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Wolf H, Singh N. Using Multidisciplinary Teams to Improve Outcomes for Treating Chronic-Limb Threatening Ischemia. Ann Vasc Surg 2024; 107:37-42. [PMID: 38604501 DOI: 10.1016/j.avsg.2023.11.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/23/2023] [Indexed: 04/13/2024]
Abstract
Multidisciplinary teams are necessary to treat complex patients with chronic limb-threatening ischemia (CLTI). The need for adequate wound care and control of comorbid conditions cannot be accomplished by the vascular specialist alone. Numerous specialties have a role in this group to include surgical podiatrists, orthopedic surgery, plastic and reconstructive surgery endocrinology, and wound care. However, the vascular specialist must drive this team as the patients are usually referred to them and numerous studies have shown a direct correlation between major amputations and the lack of vascular involvement. Creating these teams is unique in each community and must consider practice patterns that are relevant in the local region. CLTI is a challenging disease to manage, and multidisciplinary teams have demonstrated an ability to improve outcomes and deliver superior care to this patient population.
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Affiliation(s)
- Hannah Wolf
- University of Washington School of Medicine, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
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2
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Jupiter DC, Zhang Y, Shibuya N. Trajectories of Diabetes-Related Sequelae for Identifying Transition Probabilities, and Optimal Timepoints for Prevention of Ulceration, Infection, and Amputation. J Foot Ankle Surg 2024; 63:570-576. [PMID: 38876208 DOI: 10.1053/j.jfas.2024.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 03/30/2024] [Accepted: 05/25/2024] [Indexed: 06/16/2024]
Abstract
To reduce diabetes-related complications and to avoid futile procedures, foot and ankle surgeons need to understand the relative timings of catastrophic events, their incidence, and probabilities of transitions between disease states in diabetes in different patient populations. For this study, we tracked medical events (including an initial diagnosis of diabetes, ulcer, wound care, osteomyelitis, amputation, and reamputation, in order of severity) and the time between each such event in patients with diabetes, stratifying by sex, race, and ethnicity. We found that the longest average duration between the different lower extremity states was a diagnosis of diabetes to the occurrence of ulcer at 1137 days (38 months). The average durations of amputation to reamputation, osteomyelitis, wound care, and ulcer were 18, 49, 23, and 18 days, respectively. The length of each disease transition for females was greater, while those of the Hispanic population were shorter than in the total cohort. This knowledge may permit surgeons to time and tailor treatments to their patients, and help patients to address, delay, or avoid complications.
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Affiliation(s)
- Daniel C Jupiter
- Associate Professor, Department of Biostatistics and Data Science, Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, TX
| | - Yuanyi Zhang
- Senior Biostatistician, Department of Biostatistics and Data Science, The University of Texas Medical Branch, Galveston, TX
| | - Naohiro Shibuya
- Clinical Professor, University of Texas Rio Grande Valley, School of Podiatric Medicine, Harlingen, TX.
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3
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Li J, Varcoe R, Manzi M, Kum S, Iida O, Schmidt A, Shishehbor MH. Below-the-Knee Endovascular Revascularization: A Position Statement. JACC Cardiovasc Interv 2024; 17:589-607. [PMID: 38244007 DOI: 10.1016/j.jcin.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 10/30/2023] [Accepted: 11/28/2023] [Indexed: 01/22/2024]
Abstract
Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.
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Affiliation(s)
- Jun Li
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Ramon Varcoe
- Prince of Wales Hospital, Sydney, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Marco Manzi
- Interventional Radiology Unit, Foot and Ankle Clinic, Policlinico Abano Terme, Abano Terme, Italy
| | - Steven Kum
- Department of Surgery, Changi General Hospital, Singapore
| | - Osamu Iida
- Kasai Rosai Hospital Cardiovascular Center, Amagasaki, Japan
| | - Andrej Schmidt
- Division of Angiology, Department of Internal Medicine, Neurology and Dermatology, University Hospital Leipzig, Leipzig, Germany
| | - Mehdi H Shishehbor
- University Hospitals Harrington Heart and Vascular Institute, Cleveland, Ohio, USA; Case Western Reserve University School of Medicine, Cleveland, Ohio, USA.
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4
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Pennington E, Bell S, Hill JE. Should video laryngoscopy or direct laryngoscopy be used for adults undergoing endotracheal intubation in the pre-hospital setting? A critical appraisal of a systematic review. JOURNAL OF PARAMEDIC PRACTICE : THE CLINICAL MONTHLY FOR EMERGENCY CARE PROFESSIONALS 2023; 15:255-259. [PMID: 38812899 PMCID: PMC7616025 DOI: 10.1002/14651858] [Citation(s) in RCA: 2562] [Impact Index Per Article: 2562.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The safety and utility of endotracheal intubation by paramedics in the United Kingdom is a matter of debate. Considering the controversy surrounding the safety of paramedic-performed endotracheal intubation, any interventions that enhance patient safety should be evaluated for implementation based on solid evidence of their effectiveness. A systematic review performed by Hansel and colleagues (2022) sought to assess compare video laryngoscopes against direct laryngoscopes in clinical practice. This commentary aims to critically appraise the methods used within the review by Hansel et al (2022) and expand upon the findings in the context of clinical practice.
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Affiliation(s)
| | - Steve Bell
- Consultant Paramedic, North West Ambulance Service NHS Trust
| | - James E Hill
- University of Central Lancashire, Colne, Lancashire
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5
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Driver VR, Couch KS, Eckert KA, Gibbons G, Henderson L, Lantis J, Lullove E, Michael P, Neville RF, Ruotsi LC, Snyder RJ, Saab F, Carter MJ. The impact of the SARS-CoV-2 pandemic on the management of chronic limb-threatening ischemia and wound care. Wound Repair Regen 2021; 30:7-23. [PMID: 34713947 PMCID: PMC8661621 DOI: 10.1111/wrr.12975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/13/2021] [Accepted: 10/05/2021] [Indexed: 01/02/2023]
Abstract
In the wake of the coronavirus pandemic, the critical limb ischemia (CLI) Global Society aims to develop improved clinical guidance that will inform better care standards to reduce tissue loss and amputations during and following the new SARS‐CoV‐2 era. This will include developing standards of practice, improve gaps in care, and design improved research protocols to study new chronic limb‐threatening ischemia treatment and diagnostic options. Following a round table discussion that identified hypotheses and suppositions the wound care community had during the SARS‐CoV‐2 pandemic, the CLI Global Society undertook a critical review of literature using PubMed to confirm or rebut these hypotheses, identify knowledge gaps, and analyse the findings in terms of what in wound care has changed due to the pandemic and what wound care providers need to do differently as a result of these changes. Evidence was graded using the Oxford Centre for Evidence‐Based Medicine scheme. The majority of hypotheses and related suppositions were confirmed, but there is noticeable heterogeneity, so the experiences reported herein are not universal for wound care providers and centres. Moreover, the effects of the dynamic pandemic vary over time in geographic areas. Wound care will unlikely return to prepandemic practices. Importantly, Levels 2–5 evidence reveals a paradigm shift in wound care towards a hybrid telemedicine and home healthcare model to keep patients at home to minimize the number of in‐person visits at clinics and hospitalizations, with the exception of severe cases such as chronic limb‐threatening ischemia. The use of telemedicine and home care will likely continue and improve in the postpandemic era.
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Affiliation(s)
- Vickie R Driver
- Wound Healing, Limb Preservation and Hyperbaric Centers, Inova Heart and Vascular Institute Inova Health System, Falls Church, Virginia, USA
| | - Kara S Couch
- Wound Care Services, George Washington University Hospital, Washington, District of Columbia, USA
| | | | - Gary Gibbons
- Center for Wound Healing, South Shore Health, Weymouth, Massachusetts, USA.,Boston University School of Medicine, Boston, Massachusetts, USA
| | - Lorena Henderson
- PULSE Amputation Prevention Centers, Affiliates, El Paso Cardiology Associates, P.A., El Paso, Texas, USA
| | - John Lantis
- Mount Sinai West Hospital, Icahn School of Medicine, New York, New York, USA
| | - Eric Lullove
- West Boca Center for Wound Healing, Coconut Creek, Florida, USA
| | - Paul Michael
- Palm Beach Heart & Vascular, JFK Wound Management & Limb Preservation Center, Lake Worth, Florida, USA
| | - Richard F Neville
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.,Department of Surgery, Inova Health System, Falls Church, Virginia, USA
| | - Lee C Ruotsi
- Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, New York, USA
| | - Robert J Snyder
- Barry University School of Podiatric Medicine, Miami Shores, Florida, USA
| | - Fadi Saab
- Advanced Cardiac & Vascular Centers for Amputation Prevention, Grand Rapids, Michigan, USA
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Mahé G, Boge G, Bura-Rivière A, Chakfé N, Constans J, Goueffic Y, Lacroix P, Le Hello C, Pernod G, Perez-Martin A, Picquet J, Sprynger M, Behar T, Bérard X, Breteau C, Brisot D, Chleir F, Choquenet C, Coscas R, Detriché G, Elias M, Ezzaki K, Fiori S, Gaertner S, Gaillard C, Gaudout C, Gauthier CE, Georg Y, Hertault A, Jean-Baptiste E, Joly M, Kaladji A, Laffont J, Laneelle D, Laroche JP, Lejay A, Long A, Loric T, Madika AL, Magnou B, Maillard JP, Malloizel J, Miserey G, Moukarzel A, Mounier-Vehier C, Nasr B, Nelzy ML, Nicolini P, Phelipot JY, Sabatier J, Schaumann G, Soudet S, Tissot A, Tribout L, Wautrecht JC, Zarca C, Zuber A. Disparities Between International Guidelines (AHA/ESC/ESVS/ESVM/SVS) Concerning Lower Extremity Arterial Disease: Consensus of the French Society of Vascular Medicine (SFMV) and the French Society for Vascular and Endovascular Surgery (SCVE). Ann Vasc Surg 2021; 72:1-56. [DOI: 10.1016/j.avsg.2020.11.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 11/05/2020] [Indexed: 12/24/2022]
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7
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VAN DEN Berg JC, Driver VR, Holden A, Jaff MR, Lookstein RA, Mustapha JA, Neville RF, Zeller T, Katzen BT. Modern multidisciplinary team approach is crucial in treatment for critical limb threatening ischemia. THE JOURNAL OF CARDIOVASCULAR SURGERY 2021; 62:124-129. [PMID: 33496424 DOI: 10.23736/s0021-9509.21.11725-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The aim of this study was to provide a brief overview of the history the multidisciplinary team approach, highlighting the benefit to the patient with critical limb threatening ischemia in relation to health care economics. Furthermore, we provided a description of the requisites and key components, showing how to build a multidisciplinary team.
