Age, diabetes and smoking in lower limb amputation for arterial occlusive disease

Potassium permanganate in treatment of diabetic foot ulcer: A randomized clinical trial

Background and Aims

Diabetic foot ulcers (DFU) are a severe complication in diabetes patients, often resulting in significant morbidity and mortality due to non-healing. This study investigated the effectiveness of 5% topical potassium permanganate on these ulcers.

Methods

A clinical trial was conducted on 23 patients with Wagner grade I and II DFU. Patients in the control group received standard treatment, while those in the intervention group also received 5% potassium permanganate topically. Data were recorded at 0, 7, 14, and 21 days for analysis.

Results

Among 23 patients studied, 7 (30.4%) were male and 16 (43.7%) female, with an average age of 59 ± 4 years. Both groups showed a statistically significant decrease in wound size and infection over time (p < 0.001). The intervention group, however, had a more substantial reduction in wound size and infection rate (p < 0.05).

Conclusion

Potassium permanganate, when applied topically, is both well-tolerated and effective in enhancing wound healing and reducing infection in DFU, suggesting its potential as a complementary treatment.

Reasons for admission of individual with diabetes to the Tripoli Medical Center in 2015

BACKGROUND

Diabetes mellitus is a complex, chronic, metabolic disease manifested in hyperglycemia and associated with various complications, Consequently, people with diabetes have higher rates of hospital admissions than the general population. There is little information about the burden of hospitalizations of diabetic patients in Libya.

AIM

The aim was to identify the causes of admission of individual with diabetes and to identify the risk factors for hospitalization.

PATIENTS AND METHODS

This is a retrospective case-series study conducted in Tripoli Medical Center, Tripoli. It covers 1037 individual with diabetes admitted between 1 January 2015 and 31 December 2015. All the data were collected from the patient files.

RESULTS

The mean age of the patients was 60.7 years ±15.1 standard deviation. The male-to-female ratio was 1:1. Type 2 diabetes accounted for 90.2% of the patients, 56.5% of whom had diabetes for >10 years, 40.5% had no prior chronic illness, 26.7% had hypertension, and 26.4% had multiple co-morbidities. The mean hospital stay was 6.1 days, and 60.8% of the patients were on insulin therapy. The main causes of admission were infection (23%), mainly in the chest, followed by lower extremity disease (22.4%), cardiovascular disease (19.3%), cerebrovascular disease (14.4%) and renal disease (11.8%).

CONCLUSIONS

The main causes of hospitalization as shown by this study were infections, and chronic complications of diabetes in the lower extremities and cardiovascular system. Most of the patients were >60 years old, had diabetes type 2 for >10 years, were on insulin treatment, and had no other comorbidity.

Review of the role of cigarette smoking in diabetic foot

Diabetic foot ulceration has been a serious issue over the past decades in Asia, causing economic and social problems. Therefore, it is important to identify and reduce the risk factors of diabetic foot. Cigarette smoking has been reported to be associated with diabetes and its macrovascular complications, but the relationship between smoking and diabetic foot ulcers is still unclear. In the present review, we summarize the effects of cigarette smoking on diabetic foot ulcers with respect to peripheral neuropathy, vascular alterations and wound healing. One underlying mechanism of these impacts might be the smoking-induced oxidative stress inside the cells. At the end of this review, the current mainstream therapies for smoking cessation are also outlined. We believe that it is urgent for all diabetic patients to quit smoking so as to reduce their chances of developing foot ulcers and to improve the prognosis of diabetic foot ulcers.

Medical strategies to reduce amputation in patients with type 2 diabetes

Lower extremity amputation is a common and disabling complication of Type 2 diabetes. Whilst the introduction of specialist multidisciplinary teams has led to a reduction in the incidence of lower extremity amputation in some centres, the overall prevalence of diabetes-related amputation has actually increased in recent decades. The aetiology of diabetes-related amputation is complex, with neuropathy, macrovascular and microvascular disease contributing significantly. Ulceration, previous amputation, increasing diabetes duration and poor long-term control of glycaemia and lipids are important risk factors for amputation in populations with diabetes. Major randomized intervention trials of blood glucose-lowering or anti-hypertensive therapies in populations with diabetes have shown limited reductions in neuropathy and/or macrovascular disease, and no benefit on amputation rates. In contrast, a recent analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study showed a significantly reduced rate of minor, but not major amputations in patients with Type 2 diabetes treated with fenofibrate. Mechanistic studies are clearly needed to understand the basis of this benefit.

