Postoperative Death After Lower-Limb Amputation in a National Prevalent Cohort of Patients With Diabetes

An investigation of allied health and medical clinicians' viewpoint on prosthetic rehabilitation and cognition

PURPOSE

To explore the factors that influence clinicians (occupational therapists, physiotherapists, vascular surgeons, and rehabilitation medicine physicians) when prescribing prosthetic rehabilitation. Additionally, the study aimed to gain insight into clinicians' perspectives regarding the role of patient cognition in prosthetic rehabilitation.

MATERIALS AND METHODS

This research constitutes one segment of a broader action research study which was undertaken in 2022. A total of thirty-four key clinicians involved in the amputation and prosthetic rehabilitation pathway within a local health district in Australia were engaged through a combination of group and individual interviews as well as surveys.

RESULTS

Five essential considerations when prescribing prosthetic rehabilitation emerged. These included patient's goals, medical history, quality of life, cognitive abilities, and the support available on discharge. This study also revealed variations in opinions among different disciplines concerning appropriateness of prosthetic rehabilitation for the patient cohort. Despite this, there was a desire to build a consensus around a shared approach of identification for patients and clinicians.

CONCLUSION

The identification of these key pillars for clinician consideration has simplified a complex area of care. These pillars could be used to guide pertinent conversations regarding prosthetic rehabilitation and are closely linked with the patient's cognition.

The Decision for Amputation Versus Limb Salvage in Patients with Limb-threatening Lower Extremity Indications: An Ethical Analysis

Ethical decision-making in the amputation versus limb salvage context requires consideration of respect for patient autonomy, beneficence, and nonmaleficence. The surgical options demonstrate near equivalent outcomes for traumatic indications, while reconstruction is generally favored for threatened limbs due to diabetic complications. The decision for amputation versus limb salvage must be considered in each individual patient's situation, with a shared decision-making process of paramount importance. Discussion should involve the best, worst, and most likely case for each surgical option to allow the patient to better understand the range of potential postoperative courses and make an informed decision.

Association Between the Diabetes mellitus Duration and the Severity of Diabetic Foot Disease in Hospitalized Patients in Latin America

The objective was to determine the association between a diabetes mellitus duration greater than 10 years and the severity of diabetic foot in hospitalized patients in Latin America.Analytical, observational, and retrospective study based in secondary databases. Patients older than 18 years with diagnosis of diabetes mellitus (DM) and hospitalized for any causes were included. The independent and dependent variables were having more than 10 years of diagnosis of DM and the severity of the diabetic foot disease (Wagner> = 2), respectively. A crude Poisson regression analysis was performed to obtain prevalence rates adjusted to confounders.Male gender was 54.8% and the median age was 62 years. In the group with more than10 years of disease (n = 903) 18% (n = 162) had severe injuries. We performed two Poisson regression analyzes, one of which included the entire sample; and in the other, only patients with some degree of ulcer were included at the time of evaluation (Wagner > = 1). In the first analysis the PR was 1.95 (p < 0.01) adjusted for the significant variables in the bivariate analysis and in the second analysis the PR was 1.18 (p < 0.01) adding to the adjustment the days of injury prior to hospitalization and the location of the ulcer.We conclude that in patients with more than 10 years of diabetes mellitus, diabetic foot injuries are more severe, regardless type of diabetes, gender, age, history of amputation and days of injury prior to hospitalization for inpatients in Latin America.

User perceptions of intelligent offloading diabetic footwear

Aims

Adherence to therapeutic footwear is vital for effective diabetic foot ulcer prevention and treatment. Understanding the key adherence factors and potential barriers is important for footwear design and implementation. Our team is creating intelligent offloading footwear to prevent lower extremity amputations in people living with diabetes (PLwD). This exploratory study assessed the ability of the established Unified Theory of Acceptance and Use of Technology (UTAUT) model to predict behavioral intention to use or recommend this intelligent offloading footwear by PLwD, caregivers of PLwD, or medical professionals treating PLwD.

Methods

Online and paper questionnaires were implemented to assess the impact of the UTAUT model factors (performance expectancy, effort expectancy, social influence, facilitating conditions) and psychosocial factors (attitude, anxiety, self-efficacy) on the overall behavioral intention to use the footwear. Furthermore, factors influencing potential acceptance and rejection of the footwear were explored.

Results

Patients (4.0/5) and medical professionals (4.1/5) showed a behavioral intention to "agree" to use or recommend the footwear when it becomes available. Structural equation modeling showed that the UTAUT constructed model may not be the best indicator for behavioral intention here based on a lack of statistical significance. However, the logistic regression modeling showed that the social influence for PLwD (p=0.004) and the attitude toward the footwear for medical professionals (p=0.001) may be the most important when designing and implementing the footwear, though several other factors (performance expectancy, effort expectancy, facilitating conditions, and self-efficacy) were also important for one or both of these populations. Additionally, cost and clinician support were shown to be important factors influencing potential acceptance of the footwear.

Conclusions

The study found promising intention to use the intelligent footwear in the future. This highlights the need to continue future development and implementation of the footwear to incorporate these results, thus improving the likelihood of high adherence of the footwear.