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Affiliation(s)
- Jos C VAN DEN Berg
- Centro Vascolare Ticino, Ospedale Regionale di Lugano, Lugano, Switzerland - .,Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital Bern, Bern, Switzerland -
| | - Vickie R Driver
- Department of Orthopedic Surgery, Brown University, Providence, RI, USA
| | - Andrew Holden
- Northern Region Interventional Radiology Service, Auckland City Hospital, Auckland, New Zealand
| | | | - Robert A Lookstein
- Department of Radiology, Ichan School of Medicine at Mount Sinai, New York, NY, USA
| | - Jihad A Mustapha
- Advanced Cardiac & Vascular Centers for Amputation Prevention, Grand Rapids, MI, USA
| | - Richard F Neville
- Department of Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum, Bad Krozingen, Germany
| | - Barry T Katzen
- Division of Interventional Radiology, Miami Cardiac and Vascular Institute, FIU Herbert Wertheim College of Medicine, Miami, FL, USA
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Nickinson ATO, Houghton JSM, Bridgwood B, Essop-Adam A, Nduwayo S, Payne T, Sayers RD, Davies RSM. The utilisation of vascular limb salvage services in the assessment and management of chronic limb-threatening ischaemia and diabetic foot ulceration: A systematic review. Diabetes Metab Res Rev 2020; 36:e3326. [PMID: 32314493 DOI: 10.1002/dmrr.3326] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/08/2019] [Accepted: 04/12/2020] [Indexed: 11/10/2022]
Abstract
Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.
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Affiliation(s)
- A T O Nickinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - J S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - B Bridgwood
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - A Essop-Adam
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - S Nduwayo
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - T Payne
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - R D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - R S M Davies
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
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9
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Duwayri YM, Woo K, Aiello FA, Adams JG, Ryan PC, Tracci MC, Hurie J, Davies MG, Shutze WP, McDevitt D, Lum YW, Sideman M, Zwolak RM. The Society for Vascular Surgery Alternative Payment Model Task Force report on opportunities for value-based reimbursement in care for patients with peripheral artery disease. J Vasc Surg 2020; 73:1404-1413.e2. [PMID: 32931874 DOI: 10.1016/j.jvs.2020.08.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 08/15/2020] [Indexed: 10/23/2022]
Abstract
The Society for Vascular Surgery Alternative Payment Model (APM) Taskforce document explores the drivers and implications for developing objective value-based reimbursement plans for the care of patients with peripheral arterial disease (PAD). The APM is a payment approach that highlights high-quality and cost-efficient care and is a financially incentivized pathway for participation in the Quality Payment Program, which aims to replace the traditional fee-for-service payment method. At present, the participation of vascular specialists in APMs is hampered owing to the absence of dedicated models. The increasing prevalence of PAD diagnosis, technological advances in therapeutic devices, and the increasing cost of care of the affected patients have financial consequences on care delivery models and population health. The document summarizes the existing measurement methods of cost, care processes, and outcomes using payor data, patient-reported outcomes, and registry participation. The document also evaluates the existing challenges in the evaluation of PAD care, including intervention overuse, treatment disparities, varied clinical presentations, and the effects of multiple comorbid conditions on the cost potentially attributable to the vascular interventionalist. Medicare reimbursement data analysis also confirmed the prolonged need for additional healthcare services after vascular interventions. The Society for Vascular Surgery proposes that a PAD APM should provide patients with comprehensive care using a longitudinal approach with integration of multiple key medical and surgical services. It should maintain appropriate access to diagnostic and therapeutic advancements and eliminate unnecessary interventions. It should also decrease the variability in care but must also consider the varying complexity of the presenting PAD conditions. Enhanced quality of care and physician innovation should be rewarded. In addition, provisions should be present within an APM for high-risk patients who carry the risk of exclusion from care because of the naturally associated high costs. Although the document demonstrates clear opportunities for quality improvement and cost savings in PAD care, continued PAD APM development requires the assessment of more granular data for accurate risk adjustment, in addition to largescale testing before public release. Collaboration between payors and physician specialty societies remains key.
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Affiliation(s)
- Yazan M Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta, Ga.
| | - Karen Woo
- University of California, Los Angeles, Los Angeles, Calif
| | | | | | | | | | - Justin Hurie
- Wake Forest School of Medicine, Winston-Salem, NC
| | - Mark G Davies
- University of Texas Health at San Antonio, San Antonio, Tex
| | | | | | - Ying Wei Lum
- The Johns Hopkins School of Medicine, Baltimore, Md
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10
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Abstract
Minimally invasive distal metatarsal diaphyseal osteotomy (DMDO) is an effective procedure for the treatment of complicated chronic diabetic foot ulcers under the heads of all lateral metatarsal bones (including the fifth). Resistant toe ulcers and recurrent pressure ulcers can be treated effectively by DMDO. For diabetic patients, the main advantages of this method are minimal surgical scars and tissue damage, immediately postoperative weight bearing, absence of osteosynthesis and consequent potential infection of metal fixation, reduction of the previous high plantar pressures by the restoration of a harmonic balanced forefoot arch, and rapid ulcer healing.
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Affiliation(s)
- Carlo Biz
- Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopedic and Traumatologic Clinic, University of Padova, Via Giustiniani 2, Padova 35128, Italy; GRECMIP-MIFAS (Groupe de Recherche et d'Etude en Chirurgie Mini-Invasive du Pied-Minimally Invasive Foot and Ankle Society), Merignac, France.
| | - Pietro Ruggieri
- Department of Surgery, Oncology and Gastroenterology DiSCOG, Orthopedic and Traumatologic Clinic, University of Padova, Via Giustiniani 2, Padova 35128, Italy
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11
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Hemingway J, Hoffman R, Starnes B, Quiroga E, Tran N, Singh N. The Impact of a Limb Preservation Service on the Incidence of Major Amputations for All Indications at a Level I Trauma Center. Ann Vasc Surg 2020; 70:43-50. [PMID: 32822759 DOI: 10.1016/j.avsg.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Multidisciplinary limb preservation services (LPS) have improved the care of patients with limb-threatening vascular disease. However, the impact of an LPS on major amputations for nonvascular etiologies is unknown. We sought to characterize the trends in major amputations performed at a level I trauma center following the institution of an LPS. METHODS A retrospective review of all patients undergoing amputation at a level I trauma center from January 2009 to December 2018 was performed. Patients were divided into 2 cohorts: those undergoing amputation pre-LPS (2009-2013) and post-LPS (2014-2018). Major amputations were defined as any amputation at or proximal to the below-knee level. Indications for amputation included chronic limb-threatening ischemia (CLTI), acute limb ischemia (ALI), trauma, infection, and revision amputations. RESULTS During the study period, 609 major amputations were performed, 490 pre-LPS and 119 post-LPS, representing a 76% reduction. Reductions were seen for every indication, including trauma (95%), ALI (90%), chronic infection (83%), revision (79%), CLTI (68%), and acute infection (62%). CONCLUSIONS Although previous work has validated the role of an LPS in advanced vascular disease, its value extends beyond vascular disease alone. The drastic reductions seen in the number of amputations performed for a variety of indications, including trauma and diabetic foot infections, further validate the use of a multidisciplinary LPS.