A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients

Background

A diabetic foot or lower extremity amputation may be exacerbated by or related to the smoking habits and history of the patient.

Patients and methods

Of the 112 diabetic patients in this retrospective study, 46 were non-smokers and 66 were smokers. The smokers were further categorized into patients who: 1) did not cease smoking; 2) ceased in the immediate post-operative period but resumed within 3 months; and 3) ceased up to and at the 3-month post-operative period. The patients were also divided by their amputation level of forefoot, midfoot/rearfoot, and proximal leg.

Results

Smoking diabetic patients underwent more amputations, as well as more proximal amputations than those who did not smoke. The higher amount of smoking in pack years followed an increasing trend of more proximal amputations as well.

Conclusion

Neither the amputation level nor the amputation itself was enough motivation for the patients to participate in smoking cessation.

Orthopedic Technology for the Elderly

The term orthopedics was introduced in 1741 by Nicolas André in Paris for “the Art of Prevention and Correction of Deformities in Children” and for 200 years orthopedic institutions were mainly concerned with locomotor problems in children and young adults. After World War II, however, the majority of orthopedic patients were not children. Devas (6) has coined the expression “geriatric orthopedics”, a semantic contradiction which highlights that we now face an increasing volume of elderly patients in whom the locomotor system causes severe problems. For example, in my own institution an orthopedic wing built in 1928 contained 135 beds, the majority of which were occupied by children. Today 10 beds suffice for our orthopedic children. Half of all orthopedic beds in Sweden are used for hip surgery in the very old.

Reducing lower extremity amputations due to diabetes: the application of diabetic-foot protocol in Chiang Mai University Hospital

The aim of this study was to determine whether intensive treatment and education strategies for diabetic patients with ulcers help in preventing leg amputation. From August 2005 to March 2007, a diabetic-foot protocol using a multidisciplinary approach was applied at our hospital. All the subjects were educated regarding diabetic-foot disease and its complications and prevention. This report compares the amputation rate in patients receiving the protocol care from August 2005 to March 2007 with those who had standard care from August 2003 to July 2005. Seventy-three and 110 diabetic-foot ulcer patients received protocol and standard foot care, respectively. The incidence of major amputations in the protocol and standard care groups was 4.1% and 13.6%, respectively (P= .03). Our protocol was associated with improved diabetic-foot care outcomes. It can be used by any hospital to improve outcomes for patients with diabetes.

Persistent depressive symptoms and functional decline among patients with peripheral arterial disease

OBJECTIVE

Because depressive symptoms are prevalent among patients with peripheral arterial disease (PAD), our goal was to study the effect of depressive symptoms over time on functional decline among patients with PAD.

METHODS

We conducted a prospective cohort study of 417 patients with PAD followed annually for 2 years. A Geriatric Depression Scale Short Form (GDS-S) score >5 was considered positive for depressive symptoms. Depressive symptom categories based on annual GDS-S measures included persistent, new, resolved, and no depressive symptoms. Outcome variables were change in 6-minute walk distance, 4-meter fast walking velocity, and short physical performance battery (0-12 scale, 12 = best). Results are adjusted for age, sex, race, body mass index, marital status, exercise level, smoking, ankle brachial index, leg symptoms, comorbidities, beta-blocker medication use, anti-depressant medications, and interim medical events.

RESULTS

In adjusted analyses, patients with new depressive symptoms had greater annual decline in fast walking velocity compared with that of patients with no depressive symptoms (-0.08 versus -0.01 meters/second per year, p = .02). Patients with persistent depressive symptoms had greater annual decline in 6-minute walk distance (-86.4 versus -41.5 feet/yr, p = .04), fast walking velocity (-0.08 versus -0.01 meters/second per year, p = .004), and short physical performance battery (-0.73 versus -0.18 per year, p = .005) compared with that of patients with no depressive symptoms.

CONCLUSIONS

Among patients with PAD, persistent and new depressive symptoms are associated with greater annual decline in functional performance. Further study is needed to determine the mechanisms of these associations and whether treatment of depressive symptoms prevents functional decline in persons with PAD.

