their DIAFORA score: low-risk (<15), medium-risk (15-25), and high-risk (>25). Participants were followed until healing, LEA, death, or at least 3 months. Discriminative accuracy was evaluated using sensitivity, specificity, likelihood ratios (LRs) and the area under the curve (AUC).

RESULTS

All 317 participants completed at least 3 months of follow-up for a median duration of 146 days, during which 12.6% underwent minor amputation and 2.5% major amputation. People in the low- and medium-risk categories had major amputation rates of 0.9% and 2.1%, respectively, and negative LR of major LEA of 0.10 and 0.38, respectively, while the people in the high-risk category had an amputation rate of 25.0% and a positive LR of 12.9. The DIAFORA risk groups had a sensitivity of 75.0% and a specificity of 65.7%, with a corresponding AUC of 0.78 (95% CI 0.68-0.87) for the prediction of major LEA.

CONCLUSION

The DIAFORA score is a useful tool for risk stratification of people presenting with a newly occurred DFU, with the external validation presenting results similar to those presented in the original study. The DIAFORA score may guide clinicians towards more individualized DFU treatment regimens.

Prevalence of painful and painless diabetic peripheral neuropathy in the Northern Danish Region: A population-based study

BACKGROUND

Diabetic peripheral neuropathy (DPN) is a common complication of diabetes, yet varying estimates of its prevalence exist. The present study aimed to estimate a questionnaire-centered prevalence of painful and painless DPN in the Northern Danish Region, examine its geographical distribution within the region, and investigate associations between DPN and potential risk factors.

METHODS

A questionnaire-based survey was sent to all persons living with diabetes in the Northern Danish Region using electronic mail. Persons with diabetes were identified using The National Health Insurance Service Registry. The survey included information on demographics, socioeconomics, municipality, diabetes type, duration, and treatment, as well as the validated questionnaires Michigan Neuropathy Screening Instrument-questionnaire (MNSIq) and the Douleur Neuropathique en 4 Questions (DN4)-interview. Possible DPN was defined as an MNSIq-score ≥ 4, while possible painful DPN was defined as pain in both feet and a DN4-interview score ≥ 3.

RESULTS

A total of 23,206 eligible people were identified as having diabetes and approximately 33 % answered all questionnaires. The prevalence of possible DPN was 23.3 % (95 % CI: 22.4-24.3 %), while the prevalence of possible painful DPN was 18.0 % (17.1-18.8 %). The prevalence of possible DPN ranged from 22.1 % to 35.0 % between municipalities, while the prevalence of possible painful DPN ranged from 15.6 % to 20.0 %. High body-mass index, long diabetes duration, insulin use, glucagon-like-peptide-1-analogue use, and low income were associated with increased risk of DPN.

CONCLUSION

The high prevalence of possible painless and painful DPN emphasizes the need for better prevention and careful screening even in high-income countries.

Declining Incidence of Major Lower-Extremity Amputations in the Northern Danish Region Between 2016 and 2021: The Impact of Diabetes and Preventive Vascular Procedures

BACKGROUND

Preventing lower-extremity amputations (LEAs) is pivotal. In the present study, we aimed to examine the recent trends in nontraumatic LEAs seen in the Northern Danish Region.

METHODS

Using data from the regional Business Intelligence unit, we identified all nontraumatic LEAs (n = 689) performed in people above 50 years of age in the Northern Danish Region between January 2016 and December 2021 (approximately 600,000 inhabitants). Persons with diabetes (n = 26,025) were identified based on International Classification of Diseases-10 codes and data from the National Health Insurance Service Registry, while preventive vascular procedures (n = 1,097) were identified using surgical codes. Major LEA was defined as any amputation above the ankle. Incidence rates were expressed as events per 1,000 person-years. Trends were described as differences between the periods 2016-2018 and 2019-2021.