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Affiliation(s)
- Jake Hemingway
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA.
| | - Rachel Hoffman
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Benjamin Starnes
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Elina Quiroga
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Nam Tran
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
| | - Niten Singh
- Division of Vascular Surgery, Department of Surgery, University of Washington, Seattle, WA
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12
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Norman G, Westby MJ, Vedhara K, Game F, Cullum NA. Effectiveness of psychosocial interventions for the prevention and treatment of foot ulcers in people with diabetes: a systematic review. Diabet Med 2020; 37:1256-1265. [PMID: 32426913 DOI: 10.1111/dme.14326] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
AIM To identify and synthesize the evidence for the effectiveness of psychosocial interventions to promote the healing, and/or reduce the occurrence of, foot ulceration in people with diabetes. METHODS In March 2019 we searched CENTRAL, Medline, Embase and PsycInfo for randomized controlled trials of interventions with psychosocial components for people with diabetes. The primary outcomes of this review were foot ulceration and healing. We assessed studies using the Cochrane risk-of-bias tool, the TIDieR checklist and GRADE. We conducted narrative synthesis and random-effects meta-analysis. RESULTS We included 31 randomized controlled trials (4511 participants), of which most (24 randomized controlled trials, 4093 participants) were prevention studies. Most interventions were educational with a modest psychosocial component. Ulceration and healing were not reported in most studies; secondary outcomes varied. Evidence was of low or very low quality because of high risks of bias and imprecision, and few studies reported adherence or fidelity. In groups where participants had prior ulceration, educational interventions had no clear effect on new ulceration (low-quality evidence). Two treatment studies, assessing continuous pharmacist support and an intervention to promote understanding of well-being, reported healing but their evidence was also of very low quality. CONCLUSION Most psychosocial intervention randomized controlled trials assessing foot ulcer outcomes in people with diabetes were prevention studies, and most interventions were primarily educational. Ulcer healing and development were not well reported. There is a need for better understanding of psychological and behavioural influences on ulcer incidence, healing and recurrence in people with diabetes. Randomized controlled trials of theoretically informed interventions, which assess clinical outcomes, are urgently required. (PROSPERO registration: CRD42016052960).
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Affiliation(s)
- G Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M J Westby
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - K Vedhara
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - F Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - N A Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Research and Innovation Division, Manchester University Foundation NHS Trust, Manchester, UK
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Huizing E, Schreve MA, Kortmann W, Bakker JP, de Vries JPPM, Ünlü Ç. The effect of a multidisciplinary outpatient team approach on outcomes in diabetic foot care: a single center study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 60:662-671. [DOI: 10.23736/s0021-9509.19.11091-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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14
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Hicks CW, Canner JK, Karagozlu H, Mathioudakis N, Sherman RL, Black JH, Abularrage CJ. Quantifying the costs and profitability of care for diabetic foot ulcers treated in a multidisciplinary setting. J Vasc Surg 2019; 70:233-240. [DOI: 10.1016/j.jvs.2018.10.097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 10/13/2018] [Indexed: 01/22/2023]
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 746] [Impact Index Per Article: 149.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 719] [Impact Index Per Article: 143.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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Liu Z, Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2018; 10:CD010318. [PMID: 30328611 PMCID: PMC6517143 DOI: 10.1002/14651858.cd010318.pub3] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. People with DM are prone to developing foot ulcers and, if these do not heal, they may also undergo foot amputation surgery resulting in postoperative wounds. Negative pressure wound therapy (NPWT) is a technology that is currently used widely in wound care. NPWT involves the application of a wound dressing attached to a vacuum suction machine. A carefully controlled negative pressure (or vacuum) sucks wound and tissue fluid away from the treated area into a canister. A clear and current overview of current evidence is required to facilitate decision-making regarding its use. OBJECTIVES To assess the effects of negative pressure wound therapy compared with standard care or other therapies in the treatment of foot wounds in people with DM in any care setting. SEARCH METHODS In January 2018, for this first update of this review, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We identified six additional studies for inclusion in the review. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any brand of NPWT in the treatment of foot wounds in people with DM, irrespective of date or language of publication. Particular effort was made to identify unpublished studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. We presented and analysed data separately for foot ulcers and postoperative wounds. MAIN RESULTS Eleven RCTs (972 participants) met the inclusion criteria. Study sample sizes ranged from 15 to 341 participants. One study had three arms, which were all included in the review. The remaining 10 studies had two arms. Two studies focused on postamputation wounds and all other studies included foot ulcers in people with DM. Ten studies compared NPWT with dressings; and one study compared NPWT delivered at 75 mmHg with NPWT delivered at 125 mmHg. Our primary outcome measures were the number of wounds healed and time to wound healing.NPWT compared with dressings for postoperative woundsTwo studies (292 participants) compared NPWT with moist wound dressings in postoperative wounds (postamputation wounds). Only one study specified a follow-up time, which was 16 weeks. This study (162 participants) reported an increased number of healed wounds in the NPWT group compared with the dressings group (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.03 to 2.01; low-certainty evidence, downgraded for risk of bias and imprecision). This study also reported that median time to healing was 21 days shorter with NPWT compared with moist dressings (hazard ratio (HR) calculated by review authors 1.91, 95% CI 1.21 to 2.99; low-certainty evidence, downgraded for risk of bias and imprecision). Data from the two studies suggest that it is uncertain whether there is a difference between groups in amputation risk (RR 0.38, 95% CI 0.14 to 1.02; 292 participants; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision).NPWT compared with dressings for foot ulcersThere were eight studies (640 participants) in this analysis and follow-up times varied between studies. Six studies (513 participants) reported the proportion of wounds healed and data could be pooled for five studies. Pooled data (486 participants) suggest that NPWT may increase the number of healed wounds compared with dressings (RR 1.40, 95% CI 1.14 to 1.72; I² = 0%; low-certainty evidence, downgraded once for risk of bias and once for imprecision). Three studies assessed time to healing, but only one study reported usable data. This study reported that NPWT reduced the time to healing compared with dressings (hazard ratio (HR) calculated by review authors 1.82, 95% CI 1.27 to 2.60; 341 participants; low-certainty evidence, downgraded once for risk of bias and once for imprecision).Data from three studies (441 participants) suggest that people allocated to NPWT may be at reduced risk of amputation compared with people allocated to dressings (RR 0.33, 95% CI 0.15 to 0.70; I² = 0%; low-certainty evidence; downgraded once for risk of bias and once for imprecision).Low-pressure compared with high-pressure NPWT for foot ulcersOne study (40 participants) compared NPWT 75 mmHg and NPWT 125 mmHg. Follow-up time was four weeks. There were no data on primary outcomes. There was no clear difference in the number of wounds closed or covered with surgery between groups (RR 0.83, 95% CI 0.47 to 1.47; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision) and adverse events (RR 1.50, 95% CI 0.28 to 8.04; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision). AUTHORS' CONCLUSIONS There is low-certainty evidence to suggest that NPWT, when compared with wound dressings, may increase the proportion of wounds healed and reduce the time to healing for postoperative foot wounds and ulcers of the foot in people with DM. For the comparisons of different pressures of NPWT for treating foot ulcers in people with DM, it is uncertain whether there is a difference in the number of wounds closed or covered with surgery, and adverse events. None of the included studies provided evidence on time to closure or coverage surgery, health-related quality of life or cost-effectiveness. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making regarding the use of NPWT to treat foot wounds in people with DM.
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Affiliation(s)
- Zhenmi Liu
- West China Hospital, Sichuan UniversityWest China School of Public HealthChengduSichuanChina610041
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Robert J Hinchliffe
- St George's Healthcare NHS TrustSt George's Vascular Institute4th Floor, St James WingBlackshaw RoadLondonUKSW17 0QT
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Fran Game
- Derby Hospitals NHS Foundation TrustDepartment of Diabetes and EndocrinologyUttoxeter RoadDerbyUKDE22 3NE
| | - Nikki Stubbs
- St Mary's HospitalLeeds Community Healthcare NHS Trust3 Greenhill RoadLeedsUKLS12 3QE
| | - Michael Sweeting
- University of LeicesterDepartment of Health Sciences, College of Life SciencesGeorge Davies CentreUniversity RoadLeicesterUKLE1 7RH
| | - Frank Peinemann
- Children's Hospital, University of ColognePediatric Oncology and HematologyKerpener Str. 62CologneGermany50937
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18
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Risk of contralateral lower limb amputation and death after initial lower limb amputation - a population-based study. Heliyon 2018; 4:e00836. [PMID: 30320234 PMCID: PMC6180416 DOI: 10.1016/j.heliyon.2018.e00836] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 07/25/2018] [Accepted: 09/26/2018] [Indexed: 11/26/2022] Open
Abstract
Background Lower limb amputation (LLA) is a complication of lower limb atherosclerosis, infection and tissue gangrene. Following ipsilateral LLA, the risk of major amputation of the contralateral limb or of death is unknown. The aim of this study was to determine the incidence of a contralateral major LLA, comparing those with a non-malignant/non-traumatic ipsilateral major vs. ipsilateral minor LLA. Methods We used pre-existing linked administrative health databases for the study. Data were provided by the Institute for Clinical Evaluation Sciences (ICES), Toronto, Ontario. This is a retrospective population-based cohort study across Ontario, Canada, 2002–2012. Cause-specific Cox regression models were used to obtain hazard ratios. Cumulative incidence functions were used to calculate the risk of contralateral major LLA and the risk of the competing event death. Individuals who did not survive at least 30 days after their first ipsilateral LLA were excluded since they were ineligible to have a contralateral LLA. Results 5,816 adults underwent an ipsilateral major and 4,143 an ipsilateral minor LLA. The incidences of contralateral major LLA were 4.8 and 2.2 (adjusted HR 2.41, 95% CI 2.04–2.84) after ipsilateral major and minor LLA, respectively. Incidence of death was 18.9 and 11.4 (adjusted HR 1.22, 95% CI 1.13–1.31) following ipsilateral major and minor LLA, respectively. Conclusion There is high incidence of a contralateral major LLA and even higher risk of death following the ipsilateral LLA. Healthcare professionals should develop strategies for contralateral limb preservation in individuals with existing ipsilateral LLA.