Disparities in perioperative mortality outcomes between First Nations and non-First Nations peoples in Australia: protocol for a systematic review and planned meta-analysis

BACKGROUND

Health inequities persist among First Nations people living in developed countries. Surgical care is pivotal in addressing a significant portion of the global disease burden. Evidence regarding surgical outcomes among First Nations people in Australia is limited. The perioperative mortality rate (POMR) indicates timely access to safe surgery and predicts long-term survival after major surgery. This systematic review will examine POMR among First Nations and non-First Nations peoples in Australia.

METHODS

A systematic search strategy using MEDLINE, Embase, Emcare, Global Health, and Scopus will identify studies that include First Nations people and non-First Nations people who underwent a surgical intervention under anaesthesia in Australia. The primary focus will be on documenting perioperative mortality outcomes. Title and abstract screening and full-text review will be conducted by independent reviewers, followed by data extraction and bias assessment using the ROBINS-E tool. Meta-analysis will be considered if there is sufficient homogeneity between studies. The quality of cumulative evidence will be evaluated following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria.

DISCUSSION

This protocol describes the comprehensive methodology for the proposed systematic review. Evaluating disparities in perioperative mortality rates between First Nations and non-First Nations people remains essential in shaping the discourse surrounding health equity, particularly in addressing the surgical burden of disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021258970.

The Incidence and Outcomes of Major Limb Amputation in New Zealand from 2010 to 2021

Background: Major limb amputation (MLA) can be a common outcome due to severe peripheral artery disease (PAD) and diabetic foot disease (DFD), and it carries a significant mortality burden. In New Zealand (NZ), there is little documentation of the incidence rate and mortality after MLA. The aim was to report the national crude and standardised rates and the mortality post MLA. Methods: This retrospective observational study included all MLAs that occurred within NZ from 1/1/2010 to 31/12/2021 due to DFD and/or PAD. Two national databases (National Minimum Dataset and the Australasian Vascular Audit) were utilised. The crude rates were calculated as cases per 100,000 in the NZ population per year including all ages (using the 2013 and 2018 NZ census figures). The age-standardised rates used the World Health Organization standard population. Post-operative mortality was calculated from the date of first hospitalisation for MLA. Results: From 2010 to 2021, there were 5293 MLA procedures in 4242 patients. On average, there were 8.5 MLAs per week and 441.1 MLAs annually. The overall crude rate was 9.44 per 100,000, and the standardised rate was 6.12 per 100,000. Over the 12 years, the crude rate decreased by 22% (p < 0.001), and the standardised rate decreased by 20.4% (p < 0.001). After MLA, the 30-day and 1-year mortality was 9.5% and 29.6%, respectively. From 2010 to 2021, the relative reduction in 30-day mortality was 45.1% (p < 0.001), and the reduction in 1-year mortality was 24.5% (p < 0.001). Increasing age, female sex and end-stage renal failure were predictors of 30-day and 1-year mortality. Conclusions: A considerable number of MLAs occur in NZ, with substantial perioperative mortality; however, the national incidence rates and mortality have improved over the last 12 years. This data might serve as benchmark to further reduce MLAs and improve patient outcomes.

Comprehensive Factors for Predicting the Complications of DiabetesMellitus: A Systematic Review

BACKGROUND

This article focuses on extracting a standard feature set for predicting the complications of diabetes mellitus by systematically reviewing the literature. It is conducted and reported by following the guidelines of PRISMA, a well-known systematic review and meta-analysis method. The research articles included in this study are extracted using the search engine "Web of Science" over eight years. The most common complications of diabetes, diabetic neuropathy, retinopathy, nephropathy, and cardiovascular diseases are considered in the study.

METHOD

The features used to predict the complications are identified and categorised by scrutinising the standards of electronic health records.

RESULT

Overall, 102 research articles have been reviewed, resulting in 59 frequent features being identified. Nineteen attributes are recognised as a standard in all four considered complications, which are age, gender, ethnicity, weight, height, BMI, smoking history, HbA1c, SBP, eGFR, DBP, HDL, LDL, total cholesterol, triglyceride, use of insulin, duration of diabetes, family history of CVD, and diabetes. The existence of a well-accepted and updated feature set for health analytics models to predict the complications of diabetes mellitus is a vital and contemporary requirement. A widely accepted feature set is beneficial for benchmarking the risk factors of complications of diabetes.

CONCLUSION

This study is a thorough literature review to provide a clear state of the art for academicians, clinicians, and other stakeholders regarding the risk factors and their importance.

Mouse models of diabetes-related ulcers: a systematic review and network meta-analysis

BACKGROUND

Diabetic foot ulcers (DFUs) are a common complication of diabetes, associated with important morbidity. Appropriate animal models of DFUs may improve drug development, and subsequently the success rate of clinical trials. However, while many models have been proposed, they are extremely heterogeneous, and no standard has emerged. We thus propose a systematic review with a network meta-analysis (NMA) to gather direct and indirect evidence, and compare the different mouse models of diabetes-related ulcers.