RESULTS

A total of 249 (36%) major LEAs were performed in people with diabetes. People with diabetes were younger (71 vs 77 years, P < 0.001) and more frequently male (70% versus 54%, P < 0.001). Between 2016-2018 and 2019-2021, the incidence of major LEA declined from 1.76 (95% CI: 1.75-1.76) to 1.39 (1.39-1.39) in people with diabetes and from 0.47 (0.47-0.47) to 0.20 (0.20-0.20) in people without diabetes (all P < 0.001). Simultaneously, the incidence of preventive vascular surgery increased from 2.26 (2.26-2.26) to 3.48 (3.48-3.48) in people with diabetes and declined slightly in people without 0.49 (0.49-0.49) to 0.47 (0.47-0.47) (all P < 0.001).

CONCLUSIONS

Despite significant declines in major LEA in both people with and without diabetes, most of the decline was driven by a large reduction in major LEAs in people without diabetes.

Diagnostic Accuracy of Perception Threshold Tracking in the Detection of Small Fiber Damage in Type 1 Diabetes

AIM

An objective assessment of small nerve fibers is key to the early detection of diabetic peripheral neuropathy (DPN). This study investigates the diagnostic accuracy of a novel perception threshold tracking technique in detecting small nerve fiber damage.

METHODS

Participants with type 1 diabetes (T1DM) without DPN (n = 20), with DPN (n = 20), with painful DPN (n = 20) and 20 healthy controls (HCs) underwent perception threshold tracking on the foot and corneal confocal microscopy. Diagnostic accuracy of perception threshold tracking compared to corneal confocal microscopy was analyzed using logistic regression.

RESULTS

The rheobase, corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), and corneal nerve fiber length (CNFL) (all P < .001) differed between groups. The diagnostic accuracy of perception threshold tracking (rheobase) was excellent for identifying small nerve fiber damage, especially for CNFL with a sensitivity of 94%, specificity 94%, positive predictive value 97%, and negative predictive value 89%. There was a significant correlation between rheobase with CNFD, CNBD, CNFL, and Michigan Neuropathy Screening Instrument (all P < .001).

CONCLUSION

Perception threshold tracking had a very high diagnostic agreement with corneal confocal microscopy for detecting small nerve fiber loss and may have clinical utility for assessing small nerve fiber damage and hence early DPN.

CLINICAL TRIALS

NCT04078516.

Exploring potential risk factors for lower limb amputation in people with diabetes-A national observational cohort study in Sweden

AIMS

Risk factors for lower limb amputation (LLA) in individuals with diabetes have been under-studied. We examined how 1/demographic and socioeconomic, 2/medical, and 3/lifestyle risk factors may be associated with LLA in people with newly diagnosed diabetes.

METHODS

Using the Swedish national diabetes register from 2007 to 2016, we identified all individuals ≥18 years with an incident diabetes diagnosis and no previous amputation. These individuals were followed from the date of diabetes diagnosis to amputation, emigration, death, or the end of the study in 2017 using data from the In-Patient Register and the Total Population Register. The cohort consisted of 66,569 individuals. Information about demographic, socioeconomic, medical, and lifestyle risk factors was ascertained around the time of the first recorded diabetes diagnosis, derived from the above-mentioned registers. Cox proportional hazard models were used to obtain hazard ratios (HR) with 95% confidence intervals (CI).

RESULTS

During the median follow-up time of 4 years, there were 133 individuals with LLA. The model adjusting for all variables showed a higher risk for LLA with higher age, HR 1.08 (95% CI 1.05-1.10), male sex, HR 1.57 (1.06-2.34), being divorced, HR 1.67 (1.07-2.60), smokers HR 1.99 (1.28-3.09), insulin treated persons HR 2.03 (1.10-3.74), people with low physical activity (PA) HR 2.05 (1.10-3.74), and people with an increased foot risk at baseline HR > 4.12. People with obesity had lower risk, HR 0.46 (0.29-0.75).

CONCLUSIONS

This study found a higher risk for LLA among people with higher age, male sex, who were divorced, had a higher foot risk group, were on insulin treatment, had lower PA levels, and were smokers. No significant association was found between risk for LLA and education level, country of origin, type of diabetes, blood glucose level, hypertension, hyperlipidemia, creatinine level, or glomerular filtration rate. Obesity was associated with lower risk for LLA. Identified variables may have important roles in LLA risk among people with diabetes.