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Bohn B, Grünerbel A, Altmeier M, Giesche C, Pfeifer M, Wagner C, Heise N, Best F, Fasching P, Holl RW. Diabetic foot syndrome in patients with diabetes. A multicenter German/Austrian DPV analysis on 33 870 patients. Diabetes Metab Res Rev 2018; 34:e3020. [PMID: 29726089 DOI: 10.1002/dmrr.3020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/08/2018] [Accepted: 04/22/2018] [Indexed: 12/12/2022]
Abstract
AIMS The diabetic foot syndrome (DFS) is a serious complication in patients with diabetes increasing the risk for minor/major amputations. This analysis aimed to examine differences in diabetes patients with or without DFS stratified by type 1 (T1D) or type 2 diabetes (T2D). MATERIAL AND METHODS Adult patients (≥20y of age) with diabetes from the German/Austrian diabetes patients follow-up registry (DPV) were included. The cross-sectional study comprised 45 722 subjects with T1D (nDFS = 2966) and 313 264 with T2D (nDFS = 30 904). In DFS, minor/major amputations were analysed. To compare HbA1C , neuropathy, nephropathy, cardiovascular disease risk factors, and macrovascular complications between patients with or without DFS, regression models were conducted. Confounders: age, sex, diabetes duration. RESULTS In patients with DFS, a minor amputation was documented in 27.2% (T1D) and 25.9% (T2D), a major amputation in 10.2% (T1D) and 11.3% (T2D). Regression models revealed that neuropathy was more frequent in subjects with DFS compared with patients without DFS (T1D: 70.7 vs 29.8%; T2D: 59.4% vs 36.9%; both P < 0.0001). Hypertension, nephropathy, peripheral vascular disease, stroke, or myocardial infarction was more common compared with patients without DFS (all P < 0.0001). In T1D with DFS, a slightly higher HbA1C (8.11% vs 7.95%; P < 0.0001) and in T2D with DFS a lower HbA1C (7.49% vs 7.69%; P < 0.0001) was observed. CONCLUSIONS One third of the patients with DFS had an amputation of the lower extremity. Especially neuropathy or peripheral vascular disease was more prevalent in patients with DFS. New concepts to prevent DFS-induced amputations and to reduce cardiovascular risk factors before the occurrence of DFS are necessary.
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Affiliation(s)
- Barbara Bohn
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Arthur Grünerbel
- Specialized Practice for Diabetes and Nutritional Medicine, Munich, Germany
| | | | - Carsten Giesche
- Clinic of Internal Medicine, Alexianer St. Hedwig Hospital, Berlin, Germany
| | | | | | - Nikolai Heise
- Alb Fils Kliniken, Helfenstein Clinic, Geislingen, Germany
| | - Frank Best
- Diabetes-Practice Dr. Best, Essen, Germany
| | - Peter Fasching
- 5th Medical Department, Wilhelminenspital, Vienna, Austria
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Kum S, Huizing E, Schreve MA, Ünlü Ç, Ferraresi R, Samarakoon LB, van den Heuvel DA. Percutaneous deep venous arterialization in patients with critical limb ischemia. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 59:665-669. [PMID: 29786410 DOI: 10.23736/s0021-9509.18.10569-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI) is the presentation of end stage peripheral arterial disease and typically presents with rest pain, ulceration and gangrene. The outcome of conservative treatment is poor and often leads to amputations. Arterial revascularization plays an important role in amputation prevention. Unfortunately, a significant percentage of CLI patients cannot be revascularized and subsequently end up with a palliative amputation. This has led to the need and exploration of new treatment options in this no option subgroup of CLI. Deep venous arterialization (DVA) is one of them and has been reported as a save and feasible novel and promising alternative to amputation. The goal of DVA is to provide arterialized blood in significant volumes and pressure to the plantar venous arch and ischemic tissue to enable wound healing. Selecting the right patients is critical for successful DVA and requires that extra attention is paid to the wounds as well as arterial and venous vascular status. METHODS The procedure was previously described in our initial experience in the first-in-man study performed on 7 patients with NOP-CLI. The angiographic goal of the procedure is to deliver arterialized blood to the plantar venous arch in significant volumes and pressure, circumventing the numerous valves in the process. The clinical goal is to achieve wound healing. RESULTS Technical success was achieved in all patients. Flow in the plantar arch was achieved in 5 of the 7 patients. One patient with chronic rest pain became pain free within 48 hours after the procedure. Complete wound healing was achieved at 12 months in 5 of the 7 patients. Reinterventions were performed in 5 of 7 patients to maintain patency. Of the 7 study patients, five underwent minor amputation of one or more toes, and two underwent major amputations within 12 months (limb salvage, 71%). CONCLUSIONS The LimFlow system is currently the only registered device a total percutaneous DVA can be performed with. In addition to the percutaneous creation of an arteriovenous fistula (AVF), it also allows disruption of the veins with a dedicated valvulotome.
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Affiliation(s)
- Steven Kum
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore, Singapore -
| | - Eline Huizing
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Michiel A Schreve
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Çagdas Ünlü
- Department of Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Roberto Ferraresi
- Peripheral Interventional CathLab, Humanitas Gavazzeni, Bergamo, Italy
| | - Lasitha B Samarakoon
- Vascular Service, Department of Surgery, Changi General Hospital, Singapore, Singapore
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Arifin N, Hasbollah HR, Hanafi MH, Ibrahim AH, Rahman WAWA, Aziz RC. Provision of Prosthetic Services Following Lower Limb Amputation in Malaysia. Malays J Med Sci 2017; 24:106-111. [PMID: 29386978 PMCID: PMC5772821 DOI: 10.21315/mjms2017.24.5.12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 08/11/2017] [Indexed: 10/18/2022] Open
Abstract
The incidence of lower limb amputation is high across the globe and continues to be a major threat to morbidity and mortality. Consequently, the provision of high quality and effective prosthetics services have been known as an essential component for a successful rehabilitation outcome. In Malaysia, amputation prevalence has been increasing in which several main components of service delivering aspects (such as service intervention, prosthetic personnel) should be anticipated to accommodate for the increasing demand. This article highlights the hurdles experienced in providing prosthetic services in Malaysia from multiple aspects such as financial burden to acquire the prosthesis and lack of expertise to produce quality prosthesis. This paramount issues consequently justify for the urgency to carry out national level survey on the current statistics of lower limb amputation and to ascertain the available workforce to provide a quality prosthetics services. Only with accurate and current information from the national survey, strategies and policies aimed at enhancing the outcome from prosthetics services can be achieved.
