Rates and risk factors for amputation in people with diabetes in Japan: a historical cohort study using a nationwide claims database

The associations of body mass index and waist circumference with the risk of diabetic complications in people with type 2 diabetes mellitus

AIMS

To determine the associations of body mass index (BMI) and waist circumference (WC) with severe diabetic complications in patients with type 2 diabetes.

MATERIALS AND METHODS

In total, 114 254 participants with type 2 diabetes (82% male; mean age, 52.52 ± 8.27 years; median follow-up, 4.64 years) were enrolled from a nationwide Japanese medical claims database. Cox proportional models with multivariate adjustment were used to assess the associations of BMI and WC with treatment-requiring diabetic eye disease (TRDED), initiation of dialysis, coronary artery disease (CAD), cerebrovascular disease (CVD), heart failure (HF) and amputation.

RESULTS

BMI was inversely associated with TRDED, especially in women. Men with WC ≥ 95 cm had a significantly lower risk of TRDED (hazard ratio [HR] = 0.79, 95% CI = 0.69-0.91). Dialysis initiation displayed L-shaped associations with BMI and WC. The risk of CAD was significantly reduced among men with BMI < 20.0 kg/m2 (HR = 0.68, 95% CI = 0.49-0.94). HF had U-shaped associations with BMI and WC. Abdominal obesity increased CVD risk (HR = 1.36, 95% CI = 1.08-1.70). BMI ≥ 25 kg/m2/WC ≥ 90 cm significantly reduced the risk of dialysis (HR = 0.42, 95% CI = 0.29-0.62) and increased the risk of HF (HR = 1.33, 95% CI = 1.03-1.72).

CONCLUSIONS

BMI/WC had both positive and negative associations with diabetic complications. Therefore, each patient's BMI/WC target should be carefully determined for each diabetic complication, considering the risk of developing other diseases.

Does preoperative muscle biopsy predict the outcome of lower extremity amputation in diabetic patients? a prospective observational study

BACKGROUND

Determining the most appropriate level of amputation in patients with diabetes mellitus has not been well established. The purpose of this study is to determine whether muscle biopsy reveals predictive information about the success rate of patients undergoing diabetic major lower limb amputation.

METHODS

A prospective observational study was conducted among diabetic patients who underwent below-knee amputation. Skin-subcutaneous and muscle biopsy samples were obtained during the operation from 62 patients who undergo major limb amputation. Depending on the complications after surgery, patients were assigned into three groups: Group 1 consisted of patients with adequate wound healing without any complications; Group 2 included patients with prolonged wound healing requiring additional interventions like debridement; and Group 3 consisted of patients who underwent reamputation at a more proximal level. Biopsy samples of the groups were compared regarding degenerative cells, inflammatory cells, and the presence of infection.

RESULTS

There was a significant difference between Groups 1 and 3 regarding the presence of abscess formation and infection (p < 001). Comparison of Groups 1 and 3 revealed significant differences regarding inflammatory cell count, respectively (p < 001). According to the results of the ROC analysis performed for histopathologic cellular evaluation, 15% for inflammatory cell ratio in muscle samples and 25% for degenerative cell ratio both in muscle and skin samples were determined as cut-off values.

CONCLUSIONS

The presence of increased degenerative cell count and infection in muscle biopsy areassociated with higher rates of reoperation. The present study revealed that preoperative muscle biopsy has predictive value in patients undergoing major limb amputation.

LEVEL OF EVIDENCE

Level II, Prospective observational study.