The co-existence of peripheral and vestibular neuropathy in diabetes: a cross-sectional study

PURPOSE

Diabetic neuropathy can lead to decreased peripheral sensation and motor neuron dysfunction associated with impaired postural control and risk of falling. However, the relationship between decreased peripheral sensation and impaired vestibular function in diabetes mellitus is poorly investigated. Therefore, the aim of this study was to investigate the relationship between peripheral and autonomic measurements of diabetic neuropathy and measurements of vestibular function.

METHODS

A total of 114 participants with type 1 diabetes (n = 52), type 2 diabetes (n = 51) and controls (n = 11) were included. Vestibular function was evaluated by video head impulse testing. Peripheral neuropathy was assessed by quantitative sensory testing and nerve conduction. Autonomic neuropathy using the COMPASS 31 questionnaire. Data were analyzed according to data type and distribution.

RESULTS

Measurements of vestibular function did not differ between participants with type 1 diabetes, type 2 diabetes or controls (all p-values above 0.05). Subgrouping of participants according to the involvement of large-, small- or autonomic nerves did not change this outcome. Correlation analyses showed a significant difference between COMPASS 31 and right lateral gain value (ρ = 0.23, p = 0.02,), while no other significant correlations were found.

CONCLUSION

Diabetic neuropathy does not appear to impair vestibular function in diabetes, by means of the VOR.

CLINICAL TRIALS

NCT05389566, May 25th, 2022.

The Moment Criterion of Anthropomorphicity of Prosthetic Feet as a Potential Predictor of Their Functionality for Transtibial Amputees

The purpose of this paper is to discuss a new quantitative mechanical parameter of prosthetic feet called the Index of Anthropomorphicity (IA), which has the potential to be adopted as an objective predictor of their functionality. The objectives are to present the research findings supporting the introduction of IA and unify previous results into a coherent theory. The IA is founded on the moment criterion of the anthropomorphicity of prosthetic feet. The term "anthropomorphicity" is defined for this application. Studies with a small number of human subjects and prostheses have shown that the value of the parameter is positively correlated with patient comfort and with the restoration of certain normal gait characteristics. Confirmatory studies with controlled human trials and mechanical tests with a wider selection of prosthesis types can give prosthesis manufacturers a new criterion to follow in the design process, and prosthetists may use the IA for selecting more suitable prostheses for a patient's comfort and health.

Lower Extremity Amputation Rates in People With Diabetes Mellitus: A Retrospective Population Based Cohort Study in Zwolle Region, The Netherlands

OBJECTIVE

Lower extremity amputations are a major complication of diabetes mellitus (DM). In a previous Dutch study, the incident rate of major amputations was 89.2 per 100 000 person years. The primary aim of this study was to describe the lower extremity amputation rates in people with DM in the Zwolle region, where preventive and curative footcare is organised according to the guidelines of the International Working Group of the Diabetic Foot (IWGDF). The secondary aim was to evaluate outcomes and underlying characteristics of these people.

METHODS

This was a retrospective regional population based cohort study. Data from all people with DM treated in primary and secondary care, living in the region Zwolle were collected. All amputations in the period 2017 to 2019 were analysed. Comparisons were made between those with and without an amputation.

RESULTS

In the analysis 5 915 people with DM were included, with a mean age of 67.8 (IQR 57.9, 75.9) years. Of those people, 47% were women and the median HbA1c was 53 (IQR 47, 62) mmol/mol. Over the three year study period 68 amputations were performed in 59 people: 46 minor, 22 major. This translated into an average annual crude amputation incidence rate of non-traumatic major and minor amputations of 41.5 and 86.9 per 100 000 person years among people with diabetes. Compared with those not undergoing amputations, those who underwent an amputation were more often men, older, mainly had T2DM, were treated in secondary care, had higher diastolic blood pressure, worse diabetic footcare profile, longer DM duration and higher HbA1c. At the end of the follow up, 111 people died: 96 (1.6%) without and 15 (25.4%) with amputations (p < .001).

CONCLUSIONS

This retrospective study provides detailed insight into the rate of amputations in Dutch people with diabetes in the region Zwolle. Compared with previous Dutch estimates, these data suggest a considerable decrease in the major amputation incidence rate.