The Prevalence of Chronic Critical Lower Limb Ischaemia in a Population of 20,000 Subjects 40–69 Years of Age

OBJECTIVE

To study the prevalence and possible risk factors for chronic critical lower limb ischaemia (CLI) in an unselected population of 20,291 Norwegian men and women 40-69 years of age.

METHODS

Between 1995 and 1997, all residents 20 years or older in Nord-Trøndelag County, Norway, were invited to participate in a population study (the HUNT 2 Study). Among the 71.2% who attended, 20,291 participants 40-69 years of age responded to questions specifically aimed at identifying CLI. Chronic critical ischaemia was suspected if participants indicated: (1) ulcers on toes, foot or ankle that had failed to heal and/or; (2) persistent pain in the forefoot while in the supine position, but with relief of this pain when standing up. Using logistic regression analyses, we estimated the association between the prevalence of CLI and smoking, diabetes mellitus, previous cardiovascular events, blood lipids and glucose levels, and body mass index (BMI).

RESULTS

The age-adjusted prevalence of CLI was 0.26% among men and 0.24% among women, and there was no gender difference in any age group (age-adjusted OR = 0.91, 95% CI = 0.52-1.58). The presence of increased age, diabetes mellitus, angina pectoris, high triglyceride levels, and high BMI were all independently associated with higher prevalence of CLI.

CONCLUSION

The prevalence of CLI was 0.24%, similar for both genders, and increased with age. Risk factors usually seen in atherosclerotic patients were associated with suspected CLI.

Care of elderly lower limb amputees, as described in medical and nursing records

The aim of this study was to characterize elderly lower limb amputees and explore problems/requirements inherent in their care. A retrospective study of medical and nursing records of patients who had undergone lower limb amputation (LLA) at Uddevalla General Hospital in 1997 was conducted. Demographic data were compared with those from a comparable regional health care district. Hospitalization, rehabilitation and nursing-related data related to subjects alive after 6 months were compared with data concerning those deceased during hospital stay and within 6 months after amputation. During the defined period, the study population consisted of 45 patients aged 60 and above. Fifty-six percent were men, with a mean age of 81.6. Eight patients died in the hospital post-amputation and five died within 6 months of surgery. The aetiology of the diagnosis leading to the LLA was cardiovascular disease in the majority of cases. The most common amputation level was below the knee. LLA patients were reported to have major problems maintaining physical and mental functions, markedly deteriorated general health status and severe pain problems. LLA patients require well functioning and qualified care and rehabilitation. The patients surviving after 6 months had permanent problems in the area of nutrition, elimination, skin ulceration, sleep, pain and pain alleviation. The patients who died during the hospital stay had problems in all these areas. With increasing shorter stays in hospital and decreasing resources in primary and municipal care, there is a risk that these patients' needs and requirements for professional care might be underestimated and thus remain unfulfilled.

Outcome of revascularization procedures for peripheral arterial occlusive disease in Ontario between 1991 and 1998: a population-based study

PURPOSE

We describe the outcome of revascularization procedures used to treat peripheral arterial occlusive disease (PAOD), using population-based administrative data.

METHODS

A retrospective population-based cohort study utilizing administrative databases in Ontario, Canada, was conducted for fiscal years 1991 to 1998 to identify patients who underwent arterial bypass surgery and percutaneous transluminal angioplasty to treat PAOD. The Kaplan-Meier method was used to calculate cumulative survival rate and amputation-free survival rate. To analyze factors that affect these rates, multivariate analysis was performed with Cox proportional hazard models.

RESULTS

Over the study period 15,824 patients underwent bypass operations and 11,548 underwent angioplasty. For patients who underwent bypass surgery, 5-year cumulative survival rate was 61.5% and major amputation-free survival rate was 83.4%, compared with 69% and 92.2%, respectively, for patients who underwent angioplasty. Male sex, older age, diabetes, and heart disease were associated with increased risk for death after revascularization procedures. Increased risk for major amputation after revascularization procedures was associated with male sex, older age, and diabetes, whereas hypertension was linked to decreased risk.

CONCLUSION

To evaluate the long-term outcome of revascularization procedures for PAOD at the population level, survival and major amputation-free survival rates should be used, because they provide more clinically accepted estimates compared with the correlation between utilization rates for revascularization and amputation procedures, which have been used to describe outcome in previously published reports in the literature.