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Affiliation(s)
- Nooranida Arifin
- Department of Biomedical Engineering, Faculty of Engineering University of Malaya, Kuala Lumpur
| | - Hasif Rafidee Hasbollah
- Faculty of Hospitality, Tourism, and Wellness, University Malaysia Kelantan, City Campus, Pengkalan Chepa, Kelantan
| | - Muhammad Hafiz Hanafi
- Department of Neuroscience, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan
- Center for Neuroscience Services and Research, Universiti Sains Malaysia Health Campus, 16150 Kubang Kerian, Kelantan
| | - Al Hafiz Ibrahim
- Orthopedic Department, Universiti Sains Malaysia Hospital, Kelantan
| | | | - Roslizawati Che Aziz
- Faculty of Hospitality, Tourism, and Wellness, University Malaysia Kelantan, City Campus, Pengkalan Chepa, Kelantan
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Buggy A, Moore Z. The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. J Wound Care 2017; 26:324-339. [DOI: 10.12968/jowc.2017.26.6.324] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- A. Buggy
- Professional Certificate (Community Nursing), RGN, CNM 2 Integrated Case Manager for Older Persons, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Z. Moore
- Dip First Line Management, RGN, Professor and Head of the School of Nursing and Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Bergin S, Thomas S, Royle P, Waugh N. Protease modulating dressings for treating diabetic foot ulcers. Hippokratia 2016. [DOI: 10.1002/14651858.cd005361.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Shan Bergin
- Dandenong Hospital; Diabetes Foot Unit/ Department of Podiatry; Southern Health Melbourne Victoria Australia 3175
| | - Sian Thomas
- Medical Research Council; Social and Public Health Sciences Unit; 4 Lilybank Gardens Glasgow UK G12 8RZ
| | - Pamela Royle
- Health Sciences Research Institute, Warwick Medical School, University of Warwick; Warwick Evidence; Gibbet Hill Campus Coventry UK CV4 7AL
| | - Norman Waugh
- Warwick Medical School, University of Warwick; Division of Health Sciences; Coventry UK CV4 7AL
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Abstract
BACKGROUND The Amputation Prevention Initiative is a project conducted jointly by the Massachusetts Public Health Association and the Massachusetts Podiatric Medical Society that seeks to study methods to reduce nontraumatic lower-extremity amputations from diabetes. METHODS To determine the rate of diabetes-related lower-extremity amputations in Massachusetts and identify the groups most at risk, hospital billing and discharge data were analyzed. To examine the components of the diabetic foot examination routinely performed by general practitioners, surveys were conducted in conjunction with physician meetings in Massachusetts (n = 149) and in six other states (n = 490). RESULTS The average age-adjusted number of diabetes-related lower-extremity amputations in 2004 was 30.8 per 100,000 and 5.3 per 1,000 diabetic patients in MA, with high-risk groups being identified as men and black individuals. Among the general practitioners surveyed in Massachusetts, only 2.01% reported routinely conducting all four key components of the diabetic foot examination, with 28.86% reporting not performing any components. CONCLUSIONS These findings suggest that many general practitioners may be failing to perform the major components of the diabetic foot examination believed to prevent foot ulcers and lower-extremity amputations.
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Affiliation(s)
- Emily A Cook
- Division of Podiatric Surgery, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA
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Labovitz JM, Kominski GF. Forecasting the Value of Podiatric Medical Care in Newly Insured Diabetic Patients During Implementation of the Affordable Care Act in California. J Am Podiatr Med Assoc 2016; 106:163-71. [PMID: 27269971 DOI: 10.7547/15-026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Because value-based care is critical to the Affordable Care Act success, we forecasted inpatient costs and the potential impact of podiatric medical care on savings in the diabetic population through improved care quality and decreased resource use during implementation of the health reform initiatives in California. METHODS We forecasted enrollment of diabetic adults into Medicaid and subsidized health benefit exchange programs using the California Simulation of Insurance Markets (CalSIM) base model. Amputations and admissions per 1,000 diabetic patients and inpatient costs were based on the California Office of Statewide Health Planning and Development 2009-2011 inpatient discharge files. We evaluated cost in three categories: uncomplicated admissions, amputations during admissions, and discharges to a skilled nursing facility. Total costs and projected savings were calculated by applying the metrics and cost to the projected enrollment. RESULTS Diabetic patients accounted for 6.6% of those newly eligible for Medicaid or health benefit exchange subsidies, with a 60.8% take-up rate. We project costs to be $24.2 million in the diabetic take-up population from 2014 to 2019. Inpatient costs were 94.3% higher when amputations occurred during the admission and 46.7% higher when discharged to a skilled nursing facility. Meanwhile, 61.0% of costs were attributed to uncomplicated admissions. Podiatric medical services saved 4.1% with a 10% reduction in admissions and amputations and an additional 1% for every 10% improvement in access to podiatric medical care. CONCLUSIONS When implementing the Affordable Care Act, inclusion of podiatric medical services on multidisciplinary teams and in chronic-care models featuring prevention helps shift care to ambulatory settings to realize the greatest cost savings.
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Affiliation(s)
- Jonathan M. Labovitz
- Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA; College of Podiatric Medicine, Western University of Health Sciences, Pomona, CA
| | - Gerald F. Kominski
- Center for Health Policy Research and Department of Health Policy and Management, Fielding School of Public Health, University of California Los Angeles, Los Angeles, CA
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Wu L, Norman G, Dumville JC, O'Meara S, Bell‐Syer SEM. Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews. Cochrane Database Syst Rev 2015; 2015:CD010471. [PMID: 26171906 PMCID: PMC7083265 DOI: 10.1002/14651858.cd010471.pub2] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To summarize data from systematic reviews of randomised controlled trial evidence on the effectiveness of dressings for healing foot ulcers in people with diabetes mellitus (DM). METHODS We searched the following databases for relevant systematic reviews and associated analyses: the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2015, Issue 2); Database of Abstracts of Reviews of Effects (DARE; The Cochrane Library 2015, Issue 1); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 14 April 2015); Ovid EMBASE (1980 to 14 April 2015). We also handsearched the Cochrane Wounds Group list of reviews. Two review authors independently performed study selection, risk of bias assessment and data extraction. Complete wound healing was the primary outcome assessed; secondary outcomes included health-related quality of life, adverse events, resource use and dressing performance. MAIN RESULTS We found 13 eligible systematic reviews relevant to this overview that contained a total of 17 relevant RCTs. One review reported the results of a network meta-analysis and so presented information on indirect, as well as direct, treatment effects. Collectively the reviews reported findings for 11 different comparisons supported by direct data and 26 comparisons supported by indirect data only. Only four comparisons informed by direct data found evidence of a difference in wound healing between dressing types, but the evidence was assessed as being of low or very low quality (in one case data could not be located and checked). There was also no robust evidence of a difference between dressing types for any secondary outcomes assessed. AUTHORS' CONCLUSIONS There is currently no robust evidence for differences between wound dressings for any outcome in foot ulcers in people with diabetes (treated in any setting). Practitioners may want to consider the unit cost of dressings, their management properties and patient preference when choosing dressings.
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Affiliation(s)
- Lihua Wu
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane Buildung (Room 5.311), Oxford RoadManchesterUKM13 9PL
| | - Gill Norman
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane Buildung (Room 5.311), Oxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane Buildung (Room 5.311), Oxford RoadManchesterUKM13 9PL
| | - Susan O'Meara
- University of LeedsSchool of HealthcareRoom LG.12, Baines WingLeedsUKLS2 9JT
| | - Sally EM Bell‐Syer
- University of YorkDepartment of Health SciencesArea 2 Seebohm Rowntree BuildingHeslingtonYorkNorth YorkshireUKYO10 5DD
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Prevention of lower-limb lesions and reduction of morbidity in diabetic patients. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2014; 49:482-7. [PMID: 26229849 PMCID: PMC4487491 DOI: 10.1016/j.rboe.2014.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Accepted: 08/23/2013] [Indexed: 11/22/2022]
Abstract
Objective Methods Results Conclusions
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do Amaral Júnior AH, do Amaral LAH, Bastos MG, do Nascimento LC, Alves MJM, de Andrade MAP. Prevenção de lesões de membros inferiores e redução da morbidade em pacientes diabéticos. Rev Bras Ortop 2014. [DOI: 10.1016/j.rbo.2013.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Hicks CW, Selvarajah S, Mathioudakis N, Perler BA, Freischlag JA, Black JH, Abularrage CJ. Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers. J Vasc Surg 2014; 60:1247-1254.e2. [PMID: 24939079 DOI: 10.1016/j.jvs.2014.05.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 05/08/2014] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The cost of care for diabetic foot ulcers is estimated to be more than $1.5 billion annually. The aim of this study was to analyze inpatient diabetic foot ulcer cost changes over time and to identify factors associated with these costs. METHODS The Nationwide Inpatient Sample (2005-2010) was queried using the International Classification of Diseases, Ninth Revision codes for a primary diagnosis of foot ulceration. The primary outcomes were changes in adjusted total hospital charges and costs over time. Multivariable analysis was performed to assess relative increases (RIs) in hospital charges per patient in 2005 vs 2010 adjusting for demographic characteristics, income, comorbidities (Charlson Comorbidity Index ≥3), insurance type, hospital characteristics, diagnostic imaging, revascularization, amputation, and length of stay. RESULTS Overall, 336,641 patients were admitted with a primary diagnosis of diabetic foot ulceration (mean age, 62.9 ± 0.1 years, 59% male, 61% white race). The annual cumulative cost for inpatient treatment of diabetic foot ulcers increased significantly from 2005 to 2010 ($578,364,261 vs $790,017,704; P < .001). More patients were hospitalized (128.6 vs 152.8 per 100,000 hospitalizations; P < .001), and the mean adjusted cost per patient hospitalization increased significantly over time ($11,483 vs $13,258; P < .001). The proportion of nonelective admissions remained stable (25% vs 23%; P = .32) and there were no differences in mean hospital length of stay (7.0 ± 0.1 days vs 6.8 ± 0.1 days; P = .22). Minor (17.9% vs 20.6%; P < .001), but not major amputations (3.9% vs 4.2%; P = .27) increased over time. Based on multivariable analysis, the main factors contributing to the escalating cost per patient hospitalization included increased patient comorbidities (unadjusted mean difference 2005 vs 2010 $3303 [RI, 1.08] vs adjusted $15,220 [RI, 1.35]), open revascularization (unadjusted $15,145 [RI, 1.25] vs adjusted $30,759 [RI, 1.37]), endovascular revascularization (unadjusted $17,662 [RI, 1.29] vs adjusted $28.937 [RI, 1.38]), and minor amputations (unadjusted $9918 [RI, 1.24] vs adjusted $18,084 [RI, 1.33]) (P < .001, all). CONCLUSIONS Hospital charges and costs related to diabetic foot ulcers have increased significantly over time despite stable hospital length of stay and proportion of emergency admissions. Risk-adjusted analyses suggest that this change might be reflective of increasing charges associated with a progressively sicker patient population and attempts at limb salvage. Despite this, the overall incidence of major amputations remained stable.