Perception threshold tracking: validating a novel method for assessing function of large and small sensory nerve fibers in diabetic peripheral neuropathy with and without pain

ABSTRACT

It remains unknown why some people with diabetes develop painful neuropathies while others experience no pain. This study aimed to validate a novel method for assessing the function of small sensory nerves in diabetes to further elucidate this phenomenon. The function of large and small nerves was assessed using a novel perception threshold tracking technique in 3 well-characterized groups (n = 60) with type 1 diabetes, namely, (1) painful diabetic peripheral neuropathy (T1DM + PDPN), (2) painless diabetic peripheral neuropathy (T1DM + DPN), and (3) no neuropathy (T1DM - DPN), and healthy controls (n = 20). Electrical currents with different shapes, duration, and intensities were applied by 2 different skin electrodes activating large and small fibers, respectively. The minimal current needed to activate the fibers were analyzed as the rheobase of the stimulus-response function. Nerve fiber selectivity was measured by accommodation properties of stimulated nerves. The rheobase of both fiber types were highest for T1DM + PDPN, followed by T1DM + DPN, T1DM - DPN, and healthy controls, indicating that the nerve properties are specific in individuals with diabetes and pain. There was an overall significant difference between the groups ( P < 0.01). The accommodation properties of stimulated fibers were different between the 2 electrodes ( P < 0.05) apart from in the group with T1DM + PDPN, where both electrodes stimulated nerves displaying properties similar to large fibers. Perception threshold tracking reveals differences in large and small nerve fiber function between the groups with and without diabetes, DPN, and pain. This indicates that the methods have potential applications in screening DPN and explore further the features differentiating painful from nonpainful DPN.

Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: a review of national rates in the 21st century

AIMS/HYPOTHESIS

Diabetic foot disease (DFD) is a leading cause of hospital admissions and amputations. Global trends in diabetes-related amputations have been previously reviewed, but trends in hospital admissions for multiple other DFD conditions have not. This review analysed the published incidence of hospital admissions for DFD conditions (ulceration, infection, peripheral artery disease [PAD], neuropathy) and diabetes-related amputations (minor and major) in nationally representative populations.

METHODS

PubMed and Embase were searched for peer-reviewed publications between 1 January 2001 and 5 May 2022 using the terms 'diabetes', 'DFD', 'amputation', 'incidence' and 'nation'. Search results were screened and publications reporting the incidence of hospital admissions for a DFD condition or a diabetes-related amputation among a population representative of a country were included. Key data were extracted from included publications and initial rates, end rates and relative trends over time summarised using medians (ranges).

RESULTS

Of 2527 publications identified, 71 met the eligibility criteria, reporting admission rates for 27 countries (93% high-income countries). Of the included publications, 14 reported on DFD and 66 reported on amputation (nine reported both). The median (range) incidence of admissions per 1000 person-years with diabetes was 16.3 (8.4-36.6) for DFD conditions (5.1 [1.3-7.6] for ulceration; 5.6 [3.8-9.0] for infection; 2.5 [0.9-3.1] for PAD) and 3.1 (1.4-10.3) for amputations (1.2 [0.2-4.2] for major; 1.6 [0.3-4.3] for minor). The proportions of the reported populations with decreasing, stable and increasing admission trends were 80%, 20% and 0% for DFD conditions (50%, 0% and 50% for ulceration; 50%, 17% and 33% for infection; 67%, 0% and 33% for PAD) and 80%, 7% and 13% for amputations (80%, 17% and 3% for major; 52%, 15% and 33% for minor), respectively.

CONCLUSIONS/INTERPRETATION

These findings suggest that hospital admission rates for all DFD conditions are considerably higher than those for amputations alone and, thus, the more common practice of reporting admission rates only for amputations may substantially underestimate the burden of DFD. While major amputation rates appear to be largely decreasing, this is not the case for hospital admissions for DFD conditions or minor amputation in many populations. However, true global conclusions are limited because of a lack of consistent definitions used to identify admission rates for DFD conditions and amputations, alongside a lack of data from low- and middle-income countries. We recommend that these areas are addressed in future studies.