METHODS

The systematic search was performed in Pubmed and Embase. The main outcomes were wound size measurement at days 3, 7, 11 and 15 (±1 day). The risk of bias and methodological quality of all included studies was assessed by using the Systematic Review Center for Laboratory animal Experimentation (SYRCLE) risk of bias tool. Meta-regressions were done on prespecified variables, including mouse strain, type of ulcer, sex, age, and use of a splint.

FINDINGS

We included 295 studies. Among all models, only db/db, ob/ob, streptozotocin (STZ), and STZ + high fat diet mice showed a significantly delayed wound healing, compared with controls, at each time point. Age, sex and ulcer type had influence on wound healing, although not at all time points.

INTERPRETATION

In conclusion, the db/db model is associated with the largest delay in wound healing The STZ model also exhibits significantly decreased wound healing. STZ + high fat diet and ob/ob mice may also be relevant models of diabetes-related ulcers, although the results rely on a more limited number of studies.

FUNDING

This work was funded by the Agence Nationale de la Recherche (grant ANR-18-CE17-0017).

Predictive Factors for Mortality Following Major Lower Extremity Amputation

BACKGROUND

Despite advances in techniques and care, major amputation bears a high risk for mortality. Previously identified factors associated with increased risk of mortality include amputation level, renal function, and pre-operative white cell count.

METHODS

A single center retrospective chart review was conducted identifying patients who had undergone a major amputation. Chi-squared, t-testing, and Cox proportional hazard modeling were performed examining death at 6 months and 12 months.

RESULTS

Factors associated with an increased risk of six-month mortality include age (OR 1.01-1.05, P < .001), sex (OR 1.08-3.24, P < .01), minority race (OR 1.18-18.19, P < .01), chronic kidney disease (OR 1.40-6.06, P < .001), and use of pressors at the induction of anesthesia for index amputation (OR 2.09-7.85, P < .000). Factors associated with increased risk of 12 month mortality were similar.

DISCUSSION

Patients undergoing major amputation continue to suffer high mortality. Those patients who received their amputation under physiologically stressful conditions were more likely to die within 6 months. Reliably predicting six-month mortality can assist surgeons and patients in making appropriate care decisions.

Indications for and outcomes of major lower limb amputations at a tertiary-referral centre in Australia

OBJECTIVES

Major amputations are classically associated with significant morbidity and mortality. With the increasing prevalence of risk factors for amputation, namely, diabetes and peripheral arterial disease, we sought to identify the major indications for lower limb amputation in an Australian cohort. A secondary aim was to assess the outcomes, namely, mortality, of amputees over the previous decade.

METHODS

This study assessed all patients undergoing major lower limb amputations between 2012 and 2020. Variables analysed included comorbidities, indication for amputation, in-hospital complications and mortality, duration of hospital stay, and out-patient mortality.

RESULTS

317 amputations were performed on 269 patients. 55% of amputations were below knee, 45% above knee, with one through-knee amputation. Indications included ischaemia (55.2%), infection (30.6%), malignancy (6.9%), trauma (4.4%), and chronic pain or instability (2.5%). In-patient mortality rate was 7.6%, with mortality rates of 21.5% at one year, and 70.1% at 10 years. Post-operative complications occurred in 43% of amputations. Rural, regional, and remote (RRR) patients did not suffer disproportionately from major amputations, however, were more likely to require amputations for ischaemia. Patients undergoing amputation for infective causes demonstrated lower mid-term mortality rates compared to those undergoing amputations for ischaemia (56.1 vs 60.4% at 5 years, p = 0.007).

CONCLUSION

Major amputations continue to be associated with significant morbidity and mortality, both in the short and long term. Patients undergoing amputations for ischaemic causes demonstrate poorer outcomes than their infective counterparts, with outcomes being even worse in RRR populations. Prevention of amputations via intense management of comorbidities would benefit both patients and the healthcare system.

Cost-effectiveness of guideline-based care provision for patients with diabetes-related foot ulcers: A modelled analysis using discrete event simulation

AIMS

The provision of guideline-based care for patients with diabetes-related foot ulcers (DFU) in clinical practice is suboptimal. We estimated the cost-effectiveness of higher rates of guideline-based care, compared with current practice.

METHODS

The costs and quality-adjusted life-years (QALYs) associated with current practice (30% of patients receiving guideline-based care) were compared with seven hypothetical scenarios with increasing proportion of guideline-based care (40%, 50%, 60%, 70%, 80%, 90% and 100%). Comparisons were made using discrete event simulations reflecting the natural history of DFU over a 3-year time horizon from the Australian healthcare perspective. Incremental cost-effectiveness ratios were calculated for each scenario and compared to a willingness-to-pay of AUD 28,000 per QALY. Probabilistic sensitivity analyses were conducted to incorporate joint parameter uncertainty.

RESULTS

All seven scenarios with higher rates of guideline-based care were likely cheaper and more effective than current practice. Increased proportions compared with current practice resulted in between AUD 0.28 and 1.84 million in cost savings and 11-56 additional QALYs per 1000 patients. Probabilistic sensitivity analyses indicated that the finding is robust to parameter uncertainty.