Depression as a Prognostic Factor in Lower Extremity Amputation for Diabetic Foot: Insights From a Prospective Study on Wound Healing, Infections, and Early Mortality

This study addresses the challenges faced by diabetic patients undergoing lower extremity amputation due to diabetic foot, particularly focusing on the implications for wound healing and early mortality. The wounds at the amputation stump may necessitate multiple surgical interventions. The aim is to identify prognostic factors associated with these outcomes, shedding light on the complexities surrounding the postamputation phase. A prospective study was conducted on 39 diabetic patients who underwent lower extremity amputation due to diabetic foot between 2021 and 2022. Comprehensive preoperative data, encompassing parameters such as blood count, erythrocyte sedimentation rate, C-reactive protein, procalcitonin, hemoglobin A1c, albumin, protein, transferrin, ferritin levels, age, gender, body mass index, smoking habits, dialysis, revascularization, duration of surgery, and the use of tourniquet during the procedure were meticulously recorded. Additionally, cognitive performance and depression status were assessed preoperatively using the Mini-Mental State Examination (MMSE) and Beck Depression Inventory (BDI), respectively. A follow-up period of 3 months postsurgery allowed for the comparison of patients who developed infections at the amputation stump with those who did not, as well as the distinction between patients who survived and those who succumbed to mortality. The study revealed that the use of a tourniquet during surgery significantly increased the risk of infection (p = .027), and higher BDI scores were associated with increased risks of both infection (AUC = 0.814) and mortality (AUC = 0.769), with cut-off scores of 24.0 and 23.5 predicting these outcomes with high sensitivity and specificity, respectively. Additionally, lower MMSE scores were associated with increased short-term postoperative mortality. There were no statistically significant differences between the groups in parameters such as complete blood count, ESR, CRP, procalcitonin, HbA1c, albumin, total protein, transferrin, ferritin levels, age, gender, BMI, smoking, dialysis, revascularization, and surgery duration. This investigation highlights the significance of considering tourniquet usage during amputation, preoperative depression status, and cognitive function in patients who undergo amputation due to diabetic foot. The use of a tourniquet during surgery is a significant risk factor for infection, and elevated BDI scores are strong predictors of both infection and mortality in patients undergoing amputations. The findings underscore the importance of a multidisciplinary neuropsychiatric evaluation preoperatively to enhance patient care and outcomes.

Annual Foot Exams are Associated with Reduced Incident Amputation among Older Veterans with Diabetes

We conducted a secondary data analysis to evaluate the association between annual foot exams and incident lower extremity amputations (LEA) among older veterans with diabetes during FY2007-FY2014. Older Veterans with at least one primary care provider visit each year (N = 664,162) and at least one foot exam each year (N = 72,892) and the overlap were identified from the 5 years prior to the study period of interest (FY2002-FY2006 (N = 71,122)). After excluding incident LEA related to cancer and trauma, 71,018 veterans (mean age +/- SD, % male) were included in the final cohort, which was followed from FY2007-FY2014 to evaluate the influence of subsequent annual foot exams and incident LEA. Consistent annual foot exams were protective for incident LEA in older veterans with diabetes, adjusted OR was 0.85 (97% CI: 0.74-0.96). Results indicate that adherence to annual foot exam guidelines can reduce incident LEA in older veterans with diabetes.

Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis

AIMS/HYPOTHESIS

This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020.

METHODS

Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated.

RESULTS

23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men.

CONCLUSIONS

Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.

Temporal trends in patients with peripheral artery disease influenced by diabetes mellitus in Germany

INTRODUCTION

In patients with peripheral artery disease (PAD) the presence of diabetes mellitus (DM) is associated with higher morbidity and mortality. Because huge efforts are made to improve medical care of patients with DM including chronic disease programs, the aim of the present study was to investigate temporal trends regarding the clinical burden of DM on PAD patients within a 15-year observational period.

METHODS

We analyzed all patients hospitalized because of PAD between 2005 and 2019 in Germany stratified regarding DM.

RESULTS

Overall, 2 654 871 hospitalizations of PAD patients (865 823 with DM) were included. Hospitalizations based on PAD inclined from 142 778 in 2005 to 190 135 in 2019 (β 3956 per year; 95% confidence interval [CI] 3034-4878, p < .001) with simultaneous increase of hospitalizations of PAD patients with DM (2005: 41609 (29.1%) versus 2019: 65 302 (34.3%); β 2019 per year [95% CI 1593-2446], p < .001). Amputation rates (β -0.42 [95% CI -0.44 to -0.40]; p < .001) as well as in-hospital case-fatality rate (2005: 4.7%, 2019: 2.8%; β -0.64 [95% CI -0.69 to -0.59]; p < .001) decreased in diabetic PAD patients during the observational time. In spite of improved morbidity and mortality in the last years of the observational period, patients with DM still suffered from an increased risk for morbidity and mortality during the observational period compared to nondiabetic PAD patients.