REGISTRATION

This review was registered in the Open Science Framework database ( https://doi.org/10.17605/OSF.IO/4TZFJ ).

The Kenevo microprocessor-controlled prosthetic knee compared with non-microprocessor-controlled knees in individuals older than 65 years in Sweden: A cost-effectiveness and budget-impact analysis

BACKGROUND

Growing evidence suggests that individuals with transfemoral amputation or knee disarticulation using a prosthesis equipped with a microprocessor-controlled knee (MPK) benefit from enhanced mobility and safety, including less falls. In elderly individuals, high mortality rates are assumed to reduce the expected useful life of MPKs, and this raises concerns regarding their economic effectiveness.

OBJECTIVE

To investigate the cost-effectiveness and budget impact of the Kenevo/MPK (Ottobock, Germany) compared with non-microprocessor-controlled knees (NMPKs) in people older than 65 years at the time of transfemoral amputation/knee disarticulation, from a Swedish payer's perspective.

METHODS

A decision-analytic model was developed to conduct the economic analysis of the Kenevo/MPK. Model parameters were derived from Swedish databases and published literature. Univariate and probabilistic sensitivity analyses were performed to explore parameter uncertainty.

RESULTS

Compared with NMPKs, the Kenevo/MPK reduced the frequency of hospitalizations by 137 per 1,000 person years while the frequency of fatal falls was reduced by 19 per 1,000 person-years in the simulation. Over a 25-year time horizon, the incremental cost-effectiveness ratio was EUR11,369 per quality-adjusted life year. The probability of the MPK being cost-effective at a threshold of EUR40,000 per quality-adjusted life year was 99%. The 5-year budget impact model predicted an increase in payer expenditure of EUR1.76 million if all new patients received a Kenevo/MPK, and 50% of current NMPK users switched to the MPK.

CONCLUSIONS

Results of the modeling suggest that the Kenevo/MPK is likely to be cost-effective for elderly individuals, primarily because of a reduction in falls.

Editor's Choice - Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

OBJECTIVE

This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes.

METHODS

This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex.

RESULTS

The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations.

CONCLUSION

The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.

Time trends (2001-2019) and sex differences in incidence and in-hospital mortality after lower extremity amputations among patients with type 1 diabetes in Spain

Background

We examined trends in incidence (2001–2019), clinical characteristics, and in-hospital outcomes following major and minor lower extremity amputations (LEAs) among type 1 diabetes mellitus (T1DM) patients in Spain and attempted to identify sex differences.

Methods

Retrospective cohort study using data from the Spanish National Hospital Discharge Database. We estimated the incidence of the LEA procedure stratified by type of LEA. Joinpoint regression was used to estimate incidence trends, and logistic regression was used to estimate factors associated with in-hospital mortality (IHM).

Results

LEA was coded in 6011 patients with T1DM (66.4% minor and 33.6% major). The incidence of minor LEA decreased by 9.55% per year from 2001 to 2009 and then increased by 1.50% per year, although not significantly, through 2019. The incidence of major LEA decreased by 13.39% per year from 2001 to 2010 and then remained stable through 2019. However, incidence increased in men (26.53% per year), although not significantly, from 2017 to 2019. The adjusted incidence of minor and major LEA was higher in men than in women (IRR 3.01 [95% CI 2.64–3.36] and IRR 1.85 [95% CI 1.31–2.38], respectively). Over the entire period, for those who underwent a minor LEA, the IHM was 1.58% (2.28% for females and 1.36% for males; p = 0.045) and for a major LEA the IHM was 8.57% (10.52% for females and 7.59% for males; p = 0.025).

IHM after minor and major LEA increased with age and the presence of comorbid conditions such as peripheral arterial disease, ischemic heart disease or chronic kidney disease. Female sex was associated with a higher IHM after major LEA (OR 1.37 [95% CI 1.01–1.84]).

Conclusions

Our data show a decrease in incidence rates for minor and major LEA in men and women with T1DM and a slight, albeit insignificant, increase in major LEA in men with T1DM in the last two years of the study. The incidence of minor and major LEA was higher in men than in women. Female sex is a predictor of IHM in patients with T1DM following major LEA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01502-y.