Metabolic, endocrine and haemodynamic risk factors in the patient with peripheral arterial disease

The morbidity and mortality associated with peripheral arterial disease (PAD) creates a huge burden in terms of costs both to the patient and to the health service. PAD is a deleterious and progressive condition that causes a marked increase in the risk of cardiovascular and cerebrovascular events. Further, PAD has a major negative impact on quality of life and mortality, and is associated with an increased risk of limb amputation. The clinical profile of patients at risk of PAD overlaps considerably with the known cardiovascular risk factors. These include, increasing age, smoking habit, diabetes, hypertension, dyslipidaemia, male sex and hyperhomocysteinaemia. For women, hormone replacement therapy appears to be associated with a reduced risk of PAD. Published PAD guidelines recommend aggressive management of risk factors, stressing the importance of lifestyle modification, antiplatelet agents, treating dyslipidaemia and diabetes. However, a large number of patients with PAD go undetected, either because they do not report their symptoms or because they are asymptomatic. It is therefore important to improve detection rates so that these patients can receive appropriate risk factor management.

Clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers: a prospective study of healing below or above the ankle in 187 patients

The aim of this study was to describe the clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers. In a prospective series, 187 consecutively presenting patients were investigated. From admission until final outcome, the patients were treated by a multidisciplinary team both as in- and out-patients. All the patients had one or more signs of neuropathy and 171 had evidence of peripheral vascular disease. Healing with an amputation below the ankle occurred in 74 patients, 88 patients healed with an amputation above the ankle, and 25 patients died unhealed. Amputation above the ankle was associated with high age, living in an institution, a limited walking capacity, cerebrovascular disease, congestive heart failure, and a low hemoglobin level. Amputation below the ankle was associated with diabetes diagnosis before 30 years of age and diabetes duration. In conclusion, older age, history of cerebrovascular disease and low hemoglobin level are associated with above ankle amputation level in diabetic patients with foot ulcers. However, level selection cannot be based upon these factors only, since some patients at high age, with cerebrovascular disease or with a low hemoglobin value, healed with an amputation below the ankle. None of these factors per se should be taken as a cause to choose a primary amputation above the ankle, unless amputation is supported by the total clinical picture, including local characteristics, such as type and localization of ulcer, and signs of peripheral vascular disease. More attention should be paid to biological than to chronological age.

Standing balance in trans-tibial amputees following vascular disease or trauma: a comparative study with healthy subjects

Standing balance measured as sway and standing time both on one and two legs, was studied by use of a stable force platform (Kistler) in 36 patients aged 48-87 years with trans-tibial amputation and 27 healthy subjects matched for age. The aim of the study was to compare postural function in standing in two groups with unilateral trans-tibial amputations, separating vascular disease from trauma. Results revealed that the vascular group had a significantly increased sway in the lateral direction compared with the healthy group, when standing on both feet close together for 30 seconds, looking straight ahead or blindfolded (p values ranging from 0.003 to 0.02). In the sagittal direction the trauma amputees had a significantly decreased sway when looking straight ahead, compared to the vascular and healthy groups (p values = 0.03). No significant differences in the lateral or sagittal direction were seen among the three groups when comparing standing on one leg. There was a significant difference, however, in the standing time in the one-leg standing test of the vascular group when compared with the trauma and healthy groups (p values ranging from 0.0009 to 0.02). In contrast to the vascular group, all subjects in the trauma and healthy groups from 48 to 59 years could stand on the healthy leg for 30 seconds when looking straight ahead, and from 60 to 79 years they could stand for 5 seconds. None in the vascular or trauma group older than 80 years could stand on the healthy leg for 5 seconds.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for failed healing in amputation for vascular disease. A prospective, consecutive study of 177 cases

We examined factors which may lower the mean amputation age and factors which may serve as predictors of success or failure of amputations in the lower extremities for vascular disease in 177 consecutive amputees. Smoking lowered the mean amputation age by 9 years and diabetes by 3 years. Preoperative absence of gangrene in the ischemic limb predicted a higher risk of failure compared to patients with gangrene. Also preoperative hemoglobin > 120 g/L gave a higher risk of failure. Failure to heal was not correlated with age, sex, diabetes, level of amputation, previous vascular surgery, smoking, preoperative blood pressure, serum creatinine, erythrocyte sedimentation rate, blood glucose or temperature.