CONCLUSIONS

Higher proportions of patients receiving guideline-based care are less costly and improve patient outcomes. Strategies to increase the proportion of patients receiving guideline-based care are warranted.

Contribution of diabetes to amputations in sub-Sahara Africa: A systematic review and meta-analysis

Diabetes related amputations remain a major global problem, with devastating complications. We critically appraised relevant literature to quantify the prevalence of diabetes related amputations in sub-Saharan Africa (SSA). An electronic search was performed using the EMBASE and PubMed databases until 2020. Twenty-four out of 834 studies retrieved were included. The pooled prevalence of diabetic-related amputations was 36.9% (95%CI: 32.9%-40.8%). Complications of diabetes related amputations included infection, anaemia, foot deformity and mortality. The study revealed a substantial contribution of diabetes to the burden of amputations in SSA and suggests the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of macro and microvascular complications of diabetes in SSA.

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.

Regional variation in post-operative mortality in New Zealand

BACKGROUND

There is a growing body of evidence that access to best practice perioperative care varies within our population. In this study, we use national-level data to begin to address gaps in our understanding of regional variation in post-operative outcomes within New Zealand.

METHODS

Using National Collections data, we examined all inpatient procedures in New Zealand public hospitals between 2005 and 2017 (859 171 acute, 2 276 986 elective/waiting list), and identified deaths within 30 days. We calculated crude and adjusted rates per 100 procedures for the 20 district health boards (DHBs), both for the total population and stratified by ethnicity (Māori/European). Odds ratios comparing the risk of post-operative mortality between Māori and European patients were calculated using crude and adjusted Poisson regression models.

RESULTS

We observed regional variations in post-operative mortality outcomes. Māori, compared to European, patients experienced higher post-operative mortality rates in several DHBs, with a trend to higher mortality in almost all DHBs. Regional variation in patterns of age, procedure, deprivation and comorbidity (in particular) largely drives regional variation in post-operative mortality, although variation persists in some regions even after adjusting for these factors. Inequitable outcomes for Māori also persist in several regions despite adjustment for multiple factors, particularly in the elective setting.

CONCLUSIONS

The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors suggests that multiple regions require additional resource and support to improve outcomes. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region-specific intervention.

Diabetes-related foot disease research in Aotearoa New Zealand: a bibliometric analysis (1970-2020)

Background

The aim of this bibliometric study was to examine trends in the quality and quantity of published diabetes-related foot disease (DRFD) research in Aotearoa/New Zealand (NZ) over the past five decades.

Method

In July 2021, the Scopus® database was searched for DRFD-related publications (1970–2020) using predetermined search and inclusion criteria. Bibliometric data were extracted from Scopus® and Journal Citation Reports. Retrieved bibliometric indicators were analysed in Biblioshiny, an R Statistical Software interface and reported using descriptive statistics.

Results

Forty-seven DRFD-related articles were identified. The annual number of publications showed a significant upward trend increasing from one in 1988 to a peak of six in 2018 (P < 0.001). The majority of identified articles (n = 31, 66%) were published in the last decade (2011–2020). Basic/clinical research accounted for 87% (n = 41) of publications and 14 (30%) investigated the screening and/or prevention of DRFD. The average citation per article was 20.23 (range: 0–209) and the median impact factor was 4.31 (range, 1.82–79.32). Over a third of articles (36%) had an international authorship network. Funding was reported in 15 (32%) articles; 12 (26%) were supported by public national grants vs. three (6%) reporting industry-sponsorship.

Conclusion

DRFD articles authored by NZ researchers have increased over the past five decades. Despite NZ researchers having increased their global impact through collaborative networks, most of the research was classified as low-level evidence, with limited focus on Indigenous Māori and limited financial support and funding. Increased funding for interventional research is required to enable a higher level of evidence-based and practice-changing research to occur. With rates of diabetes-related amputations higher in Māori future research must focus on reducing inequalities in diabetes-related outcomes for Māori by specifically targeting the prevention and screening of DRFD in primary care settings in NZ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00528-5.

Trends of Non-Traumatic Lower-Extremity Amputation and Type 2 Diabetes: Spain, 2001-2019

(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.

Oxygen-Releasing Composites: A Promising Approach in the Management of Diabetic Foot Ulcers

In diabetes, lower extremity amputation (LEA) is an irreversible diabetic-related complication that easily occurs in patients with diabetic foot ulcers (DFUs). Because DFUs are a clinical outcome of different causes including peripheral hypoxia and diabetic foot infection (DFI), conventional wound dressing materials are often insufficient for supporting the normal wound healing potential in the ulcers. Advanced wound dressing development has recently focused on natural or biocompatible scaffolds or incorporating bioactive molecules. This review directs attention to the potential of oxygenation of diabetic wounds and highlights current fabrication techniques for oxygen-releasing composites and their medical applications. Based on different oxygen-releasable compounds such as liquid peroxides and solid peroxides, for example, a variety of oxygen-releasing composites have been fabricated and evaluated for medical applications. This review provides the challenges and limitations of utilizing current oxygen releasable compounds and provides perspectives on advancing oxygen releasing composites for diabetic-related wounds associated with DFUs.