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Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Shalini Selvarajah
- Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Nestoras Mathioudakis
- Division of Endocrinology and Metabolism, Department of Medicine, The Johns Hopkins Hospital, Baltimore, Md; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, Md
| | - Bruce A Perler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Julie A Freischlag
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md; Center for Surgical Trials and Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md; Diabetic Foot and Wound Service, The Johns Hopkins Hospital, Baltimore, Md.
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Exploring the concept of a team approach to wound care: Managing wounds as a team. J Wound Care 2014; 23 Suppl 5b:S1-S38. [DOI: 10.12968/jowc.2014.23.sup5b.s1] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Balance control in lower extremity amputees during quiet standing: a systematic review. Gait Posture 2014; 39:672-82. [PMID: 24331296 DOI: 10.1016/j.gaitpost.2013.07.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Revised: 07/02/2013] [Accepted: 07/04/2013] [Indexed: 02/02/2023]
Abstract
Postural control has been widely evaluated for the normal population and different groups over the past 20 years. Numerous studies have investigated postural control in quiet standing posture among amputees. However, a comprehensive analysis is lacking on the possible contributing factors to balance. The present systematic review highlights the current findings on variables that contribute to balance instability for lower extremity amputees. The search strategy was performed on PubMed, Web of Science, Medline, Scopus, and CINAHL and then followed by additional manual searching via reference lists in the reviewed articles. The quality of the articles was evaluated using a methodological quality assessment tool. This review included and evaluated a total of 23 full-text articles. Despite the inconsistencies in the methodological design of the studies, all articles scored above the acceptable level in terms of quality. A majority of the studies revealed that lower extremity amputees have increased postural sway in the standing posture. Asymmetry in body weight, which is mainly distributed in the non-amputated leg, was described. Aside from the centre of pressure in postural control, sensory inputs may be a related topic for investigation in view of evidence on their contribution, particularly visual input. Other balance-related factors, such as stump length and patients' confidence level, were also neglected. Further research requires examination on the potential factors that affect postural control as the information of standing postural is still limited.
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Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2013:CD010318. [PMID: 24132761 DOI: 10.1002/14651858.cd010318.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. Negative pressure wound therapy can be used to treat these wounds and a clear and current overview of current evidence is required to facilitate decision-making regarding its use. OBJECTIVES To assess the effects of negative pressure wound therapy compared with standard care or other adjuvant therapies in the healing of foot wounds in people with DM. SEARCH METHODS In July 2013, we searched the following databases to identify reports of relevant randomised controlled trials (RCTs): Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); The Database of Abstracts of Reviews of Effects (DARE); The NHS Economic Evaluation Database; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA Published or unpublished RCTs that evaluate the effects of any brand of negative pressure wound therapy in the treatment of foot wounds in people with diabetes, irrespective of publication date or language of publication. Particular effort was made to identify unpublished studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies in this review randomising 605 participants. Two studies (total of 502 participants) compared negative pressure wound therapy with standard moist wound dressings. The first of these was conducted in people with DM and post-amputation wounds and reported that significantly more people healed in the negative pressure wound therapy group compared with the moist dressing group: (risk ratio 1.44; 95% CI 1.03 to 2.01). The second study, conducted in people with debrided foot ulcers, also reported a statistically significant increase in the proportion of ulcers healed in the negative pressure wound therapy group compared with the moist dressing group: (risk ratio 1.49; 95% CI 1.11 to 2.01). However, these studies were noted to be at risk of performance bias, so caution is required in their interpretation. Findings from the remaining three studies provided limited data, as they were small, with limited reporting, as well as being at unclear risk of bias. AUTHORS' CONCLUSIONS There is some evidence to suggest that negative pressure wound therapy is more effective in healing post-operative foot wounds and ulcers of the foot in people with DM compared with moist wound dressings. However, these findings are uncertain due to the possible risk of bias in the original studies. The limitations in current RCT evidence suggests that further trials are required to reduce uncertainty around decision making regarding the use of NPWT to treat foot wounds in people with DM.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK, M13 9PL
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Isaac AL, Armstrong DG. Negative pressure wound therapy and other new therapies for diabetic foot ulceration: the current state of play. Med Clin North Am 2013; 97:899-909. [PMID: 23992900 DOI: 10.1016/j.mcna.2013.03.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
As of 2012, the number of people with diabetes is increasing in every country, and half of the people with diabetes do not know they are afflicted with the malady.1 Furthermore, it is believed that every 20 seconds a lower limb is lost around the world because of complications related to diabetes.6 In a short period, NPWT has transformed wound care across the globe, and other technologies are beginning to emerge that may provide clinicians with the tools necessary for identifying wounds at risk for delayed healing and recurrence. The future of diabetic limb salvage will rely heavily on these and other advances.
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Affiliation(s)
- Adam L Isaac
- Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, 1501 North Campbell Avenue, Tucson, Arizona, AZ 85724, USA
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Wound dressings are regarded as important components of ulcer treatment, with clinicians and patients having many different types to choose from including hydrocolloid dressings. There is a range of different hydrocolloids available including fibrous-hydrocolloid and hydrocolloid (matrix) dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of hydrocolloid wound dressings with no dressing or alternative dressings on the healing of foot ulcers in people with diabetes. SEARCH METHODS For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrocolloid with alternative wound treatments in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies (535 participants) in the review: these compared hydrocolloids with basic wound contact dressings, foam dressings, alginate dressings and a topical treatment. Meta-analysis of two studies indicated no statistically significant difference in ulcer healing between fibrous-hydrocolloids and basic wound contact dressings: risk ratio 1.01 (95% CI 0.74 to 1.38). One of these studies found that a basic wound contact dressing was more cost-effective than a fibrous-hydrocolloid dressing. One study compared a hydrocolloid-matrix dressing with a foam dressing and found no statistically significant difference in the number of ulcers healed. There was no statistically significant difference in healing between an antimicrobial (silver) fibrous-hydrocolloid dressing and standard alginate dressing; an antimicrobial dressing (iodine-impregnated) and a standard fibrous hydrocolloid dressing or a standard fibrous hydrocolloid dressing and a topical cream containing plant extracts. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that any type of hydrocolloid wound dressing is more effective in healing diabetic foot ulcers than other types of dressing or a topical cream containing plant extracts. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- University of ManchesterDepartment of Nursing, Midwifery and Social WorkManchesterUKM13 9PL
| | - Sohan Deshpande
- Kleijnen Systematic ReviewsUnit 6, Escrick Business ParkRiccall Road, EscrickYorkUKYO19 6FD
| | - Susan O'Meara
- University of LeedsSchool of HealthcareRoom LG.12, Baines WingLeedsUKLS2 9JT
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including hydrogel dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To assess the effects of hydrogel wound dressings compared with alternative dressings or none on the healing of foot ulcers in people with diabetes. SEARCH METHODS For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrogel with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies (446 participants) in this review. Meta analysis of three studies comparing hydrogel dressings with basic wound contract dressings found significantly greater healing with hydrogel: risk ratio (RR) 1.80, 95% confidence interval (CI) 1.27 to 2.56. The three pooled studies had different follow-up times (12 weeks, 16 weeks and 20 weeks) and also evaluated ulcers of different severities (grade 3 and 4; grade 2 and grade unspecified). One study compared a hydrogel dressing with larval therapy and found no statistically significant difference in the number of ulcers healed and another found no statistically significant difference in healing between hydrogel and platelet-derived growth factor. There was also no statistically significant difference in number of healed ulcers between two different brands of hydrogel dressing. All included studies were small and at unclear risk of bias and there was some clinical heterogeneity with studies including different ulcer grades. No included studies compared hydrogel with other advanced wound dressings. AUTHORS' CONCLUSIONS There is some evidence to suggest that hydrogel dressings are more effective in healing (lower grade) diabetic foot ulcers than basic wound contact dressings however this finding is uncertain due to risk of bias in the original studies. There is currently no research evidence to suggest that hydrogel is more effective than larval therapy or platelet-derived growth factors in healing diabetic foot ulcers, nor that one brand of hydrogel is more effective than another in ulcer healing. No RCTs comparing hydrogel dressings with other advanced dressing types were found.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing, Midwifery and Social Work, University of Manchester, Manchester,
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Abstract
BACKGROUND Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of alginate wound dressings with no wound dressing or alternative dressings on the healing of foot ulcers in people with diabetes mellitus. SEARCH METHODS For this first update, in April 2013, we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of alginate dressings with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (375 participants) in this review; these compared alginate dressings with basic wound contact dressings, foam dressings and a silver-containing, fibrous-hydrocolloid dressing. Meta analysis of two studies found no statistically significant difference between alginate dressings and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI 0.66 to 1.80). Pooled data from two studies comparing alginate dressings with foam dressings found no statistically significant difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08). There was no statistically significant difference in the number of diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid dressing was compared with a standard alginate dressing (RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up times (six to 12 weeks), and small sample sizes. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES The review aimed to evaluate the effects of foam wound dressings on the healing of foot ulcers in people with diabetes. SEARCH METHODS For this first update we searched the following databases the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL in April 2013. There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects on ulcer healing of one or more foam wound dressings in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (157 participants) in this review. Meta analysis of two studies indicated that foam dressings do not promote the healing of diabetic foot ulcers compared with basic wound contact dressings (RR 2.03, 95%CI 0.91 to 4.55). Pooled data from two studies comparing foam and alginate dressing found no statistically significant difference in ulcer healing (RR 1.50, 95% CI 0.92 to 2.44). There was no statistically significant difference in the number of diabetic foot ulcers healed when foam dressings were compared with hydrocolloid (matrix) dressings. All included studies were small and/or had limited follow-up times. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that foam wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however all trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing,Midwifery and Social Work, University of Manchester, Manchester,UK.