Rehabilitation after amputation for vascular disease: a follow-up study

Rehabilitation of one hundred and twenty eight patients with lower limb amputation performed for vascular disease from 1979 to 1987 was assessed. Arteriosclerotic occlusive disease was the most frequent cause of amputation (85.9%). Sixty seven patients (52.3%) were diabetic. Early and late results were analysed. For long-term follow-up evaluation, Univariate method of Kaplan-Meyer product limit was employed. Multifactorial analysis was used to assess factors influencing mortality. On immediate evaluation of rehabilitation with a prosthesis 85.2% of patients were successfully fitted. On long term evaluation 47.8% of below-knee and 22.1% of above-knee amputees were alive and using the prosthesis full time at five years of follow-up (p = 0.0026). Opposite limb preservation at five years was 69.5% for diabetics and 90.2% for non-diabetics, respectively (p = 0.0013). Survival rate at five years was 42.4% for diabetics, and 85.0% for non-diabetics (p = 0.0002). On multifactorial analysis diabetic patients showed a risk of late mortality six times greater than non-diabetics. In conclusion rehabilitation after vascular amputation is feasible in a large number of patients, despite a limited life span. Diabetes represents a major risk factor both for life and for the opposite limb. Knee preservation is an important factor for better rehabilitation.

The peripheral vascular consequences of smoking

Cigarette smoking is associated with an increased risk and extent of advanced atherosclerotic vascular disease in peripheral as well as coronary arteries. The likelihood of claudication, amputation, stroke, abdominal aortic aneurysm, and failure of vascular reconstruction is higher in smokers than nonsmokers. Smoking exerts its deleterious effects through many interactive mechanisms. Nicotine and carbon monoxide produce acute cardiovascular consequences, including altered myocardial performance, tachycardia, hypertension, and vasoconstriction. Smoking injures blood vessel walls by damaging endothelial cells, thus increasing permeability to lipids and other blood components. Among metabolic and biochemical changes induced by smoking are elevated plasma, free fatty acids, elevated vasopressin, and a thrombogenic balance of prostacyclin and thromboxane A2. Chronic smoking is associated with a tendency for increased serum cholesterol, reduced high density lipoprotein, and other lipid effects that contribute to atherosclerosis. In addition to rheologic and hematologic changes from increased erythrocytes, leukocytes, and fibrinogen, smokers have alterations in platelet aggregation and survival that produce thrombosis. Considering the ubiquitous repercussions of this menace, vascular surgeons should play an active role in motivating their patients to quit smoking.

Lower extremity blood flow in intermittent claudication--the role of oral glucose tolerance test

Tobacco smoking is a risk factor for peripheral arterial disease. During oral glucose tolerance tests (OGTT) in a population study the author and co-workers have earlier shown that smokers have higher blood glucose values early postload and lower values at two hours compared with nonsmokers. Eighty-three patients, all with intermittent claudication but with a normal OGTT, have now been studied according to their response to an oral glucose load. The blood flow resistance during reactive hyperemia, as measured with a calf plethysmograph, was compared between subjects in the quartile of patients with the highest forty-five-minute blood glucose and those in the lowest quartile. The blood flow resistance was significantly higher in the group with a high forty-five-minute blood glucose, 13.3 +/- 1.34 vs 9.5 +/- 0.65 (mean +/- SEM), p less than 0.02. Blood pressure and blood lipids were similar in the two groups. It is suggested that an exaggerated early response in the OGTT might be an independent risk factor for peripheral arterial disease.

Leg blood flow in intermittent claudication--a comparison between non insulin dependent diabetics and non diabetics

The influence of diabetes on leg blood flow in intermittent claudication has been assessed by comparing the systolic arm-ankle pressure gradient at rest and resistance to blood flow during reactive hyperemia in patients with non-insulin dependent diabetes and non-diabetic controls. Cases and controls were matched for age and sex. Smoking habits, blood pressure, and blood lipids didn't differ in the two groups. Diabetes was associated with a higher resistance to blood flow during reactive hyperemia and a greater arm-ankle pressure gradient at rest. Resistance to blood flow during reactive hyperemia was in the non-diabetics strongly correlated to the arm-ankle pressure gradient at rest (r = 0.84). Corresponding correlation coefficient was in diabetics 0.04. In one of four diabetic legs a high resistance to blood flow during reactive hyperemia didn't correspond to a big arm-ankle pressure gradient. The results in this study support the concept of both macro- and microvascular disease in diabetes.