CONCLUSIONS

Despite the progress in DM treatments, DM still was associated with an unfavorable clinical patient profile and remained a substantial risk factor for morbidity and mortality in hospitalized patients with PAD and DM in Germany between 2005 and 2019.

Incidence of interventions for diabetic retinopathy and serious lower-limb complications and its related factors in patients with type 2 diabetes using a real-world large claims database

Aims

To examine the incidence of interventions for diabetic retinopathy and serious limb complications and to elucidate the patient attributes related to the incidence of each intervention based on real-world claims data from Japan.

Materials and methods

A retrospective longitudinal study design involving a 9 year (2009-2018) claims database obtained from the JMDC Inc. Patients with type 2 diabetes aged 20-74 years taking antidiabetic medications were divided into two groups: "patients with newly initiated antidiabetic medication" (Group 1, n = 47,201) and "patients with continuing antidiabetic medication" (Group 2, n = 82,332). The incidence rate for each intervention was analyzed. We also divided Group 1 into the former and latter periods and investigated temporal changes.

Results

The incidences of the first retinopathy intervention (laser photocoagulation, vitrectomy, or intraocular injection), vitrectomy, and lower-limb amputations in Group 1 were 7.46, 2.37, and 0.31 /1000 person-years, respectively. Those in Group 2 were about 1.2-1.5 times higher. Older age, insulin use, and being dependents rather than insured persons were associated with a higher incidence in both groups after adjustment. While the incidence of the interventions for retinopathy hardly changed during the observation period, that of lower-limb amputations decreased by 40%, with less statistical significance (p = 0.11).

Conclusions

We showed the incidences of the first retinopathy interventions and lower-limb amputations and their secular trends in patients with diabetes, stratified by whether the antidiabetic medication was newly initiated or not. Older age, insulin use, and being dependents were risk factors of these interventions for diabetic complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13340-021-00566-7.

Diabetes Mellitus and Its Impact on Patient-Profile and In-Hospital Outcomes in Peripheral Artery Disease

BACKGROUND

In patients with peripheral artery disease (PAD), the impact of diabetes mellitus (DM) on patient-profile and adverse in-hospital events is not well investigated.

METHODS

The German nationwide inpatient sample 2005-2019 was used for this analysis. Hospitalized PAD patients were stratified for DM and the influence of DM on patient-profile and adverse in-hospital events was investigated.

RESULTS

Our study comprised 2,654,871 hospitalizations (54.3% aged ≥70 years, 36.7% females) of patients with PAD in Germany 2005-2019. Among these, 864,691 (32.6%) patients had DM and 76,716 (2.9%) died during hospitalization. Diabetic PAD patients revealed an aggravated cardiovascular profile (Charlson Comorbidity Index: 6.0 (5.0-8.0) vs. 4.0 (3.0-5.0), p < 0.001). PAD patients with DM showed a higher rate of in-hospital mortality (3.5% vs. 2.6%, p < 0.001), as well as major adverse cardiovascular and cerebrovascular events (MACCE, 4.7% vs. 3.3%, p < 0.001) and had more often operated with amputation surgery (16.4% vs. 9.1%, p < 0.001). DM was an independent predictor of in-hospital mortality (OR 1.077 (95%CI 1.060-1.093), p < 0.001) and MACCE (OR 1.118 (95%CI 1.103-1.133), p < 0.001). In addition, amputations were also associated with DM (OR 1.804 (95%CI 1.790-1.818)), p < 0.001).

CONCLUSIONS

DM is associated with an unfavorable clinical patient-profile and higher risk for adverse events in PAD patients, including substantially increased in-hospital mortality as well as MACCE rate, and were more often associated with amputation surgeries.