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Goodney PP, Holman K, Henke PK, Travis LL, Dimick JB, Stukel TA, Fisher ES, Birkmeyer JD. Regional intensity of vascular care and lower extremity amputation rates. J Vasc Surg 2013; 57:1471-79, 1480.e1-3; discussion 1479-80. [PMID: 23375611 PMCID: PMC3660510 DOI: 10.1016/j.jvs.2012.11.068] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 11/16/2012] [Accepted: 11/16/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Because patient-level differences do not fully explain the variation in lower extremity amputation rates across the United States, we hypothesized that variation in intensity of vascular care may also affect regional rates of amputation and examined the relationship between the intensity of vascular care and the population-based rate of major lower extremity amputation (above-knee or below-knee) from vascular disease. METHODS Intensity of vascular care was defined as the proportion of Medicare patients who underwent any vascular procedure in the year before amputation, calculated at the regional level (2003 to 2006), using the 306 hospital referral regions in the Dartmouth Atlas of Healthcare. The relationship between intensity of vascular care and major amputation rate, at the regional level, was examined between 2007 and 2009. RESULTS Amputation rates varied widely by region, from one to 27 per 10,000 Medicare patients. Compared with regions in the lowest quintile of amputation rate, patients in the highest quintile were commonly African American (50% vs 13%) and diabetic (38% vs 31%). Intensity of vascular care also varied across regions: <35% of patients underwent revascularization in the lowest quintile of intensity, whereas nearly 60% underwent revascularization in the highest quintile. Overall, an inverse correlation was found between intensity of vascular care and the amputation rate, ranging from R = -0.36 for outpatient diagnostic and therapeutic procedures to R = -0.87 for inpatient surgical revascularizations. Analyses adjusting for patient characteristics and socioeconomic status found patients in high-intensity vascular care regions were significantly less likely to undergo amputation without an antecedent attempt at revascularization (odds ratio, 0.37; 95% confidence interval, 0.34-0.37; P < .001). CONCLUSIONS The intensity of vascular care provided to patients at risk for amputation varies, and regions with the most intensive vascular care have the lowest amputation rate, although the observational nature of these associations do not impart causality. High-risk patients, especially African American diabetic patients residing in low-intensity vascular care regions, represent an important target for systematic efforts to reduce amputation risk.
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Affiliation(s)
- Philip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766, USA.
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Buckley CM, Perry IJ, Bradley CP, Kearney PM. Does contact with a podiatrist prevent the occurrence of a lower extremity amputation in people with diabetes? A systematic review and meta-analysis. BMJ Open 2013; 3:bmjopen-2012-002331. [PMID: 23657467 PMCID: PMC3651976 DOI: 10.1136/bmjopen-2012-002331] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To determine the effect of contact with a podiatrist on the occurrence of Lower Extremity Amputation (LEA) in people with diabetes. DESIGN AND DATA SOURCES We conducted a systematic review of available literature on the effect of contact with a podiatrist on the risk of LEA in people with diabetes. Eligible studies, published in English, were identified through searches of PubMed, CINAHL, EMBASE and Cochrane databases. The key terms, 'podiatry', 'amputation' and 'diabetes', were searched as Medical Subject Heading terms. Reference lists of selected papers were hand-searched for additional articles. No date restrictions were imposed. STUDY SELECTION Published randomised and analytical observational studies of the effect of contact with a podiatrist on the risk of LEA in people with diabetes were included. Cross-sectional studies, review articles, chart reviews and case series were excluded. Two reviewers independently assessed titles, abstracts and full articles to identify eligible studies and extracted data related to the study design, characteristics of participants, interventions, outcomes, control for confounding factors and risk estimates. ANALYSIS Meta-analysis was performed separately for randomised and non-randomised studies. Relative risks (RRs) with 95% CIs were estimated with fixed and random effects models as appropriate. RESULTS Six studies met the inclusion criteria and five provided data included in meta-analysis. The identified studies were heterogenous in design and included people with diabetes at both low and high risk of amputation. Contact with a podiatrist did not significantly affect the RR of LEA in a meta-analysis of available data from randomised controlled trials (RCTs); (1.41, 95% CI 0.20 to 9.78, 2 RCTs) or from cohort studies; (0.73, 95% CI 0.39 to 1.33, 3 Cohort studies with four substudies in one cohort). CONCLUSIONS There are very limited data available on the effect of contact with a podiatrist on the risk of LEA in people with diabetes.
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Affiliation(s)
- C M Buckley
- Department of General Practice, University College Cork, Cork, Ireland
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Dumville JC, O'Meara S, Bell-Syer SEM. Dressings for treating foot ulcers in people with diabetes: an overview of systematic reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [DOI: 10.1002/14651858.cd010471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Frykberg RG, O'Connor RM, Tallis A, Tierney E. Limb salvage using advanced technologies: a case report. Int Wound J 2013; 12:53-8. [PMID: 23425603 DOI: 10.1111/iwj.12050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 01/24/2013] [Indexed: 11/28/2022] Open
Abstract
Patients with severe acute and chronic lower extremity wounds often present a significant challenge in terms of limb salvage. In addition to control of infection, assuring adequate perfusion and providing standard wound care, advanced modalities are often required to facilitate final wound closure. We herein present a case study on a diabetic patient with gangrene and necrotising soft-tissue infection who underwent a forefoot pedal amputation to control the sepsis. Despite his non invasive vascular studies demonstrating poor healing potential at this level, he was not deemed suitable for revascularisation by our vascular surgeons and ankle-level amputation was recommended. Nonetheless, over a 5-month period using multiple advanced wound care therapies, wound closure was ultimately achieved.
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Affiliation(s)
- Robert G Frykberg
- Podiatry Department, Carl T. Hayden VA Medical Center, Phoenix VA Health Care System, Phoenix, AZ, USA
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De León Rodriguez D, Allet L, Golay A, Philippe J, Assal JP, Hauert CA, Pataky Z. Biofeedback can reduce foot pressure to a safe level and without causing new at-risk zones in patients with diabetes and peripheral neuropathy. Diabetes Metab Res Rev 2013; 29:139-44. [PMID: 23081857 DOI: 10.1002/dmrr.2366] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2012] [Revised: 08/24/2012] [Accepted: 10/03/2012] [Indexed: 11/10/2022]
Abstract
BACKGROUND Plantar pressure reduction is mandatory for diabetic foot ulcer healing. Our aim was to evaluate the impact of a new walking strategy learned by biofeedback on plantar pressure distribution under both feet in patients with diabetic peripheral neuropathy. METHODS Terminally augmented biofeedback has been used for foot off-loading training in 21 patients with diabetic peripheral sensory neuropathy. The biofeedback technique was based on a subjective estimation of performance and objective visual feedback following walking sequences. The patient was considered to have learned a new walking strategy as soon as the peak plantar pressure (PPP) under the previously defined at-risk zone was within a range of 40-80% of baseline PPP in 70% of the totality of steps and during three consecutive walking sequences. The PPP was measured by a portable in-shoe foot pressure measurement system (PEDAR(®)) at baseline (T0), directly after learning (T1) and at 10-day retention test (T2). RESULTS The PPP under at-risk zones decreased significantly at T1 (165 ± 9 kPa, p < 0.0001) and T2 (167 ± 11, p = 0.001), as compared with T0 (242 ± 12 kPa) without any increase of the PPP elsewhere. At the contralateral foot (not concerned by off-loading), the PPP was slightly higher under the lateral midfoot at T1 (68 ± 8 kPa, p = 0.01) and T2 (65 ± 8 kPa, p = 0.01), as compared with T0 (58 ± 6 kPa). CONCLUSIONS The foot off-loading by biofeedback leads to a safe and regular plantar pressure distribution without inducing any new 'at-risk' area under both feet.