Incidence and Predictors of Surgical Site Infection Complications in Diabetic Patients Undergoing Lower Limb Amputation

BACKGROUND

Surgical site infections (SSIs) following lower extremity amputations (LEAs) are a major cause of patient morbidity and mortality. The objectives of this study are to investigate the annual incidence of SSI and risk factors associated with SSI after LEA in diabetic patients.

METHODS

LEAs performed on diabetic patients between 2005 and 2017 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Incidence rates were calculated and analyzed for temporal change. Multivariable logistic regression was conducted to identify the independent predictors of SSIs in LEA.

RESULTS

In 21,449 diabetic patients, the incidence of SSIs was 6.8% after LEA, with an overall decreasing annual trend (P = 0.013). Amputation location (below-knee in reference to above-knee) [OR (95% CI): 1.35 (1.20 - 1.53), P <0.001], smoking [OR (95% CI): 1.25 (1.11 - 1.41), P <0.001)], female sex [OR (95% CI): 1.16 (1.03 - 1.30)], preoperative sepsis [OR (95% CI): 1.24 (1.10 - 1.40), P <0.001], P = 0.013], emergency status [OR (95% CI): 1.38 (1.17 - 1.63), P <0.001], and obesity [OR (95% CI): 1.59 (1.12 - 2.27), P = 0.009] emerged as independent predictors of SSIs, while moderate/severe anemia emerged as a risk-adjusted protective factor [OR (95% CI): 0.75 (0.62 - 0.91), P = 0.003]. Sensitivity analysis found that moderate/severe anemia, not body mass index (BMI) class, remained a significant risk factor in the development of SSIs in below-the-knee amputations; in contrast, higher BMI, not preoperative hematocrit, was significantly associated with an increased risk for SSI in above-the-knee amputations.

CONCLUSIONS

The incidence of SSIs after LEA in diabetic patients is decreasing. Overall, below-knee amputation, smoking, emergency status, and preoperative sepsis appeared to be associated with SSIs. Obesity increased SSIs in above-the-knee amputations, while moderate/severe preoperative anemia appears to protect against below-the-knee SSIs. Surgeons should take predictors of SSI into consideration while optimizing care for their patients, and future studies should investigate the role of preoperative hematocrit correction and how it may influence outcomes positively or negatively.

Racial differences in all-cause mortality and future complications among people with diabetes: a systematic review and meta-analysis of data from more than 2.4 million individuals

AIMS/HYPOTHESIS

The aim of this work was to quantify racial/ethnic differences in risk for future diabetic complications and all-cause mortality by performing a meta-analysis of prospective studies.

METHODS

A systematic search in PubMed and EMBASE was performed from inception to May 2021. Prospective cohort studies that reported HRs and associated 95% CIs of diabetes complications and all-cause mortality among racial/ethnic groups, with White people as the reference group, were included. Study characteristics and HR estimates were extracted from each study. Estimates were pooled using random-effects inverse-variance model with the Hartung-Knapp-Sidik-Jonkman variance estimator.

RESULTS

A total of 23 studies were included, comprising 2,416,516 individuals diagnosed with diabetes (White 59.3%, Black 11.2%, Asian 1.3%, Hispanic-American 2.4%, Native American 0.2%, East Asian 1.9%, South Asian 0.8%, Pacific Islander 2.3%, Māori 2.4% and others 18.2%). Compared with White individuals with diabetes, individuals of Māori ethnicity were at higher risk for all-cause mortality (HR 1.88 [95% CI 1.61, 2.21]; I² = 7.1%), Hispanic-American individuals had a significantly lower risk for CVD (HR 0.66 [95% CI 0.53, 0.81]; I² = 0%) and Black individuals had higher risk for end-stage renal disease (HR 1.54 [95% CI 1.05, 2.24]; I² = 95.4%). No significant higher risk for diabetes complications was found in other racial/ethnic groups relative to White people.

CONCLUSIONS/INTERPRETATION

Racial/ethnic differences exist in the risk for future diabetic complications and all-cause mortality. Our results support the use of such categories for international diabetes clinical guideline recommendations until better predictors become available. Efforts to identify high-risk groups and to better control cardiovascular risk factors across ethnically diverse populations are therefore needed.

REGISTRATION

PROSPERO registration ID CRD42021239274.

The Burden of Diabetes-Related Preventable Hospitalization: 11-Year Trend and Associated Factors in a Region of Southern Italy

(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.

Amputations of Lower Limb in Subjects with Diabetes Mellitus: Reasons and 30-Day Mortality

BACKGROUND

Diabetic foot is one of the leading causes of patient disability worldwide. Lower-extremity amputations (LEAs) resulting from this disease massively decrease quality of life, the function of the patient, and incur significant healthcare costs. The aim of this study was to assess trends in the number of amputations, the diagnosis at discharge, and diagnosis-related mortality after LEA procedures in a nationwide population.

METHODS

Datasets of the National Heath Fund containing information about all services within the public healthcare system in Poland, spanning the years 2010-2019, were analyzed. The source of data regarding mortality was the database of the Polish Ministry of Digital Affairs.