Incidence, hospitalization and mortality and their changes over time in people with a first ever diabetic foot ulcer

AIMS

A diabetic foot ulcer (DFU) is a severe condition associated with morbidity and mortality. Population-based studies are rare and limited by access to reliable data. Without this data, efforts in primary prevention cannot be evaluated. Therefore, we examined the incidence and changes over time for the first DFU in people with diabetes. We also examined hospitalization and all-cause mortality and their changes over time.

METHODS

From the UK primary care CPRD GOLD database (2007-2017), we identified 129,624 people with diabetes by a prescription for insulin or a non-insulin anti-diabetic drug. DFUs were identified using Read codes and expressed as incidence rates (IRs). Changes over time were described using Poisson and logistic regression and expressed as incidence rate ratios (IRRs) and odds ratios (ORs) respectively.

RESULTS

The mean IR of first registered DFUs was 2.5 [95% CI: 2.1-2.9] per 1000 person-years for people with type 2 diabetes and 1.6 [1.3-1.9] per 1000 person-years for people with type 1. The IRs declined for people with type 2 diabetes (IRR per year: 0.97 [0.96-0.99]), while no changes were observed for people with type 1 diabetes (IRR per year: 0.96 [0.89-1.04]). Average hospitalization and 1-year mortality risk for people with type 2 diabetes were 8.2% [SD: 4.7] and 11.7% [SD: 2.2] respectively. Both declined over time (OR: 0.89 [0.84, 0.94] and 0.94 [0.89, 0.99]).

CONCLUSION

The decline in all IRs, hospitalizations and mortality in people with type 2 diabetes suggests that prevention and care of the first DFU has improved for this group in primary care in the UK.

Diabetic Peripheral Neuropathy

Diabetic painless and painful peripheral neuropathy remains the most frequent complication of diabetes mellitus, but the pathophysiology remains undescribed, there are no robust clinical endpoints and no efficient treatment exists. This hampers good clinical practice, fruitful clinical research and successful pharmacological trials, necessary for the development of early detection, prevention and treatment. This chapter supplies an update on background and treatment of diabetic peripheral neuropathy. Goals and perspectives for future clinical and scientific approaches are also described.

The effect of redox signaling on extracellular matrix changes in diabetic wounds leading to amputation

INTRODUCTION

& Objectives: Redox signaling is a critical regulator in the process of wound healing. This signaling pathway can be effective in the development or healing of diabetic ulcers through the ECM.In this study, the structure of extracellular matrix investigated in relation to redox signaling in the tissue of patients with diabetic ulcers that lead to organ amputation.

MATERIALS AND METHODS

The case-control design on diabetic patients ulcers as case group and non-diabetic limb ischemia as control were used.Hematoxylin-eosin, trichrome, and elastin staining methods were used for pathological evaluations of ECM. MDA, total thiol, and SOD levels were measured using ELISA kits to assess the oxidative stress level. Also, NO level was measured by using ELISA kits in both groups. Expression levels of genes MMP2, MMP9, and HIF were detected using real-time PCR with SYBR-green assay.

RESULTS

The pathological results showed an increase in the thickness of collagen and elastin fibers. Lipids atrophy was visible in the tissue isolated from the diabetic wound group. The amount of MAD to evaluate the level of lipid oxidation in patients with diabetic Ulcer was significantly higher than the control group(p < 0.01). Thiol level was significantly lower in the diabetic ulcer group than in the control group(p < 0.0001). The expression of metalloproteinases 2 and 9 genes in the tissues isolated from diabetic ulcers was lower than the control group(p < 0.0001). While the expression of the HIF gene in this group was higher than the control group(p < 0.0001).

CONCLUTION

In the diabetic wound, the HIF secretion due to hypoxic conditions is beneficial for matrix deposition and prevents protease activity, but if the hypoxia persists, it can lead to ECM deposition subsequently increases the tissue pressure, increases of the collagen I-to-collagen III ratio in collagen accumulation that due to more hypoxia , lipidsAtrophy and eventually amputation.