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Affiliation(s)
- D De León Rodriguez
- Faculty of Psychology and Educational Sciences, University of Geneva, Geneva, Switzerland
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Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2013. [DOI: 10.1002/14651858.cd010318] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Griffin KJ, Rashid TS, Bailey MA, Bird SA, Bridge K, Scott JDA. Toe amputation: a predictor of future limb loss? J Diabetes Complications 2012; 26:251-4. [PMID: 22516530 DOI: 10.1016/j.jdiacomp.2012.03.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 02/08/2012] [Accepted: 03/06/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND Digital toe amputation is a relatively minor surgical procedure but there is a historical view that it is the "first stage in a predictable clinical course" leading to eventual limb loss. There is a paucity of contemporaneous data on the long-term outcomes of patients undergoing toe amputation. We aim to study the experience from our institution, focussing on the risk factors for progression to future limb loss, by conducting a retrospective review of our practice. METHODS Sixty-three patients undergoing toe amputation within our institution were identified and the clinical notes retrospectively reviewed. A database of vascular risk factors and co-morbidity was constructed and correlation with future limb loss was analysed with Chi-squared testing and a logistic regression model. RESULTS Sixty-three patients with a mean age of 69 (IQR 62-76.5) years were identified. Thirty-five (55.6%) of these patients went on to have a further surgical amputation; 22 major amputations (16 below-knee and 6 above-knee amputations) and 23 minor amputations were performed in total. Forty three (68.3%) patients had diabetes and 31 (49.2%) patients had one or more revascularisation procedures undertaken. There was a significant correlation between patients who did not have diabetes and future limb loss (Chi-squared=4.31, p=0.038), however no other identified risk factor predicted the need for major amputation. CONCLUSION Toe amputation is a significant predictor of future limb loss. Our study identified that patients with diabetes are significantly less likely to progress to further limb loss than those with the disease. We hypothesise that this difference is due to the more intensive, multi-disciplinary foot care follow-up that diabetic patients receive. These results highlight the significance of toe amputation and contribute to the evidence for a more intensive out-patient service for these high risk patients.
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Affiliation(s)
- Kathryn J Griffin
- The Leeds Vascular Institute, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, United Kingdom.
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Williams DT, Majeed MU, Shingler G, Akbar MJ, Adamson DG, Whitaker CJ. A diabetic foot service established by a department of vascular surgery: an observational study. Ann Vasc Surg 2012; 26:700-6. [PMID: 22503433 DOI: 10.1016/j.avsg.2011.10.020] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/26/2011] [Accepted: 10/30/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The mechanism by which the multidisciplinary approach to diabetic foot disease reduces amputation rates is unclear. Ischemia, sepsis, and necrosis represent aspects of severe diabetic foot disease amenable to intervention. In 2006, a vascular unit introduced a rapid access service for severe foot disease, augmenting the established community provision. This study aimed to determine whether concurrent changes in amputation rates were observed, and to identify areas that may have influenced outcomes. METHODS Unit data prospectively collected during 4 years for patients with lower-limb disease were compared with data retrieved over 2 years before the foot service. Outcome measurements were major amputations, foot surgery, vascular interventions, admissions, and length of stay. RESULTS Major amputation rates associated with diabetes peaked in 2005 at 24.7/10,000 vs. 1.07/10,000 in 2009; (relative risk = 0.043, 95% confidence interval = 0.006-0.322). The proportion of diabetic to nondiabetic amputations decreased; foot surgery rates also dropped (53.7/10,000 in 2006 vs. 7.5/10,000 in 2009). The number of open revascularization procedures decreased, but the rates of endovascular procedures remained generally constant. Hospital admission rates decreased after initially peaking, and the length of stay was unchanged (16 vs. 15.5 days in 2004 and 2009, respectively). CONCLUSIONS The integration of a vascular unit with community care has been associated with improved outcomes for patients with diabetic foot disease. Improvements were not related to the increased number of vascular procedures or hospitalizations, but did coincide with a greater proportion of patients attending the foot unit. The referral of patients to the unit facilitates the rapid management of severe disease, reducing delays deleterious to outcomes.
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Affiliation(s)
- Dean T Williams
- Department of Vascular Surgery, Ysbyty Gwynedd Hospital, Bangor, Gwynedd, UK.
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Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Wound dressings are regarded as important components of ulcer treatment, with clinicians and patients having many different types to choose from including hydrocolloid dressings. There is a range of different hydrocolloids available including fibrous-hydrocolloid and hydrocolloid (matrix) dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of hydrocolloid wound dressings with no dressing or alternative dressings on the healing of foot ulcers in people with diabetes. SEARCH METHODS We searched The Cochrane Wounds Group Specialised Register (searched 4 January 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (1950 to December Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to 2011 Week 52); and EBSCO CINAHL (1982 to 30 December 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of hydrocolloid with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included four studies (511 participants) in the review: these compared hydrocolloids with basic wound contact dressings, foam dressings and alginate dressings. Meta-analysis of two studies indicated no statistically significant difference in ulcer healing between fibrous-hydrocolloids and basic wound contact dressings: risk ratio 1.01 (95% CI 0.74 to 1.38). One of these studies found that a basic wound contact dressing was more cost-effective than a fibrous-hydrocolloid dressing. One study compared a hydrocolloid-matrix dressing with a foam dressing and found no statistically significant difference in the number of ulcers healed. There was no statistically significant difference in healing between an antimicrobial (silver) fibrous-hydrocolloid dressing and standard alginate dressing; or an antimicrobial dressing (iodine-impregnated) and a standard fibrous hydrocolloid dressing. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that any type of hydrocolloid wound dressing is more effective in healing diabetic foot ulcers than other types of dressing. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK.
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Abstract
BACKGROUND Foot ulcers in people with diabetes mellitus are a common and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from including alginate dressings. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES To compare the effects of alginate wound dressings with no wound dressing or alternative dressings on the healing of foot ulcers in people with diabetes mellitus. SEARCH METHODS We searched The Cochrane Wounds Group Specialised Register (searched 4 January 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 4); Ovid MEDLINE (1950 to December Week 3 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, January 03, 2012); Ovid EMBASE (1980 to 2011 Week 52); and EBSCO CINAHL (1982 to 30 December 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that have compared the effects on ulcer healing of alginate dressings with alternative wound dressings or no dressing in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (375 participants) in this review; these compared alginate dressings with basic wound contact dressings, foam dressings and a silver-containing, fibrous-hydrocolloid dressing. Meta analysis of two studies found no statistically significant difference between alginate dressings and basic wound contact dressings: risk ratio (RR) 1.09 (95% CI 0.66 to 1.80). Pooled data from two studies comparing alginate dressings with foam dressings found no statistically significant difference in ulcer healing (RR 0.67, 95% CI 0.41 to 1.08). There was no statistically significant difference in the number of diabetic foot ulcers healed when an anti-microbial (silver) hydrocolloid dressing was compared with a standard alginate dressing (RR 1.40, 95% CI 0.79 to 2.47). All studies had short follow-up times (six to 12 weeks), and small sample sizes. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that alginate wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however many trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK.
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Dumville JC, Deshpande S, O'Meara S, Speak K. Foam dressings for healing diabetic foot ulcers. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2011. [PMID: 21901731 DOI: 10.1002/14651858.cd009111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Foot ulcers in people with diabetes are a prevalent and serious global health issue. Dressings form a key part of ulcer treatment, with clinicians and patients having many different types to choose from. A clear and current overview of current evidence is required to facilitate decision-making regarding dressing use. OBJECTIVES The review aimed to evaluate the effects of foam wound dressings on the healing of foot ulcers in people with diabetes. SEARCH STRATEGY We searched the Cochrane Wounds Group Specialised Register (searched 10 June 2011); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2); Ovid MEDLINE (1950 to June Week 1 2011); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, 8 June, 2011); Ovid EMBASE (1980 to 2011 Week 22); EBSCO CINAHL (1982 to 3 June 2011). There were no restrictions based on language or date of publication. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects on ulcer healing of one or more foam wound dressings in the treatment of foot ulcers in people with diabetes. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included six studies (157 participants) in this review. Meta analysis of two studies indicated that foam dressings do not promote the healing of diabetic foot ulcers compared with basic wound contact dressings (RR 2.03, 95%CI 0.91 to 4.55). Pooled data from two studies comparing foam and alginate dressing found no statistically significant difference in ulcer healing (RR 1.50, 95% CI 0.92 to 2.44). There was no statistically significant difference in the number of diabetic foot ulcers healed when foam dressings were compared with hydrocolloid (matrix) dressings. All included studies were small and/or had limited follow-up times. AUTHORS' CONCLUSIONS Currently there is no research evidence to suggest that foam wound dressings are more effective in healing foot ulcers in people with diabetes than other types of dressing however all trials in this field are very small. Decision makers may wish to consider aspects such as dressing cost and the wound management properties offered by each dressing type e.g. exudate management.
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Affiliation(s)
- Jo C Dumville
- Department of Health Sciences, University of York, York, UK, YO10 5DD
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