RESULTS

Between 2010 and 2019, the annual number of amputations in patients with diabetes increased significantly from 5,049 to 7,759 (p for trend < 0.000001). However, the number of amputations in patients with diabetes calculated as a number per 100,000 diabetics decreased significantly (p for trend < 0.0005) during this period. Amputations in patients with diabetes accounted for a majority of all amputations; the mean percentage of amputations in patients with diabetes was 68.6% of all amputations (from 61.1% in 2010 to 71.4% in 2019, p for trend < 0.0000001). The most common disease diagnosed at discharge after LEA in diabetic patients was diabetes itself. Vascular pathologies, such as soft-tissue/bone/joint infections and ulcerations, were the next most common. The 30-day mortality rate after LEA was rather high in patients with, as well as without, diabetes (depending on the cause for amputation 3.5-34% and 2.2-28.99%, respectively).

CONCLUSIONS

The number of LEA in patients with diabetes in Poland increased substantially between 2010 and 2019 along with an increasing number of diabetics. Vascular pathologies, infections, and ulcerations were the most common causes of LEA. The 30-day mortality rate after amputation was rather high and varied depending on the diagnoses at discharge.

Reduction in Diabetes-Related Major Amputation Rates After Implementation of a Multidisciplinary Model: An Evaluation in Alberta, Canada

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.

Postoperative Mortality of Indigenous Populations Compared With Nonindigenous Populations: A Systematic Review

Importance

A range of factors have been identified as possible contributors to racial/ethnic differences in postoperative mortality that are also likely to hold true for indigenous populations. Yet despite its severity as an outcome, death in the period following a surgical procedure is underresearched for indigenous populations.

Objective

To describe postoperative mortality experiences for minority indigenous populations compared with numerically dominant nonindigenous populations and examine the factors that drive any differences observed.

Evidence Review

This review was conducted according to PRIMSA guidelines and registered on PROSPERO. Articles were identified through searches of the Embase, Ovid MEDLINE, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases, with manual review of references and gray literature searches conducted. Eligible articles included those that reported associations between ethnicity/indigeneity and mortality up to 90 days following surgery and published in English between January 1, 1990, and March 26, 2019. Data on the study design, setting, participants (including indigeneity), and results were extracted. A modified Newcastle-Ottawa Quality Assessment Scale was used to determine study quality.

Findings

A total of 442 abstracts were screened, 92 articles were reviewed in full text, and 21 articles (from 20 studies) and 7 reports underwent data extraction. All included studies were cohort studies (3 prospective and the remainder retrospective) investigating a wide range of surgical procedures in the US, Australia, or New Zealand. Seven studies were from single facilities, while the remainder used data from national databases. Sample sizes ranged, with indigenous sample sizes ranging from 20 to 3052 patients and a number of studies reporting less than 10 indigenous deaths. The postoperative mortality experience for minority indigenous populations compared with the nonindigenous populations was mixed. There was evidence from several studies that indigenous populations may be more likely to die following cardiac procedures. However, the available evidence has overall poor study quality, with methods to identify the indigenous populations being a major limitation of most of the studies.

Conclusions and Relevance

Postoperative mortality experiences for indigenous populations should not be interpreted in isolation from the broader context of inequities across the health care pathway and must take into account the quality of data used for indigenous identification.

Medium-term outcomes of multi-disciplinary surgical management of non-ischemic diabetic heel ulcers

BACKGROUND

Heel ulcers in patients with peripheral neuropathy and diabetes pose a significant challenge to treating physicians. Infection spreading to the os calcis is associated with a poor prognosis. There is no consensus on which method of surgical treatments results in better outcomes. The aim of this study was to assess patients' survival, rate of ulcer healing following surgical treatment, along with limb salvage rate, time taken for healing, ulcer recurrence and patients' functional outcome after healing.

METHODS

We studied 29 patients (20 men, 9 women) presenting with diabetic neuropathic heel ulcers (30 feet) and no critical limb ischemia, were managed surgically in our unit and followed-up for a minimum of 12 months. We assessed their clinical and functional outcomes within a mean follow-up period of 28 months (12-83).

RESULTS

11 out of 29 patients died (38%) with mean duration of post op survival being 31months (range 4-70). 14 ulcers (50%) healed fully within a mean of 360 days (131-1676). Limb salvage was achieved in 29 feet (97%). Only 5 out of 17 patients with diabetic nephropathy (p value 0.016) and 9 out of 24 ulcers with calcaneal osteomyelitis (p value 0.044) achieved full ulcer healing. Ulcer recurrence rate was 36% (5/14) within 12 months of achieving ulcer healing. Six patients were able to return to independent walking in surgical shoes while 11 patients were mobilising using either a crutch or frame.

CONCLUSION

While excellent limb salvage can be anticipated from the outcome of surgically managed infected heel ulcers in patients with diabetes, complete healing can still be slow and unpredictable. Significant medical co-morbidities in these patients make them vulnerable to medium-term post-operative complication and survival.

Epidemiology of major lower extremity amputations in individuals with diabetes in Austria, 2014-2017: A retrospective analysis of health insurance database

AIMS

To describe the incidence, mortality, and trend of major lower extremity amputations (LEA) and to assess risk factors of all-cause mortality after major LEA in individuals with diabetes.

