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Risk factors associated with amputation-free survival in patient with diabetic foot ulcers.
Won SH, Chung CY, Park MS, Lee T, Sung KH, Lee SY, Kim TG, Lee KM. Yonsei Med J. 2014 Sep 1;55(5):1373-8.
To determine the 1-year survival rate, 1-year amputation-free survival rate and the risk factors of amputation for patients with diabetic foot ulcers.
MATERIALS AND METHODS:
One hundred seventy-three patients with diabetic foot ulcers were included in our study. Mean patient age was 67.5 (range, 29 to 87, SD ±11.4) years. 74% of the patients were male. Time from study entry to amputation and time to death were evaluated separately as censored event times by Kaplan-Meier curves and log-rank tests. A multivariate Cox proportional hazards regression analysis was carried out for determining the risk factors of amputation.
The survival rate and amputation-free survival rate were 96.5% (n=167), 65.9% (n=114), respectively, over one year study period. Severity of ulcer was the strongest significant risk factor of amputation [hazard ratio (HR): 7.99; confidence interval (CI): 3.12 to 20.47]. Peripheral artery disease was also independent risk factor of amputation (HR: 2.64; CI: 1.52 to 4.59).
In assessing the prognosis of diabetic foot ulcers, clinicians should consider the severity of ulcer and presence of peripheral artery disease. Our study provides important insights into clinical practice and supplementary information for both physicians and patients
Aims Identifying individuals with diabetes at high risk of cardiovascular disease (CVD) remains challenging. We aimed to establish whether peripheral neuropathy (PN) is associated with incident CVD events and to what extent information on PN may improve risk prediction among individuals with type 2 diabetes.
Methods We obtained data for individuals with type 2 diabetes, and free of CVD, from a large primary care patient cohort. Incident CVD events were recorded during a 30-month follow-up period. Eligible individuals had complete ascertainment of cardiovascular risk factors and PN status at baseline. The association between PN and incident CVD events (non-fatal myocardial infarction, coronary revascularisation, congestive cardiac failure, transient ischaemic attack and stroke) was evaluated using Cox regression, adjusted for standard CVD risk factors. We assessed the predictive accuracy of models including conventional CVD risk factors with and without information on PN.
Results Among 13 043 eligible individuals, we recorded 407 deaths from any cause and 399 non-fatal CVD events. After adjustment for age, sex, ethnicity, systolic blood pressure, cholesterol, body mass index, HbA1c, smoking status and use of statin or antihypertensive medication, PN was associated with incident CVD events (HR 1.33; 95% CI 1.02 to 1.75, p=0.04). The addition of information on PN to a model based on standard CVD risk factors resulted in modest improvements in discrimination for CVD risk prediction and reclassified 6.9% of individuals into different risk categories.
Conclusions PN is associated with increased risk for a first cardiovascular event among individuals with diabetes.
A great deal of emphasis, clinical and financial, is placed on limb salvage efforts in diabetic patients suffering from lower extremity ulceration. This is because of the impression that amputation in such patients may be a proximal cause of death. While amputation is certainly a negative clinical outcome, it is not entirely clear that it causes death. In this systematic review, we examine the available literature to attempt to understand the role that the ulceration itself may play in mortality. In brief, we searched for human studies in OVID, CINAHL and the COCHRANE CENTRAL DATABASE from 1980 to 2013, looking for articles related to ulcer or wound of the foot, in patients with diabetes or peripheral vascular disease, and death. We looked for articles with 5 years of follow-up, or Kaplan-Meier estimates of 5-year mortality, and excluded reviews and letters. Articles were assessed for quality and potential bias using the Newcastle-Ottawa scale. We find that while the patient populations studied varied widely in terms of demographics and comorbidities, limiting generalisability, 5-year mortality rates after ulceration were around 40%. Risk factors for death commonly identified were increased age, male gender, peripheral vascular disease and renal disease.