METHODS

Procedure codes of major LEA were extracted from the Austrian Health Insurance database (N = 507,180) during 2014-2017 to estimate crude and age-standardized rates per 100,000 population. Short- (30-day, 90-day) and long-term (1-year, 5-year) all-cause mortality after major LEA was estimated from the date of amputation till the date of death.

RESULTS

The age-standardized rate of major LEA was 6.44 with an insignificant annual change of 3% (p = 0.825) from 2014 to 2017. Cumulative 30-day mortality was 13.5%, 90-day 22.0%, 1-year 34.4%, and 5-year 66.7%. Age, male sex, above-knee amputation, Charlson index, and heart failure were significantly associated with both short- and long-term mortality. Cancer, dementia, heart failure, peripheral vascular disease, and renal disease were associated with long-term mortality.

CONCLUSIONS

The rate of major LEA in individuals with diabetes remained stable during 2014-2017 in Austria. Short- and long-term mortality rates were considerably high after major LEA. Old age, male sex, above-knee amputations, and Charlson Index were significant predictors of both short- and long-term mortality and comorbidities were significant predictors of long-term mortality only.

Major lower extremity amputations in a developing country: 10-Year experience at a tertiary medical center

BACKGROUND

Lower extremity amputation (LEA) is a major surgical procedure with a high risk of significant morbidity and mortality. The objective of this study was to describe mortality and functionality outcomes following this procedure in a developing country.

METHODS

This is a retrospective study of all patients undergoing LEA for non-traumatic etiology between 2007 and 2017. Medical records were used to retrieve demographics, comorbidities, and perioperative complications of identified patients. Patients were contacted to follow-up on their medical, postoperative care, and ambulatory status. Mortality and postoperative functionality rates were analyzed.

RESULTS

The study included 78 patients. Median follow-up duration was 24 months. Hypertension (81%) and diabetes (79%) were the most common comorbidities. Mortality rates at 30 days, 1, and 5 years were 10.3, 29.2, and 65.5%, respectively. Mortality was significantly associated with age > 70 at amputation (p = 0.042), hypertension (p = 0.003), chronic kidney disease (p = 0.031), and perioperative sepsis (p = 0.01). Only 1.6% of patients were discharged into a specialized care center, and only 27% of patients were ambulatory postoperatively, although 90.5% were fitted with a prosthesis.

CONCLUSIONS

Survival following major amputation in a developing country is currently comparable to more developed regions of the world. Major discrepancy seems to exist in ambulatory status following the procedure. Discharge placement policies should be properly set, and rehabilitation centers funding should be increased. Awareness may also be warranted to educate patients and families about the value and positive impact of rehabilitation centers.

Postoperative mortality in New Zealand following general anaesthetic: demographic patterns and temporal trends

OBJECTIVES

In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017.

DESIGN, PARTICIPANTS AND SETTING

We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period.

RESULTS AND CONCLUSION

A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.

High Levels of Oxidative Stress Create a Microenvironment That Significantly Decreases the Diversity of the Microbiota in Diabetic Chronic Wounds and Promotes Biofilm Formation

Diabetics chronic wounds are characterized by high levels of oxidative stress (OS) and are often colonized by biofilm-forming bacteria that severely compromise healing and can result in amputation. However, little is known about the role of skin microbiota in wound healing and chronic wound development. We hypothesized that high OS levels lead to chronic wound development by promoting the colonization of biofilm-forming bacteria over commensal/beneficial bacteria. To test this hypothesis, we used our db/db^−/− mouse model for chronic wounds where pathogenic biofilms develop naturally after induction of high OS immediately after wounding. We sequenced the bacterial rRNA internal transcribed spacer (ITS) gene of the wound microbiota from wound initiation to fully developed chronic wounds. Indicator species analysis, which considers a species' fidelity and specificity, was used to determine which bacterial species were strongly associated with healing wounds or chronic wounds. We found that healing wounds were colonized by a diverse and dynamic bacterial microbiome that never developed biofilms even though biofilm-forming bacteria were present. Several clinically relevant species that are present in human chronic wounds, such as Cutibacterium acnes, Achromobacter sp., Delftia sp., and Escherichia coli, were highly associated with healing wounds. These bacteria may serve as bioindicators of healing and may actively participate in the processes of wound healing and preventing pathogenic bacteria from colonizing the wound. In contrast, chronic wounds, which had high levels of OS, had low bacterial diversity and were colonized by several clinically relevant, biofilm-forming bacteria such as Pseudomonas aeruginosa, Enterobacter cloacae, Corynebacterium frankenforstense, and Acinetobacter sp. We observed unique population trends: for example, P. aeruginosa associated with aggressive biofilm development, whereas Staphylococcus xylosus was only present early after injury. These findings show that high levels of OS in the wound significantly altered the bacterial wound microbiome, decreasing diversity and promoting the colonization of bacteria from the skin microbiota to form biofilm. In conclusion, bacteria associated with non-chronic or chronic wounds could function as bioindicators of healing or non-healing (chronicity), respectively. Moreover, a better understanding of bacterial interactions between pathogenic and beneficial bacteria within an evolving chronic wound microbiota may lead to better solutions for chronic wound management.

Transmetatarsal amputation: A 12 year retrospective case review of outcomes

BACKGROUND

Diabetic foot pathology has rapidly increased, presenting a vast economic burden with severe implications for patients. Establishing effective limb salvage techniques such as transmetatarsal amputation is essential to offer viable alternatives to major limb amputation in severe foot infection, where outcomes are variable and mortality rates high.

METHODS

A retrospective review of outcomes was performed on patients who underwent TMA at a single United Kingdom hospital between 2005-2017. Healing rate and time to healing, mortality, duration of hospital admission and incidence of revision surgery was evaluated. Forty-seven patients had 54 TMA's by the Podiatric Surgery team. Data was assessed for Mean (SD) and Median. The impact of co-morbidities was considered and the perioperative and surgical management reviewed to identify techniques which may improve outcomes.

RESULTS

A 78% healing rate was achieved. Six patients (11%) died before healing. The aremaining 11% did not heal and resulted in major limb amputation. No further surgery to the same foot was required after the TMA healed. A Median healing time of 83 days was identified and the Median duration of hospital admission was 24 days. Adjunctive wound care products may to have a positive impact on these factors. Five-year mortality was 43%, and demonstrated an association with renal and/or vascular pathology. All patients had diabetes, with many also having Peripheral Vascular Disease (PVD). Almost all TMA's failing to heal had PVD. The presence and severity of renal disease also seemed to have a negative impact on wound healing.

CONCLUSION

Positive healing and mortality rates with low need for revision surgery support TMA to be an effective alternative to major limb amputation. Adjunctive agents may have a positive impact on wound healing and length of hospital admission. Skilled surgical technique and Multidisciplinary work is essential for positive long-term outcomes and cost-effective care.

Use Of Regional Anesthesia For Lower Extremity Amputation May Reduce The Need For Perioperative Vasopressors: A Propensity Score-Matched Observational Study

Purpose

Lower extremity amputation (LEA) is associated with a high risk of postoperative mortality. The effect of type of anesthesia on postoperative mortality has been studied in various surgeries. However, data for guiding the selection of optimal anesthesia for LEA are limited. This study aimed to determine the effect of anesthesia type on perioperative outcomes in patients with diabetes and/or peripheral vascular disease undergoing LEA.

Patients and methods

We reviewed the medical records of patients who underwent LEA at our center between September 2007 and August 2017, who were grouped according to use of general anesthesia (GA) or regional anesthesia (RA). Primary outcomes were 30-day and 90-day mortality. Secondary outcomes were postoperative morbidity, intraoperative events, postoperative intensive care unit admission, and postoperative length of stay. Propensity score-matched cohort design was used to control for potentially confounding factors, including patient demographics, comorbidities, medications, and type of surgery.

Results

Five hundred and nineteen patients (75% male, mean age 65 years) were identified to have received GA (n=227) or RA (n=292) for above-knee amputation (1.5%), below-knee amputation (16%), or more minor amputation (82.5%). Before propensity score matching, there was an association of GA with coronary artery disease (44% [GA] vs 34.5% [RA], p=0.028), peripheral arterial disease (73.1% vs 60.2%, p=0.002), and preoperative treatment with aspirin and clopidogrel (68.7% vs 55.1%, p=0.001; 63% vs 41.8%, p<0.001, respectively). Propensity score matching produced a cohort of 342 patients equally divided between GA and RA. There was no significant between-group difference in 30-day (3.5% vs 2.9%, p=0.737) or 90-day (6.4% vs 4.6%, p=0.474) mortality or postoperative morbidity. However, postoperative ICU admission (14.6% vs 7%, p=0.032), intraoperative hypotension (61.4% vs 14.6%, p<0.001), and vasopressor use (52% vs 14%, p<0.001) were more common with GA than with RA.

Conclusion

Type of anesthesia did not significantly affect mortality or morbidity after LEA. However, intraoperative hypotension, vasopressor use, and postoperative ICU admission rates were lower with RA.

Corneal confocal microscopy: ready for prime time

Corneal confocal microscopy is a non-invasive ophthalmic imaging modality, which was initially used for the diagnosis and management of corneal diseases. However, over the last 20 years it has come to the forefront as a rapid, non-invasive, reiterative, cost-effective imaging biomarker for neurodegeneration. The human cornea is endowed with the densest network of sensory unmyelinated axons, anywhere in the body. A robust body of evidence shows that corneal confocal microscopy is a reliable and reproducible method to quantify corneal nerve morphology. Changes in corneal nerve morphology precede or relate to clinical manifestations of peripheral and central neurodegenerative conditions. Moreover, in clinical intervention trials, corneal nerve regeneration occurs early and predicts functional gains in trials of neuroprotection. In view of these findings, it is timely to summarise the knowledge in this area of research and to explain why the case for corneal confocal microscopy is sufficiently compelling to argue for its inclusion as a Food and Drug Administration endpoint in clinical trials of peripheral and central neurodegenerative conditions.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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