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Mortality and diabetic foot related complications

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  #1  
Old 5th April 2008, 02:52 PM
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Default Mortality and diabetic foot related complications

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Does the Proximity of an Amputation, Length of Time Between Foot Ulcer Development and Amputation, or Glycemic Control at the Time of Amputation Affect the Mortality Rate of People with Diabetes who Undergo an Amputation?
Jones RN, Marshall WP.
Adv Skin Wound Care. 2008 Mar;21(3):118-23
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OBJECTIVES:: The main purpose of the authors' research was to compare the 3- and 5-year mortality rates of diabetic patients who have undergone a lower-extremity amputation, evaluating the proximity of the amputation in 3 groups (toe and foot amputation, BKA, and AKA), the timing of the amputation (within or after 2 years of the onset of the foot ulcer), and the effect of glycemic control at the time of amputation, regardless of the level of amputation.

METHODS AND DESIGN:: The subjects were 80 male inpatients at Illiana Veterans Health Care System who had diabetes, diabetic neuropathy, peripheral vascular disease, and a diabetic foot ulcer that resulted in an amputation. Of the 80 patients, 29 had a toe amputation, 30 had a BKA, and 21 had an AKA. The mean age in all 3 groups was 68.5 years +/- 7.2 years. The authors used the hemoglobin A1C (Hgb A1C) level to assess glycemic control.

MAIN OUTCOME MEASURES:: Several chi tests were used to compare the 3- and 5-year mortality rates among the amputation groups. An Hgb A1C level of 8% or less defined good glycemic control; an Hgb A1C level of more than 8% defined poor glycemic control. A chi test was used to compare glycemic control, the level of amputation, and the mortality rate. A chi test was also used to evaluate the length of time between ulcer formation and amputation, the level of amputation, and the mortality. All statistics were done using SPSS 10.0 student version.

CONCLUSIONS:: The research revealed a statistically significant difference in mortality among the 3 groups at 3 and 5 years. No statistically significant difference in mortality in patients with good glycemic control and patients with bad glycemic control was found. At 3 years, a statistically significant difference in mortality existed between patients who had an amputation within 2 years of ulcer formation and those who had an amputation after 2 years. At 5 years, no statistically significant difference existed between these 2 groups.
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Old 7th April 2008, 03:06 PM
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Default Re: Mortality and diabetes related amputations

Related threads:
Threads tagged with diabetic foot outcomes
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Old 22nd May 2008, 06:50 AM
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Default Re: Mortality and diabetes related amputations

High Rates of Comorbid Conditions in Patients With Type 2 Diabetes and Foot Ulcers
John Doupis, MD, PhD; Penelope Grigoropoulou, MD; Christina Voulgari, MD; Andreas Stylianou, MD; Anna Georga, MD; Petros Thomakos, MD; Konstantinos Xiromeritis, MD; Xrysi Koliaki, MD; Nicholas Katsilambros, MD; Nicholas Tentolouris, MD
Wounds - Volume 20 - Issue 5 - May 2008
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Background/Aim. Foot ulceration is one of the most important diabetic complications that results in major medical, social, and economic consequences for patients, their families, and society as a whole. Previous studies have shown increased mortality in patients with diabetes with foot ulcers; however, the reason for the high mortality in this group of patients is not known. The aim of this cross-sectional study was to investigate prevalence rates of comorbid conditions in patients with diabetes and foot ulcers.

Methods. A total of 742 patients with type 2 diabetes (234 with foot ulcers and 508 without ulcers), consecutively attending the outpatient diabetes and diabetic foot clinics of the authors’ hospital were reviewed. Clinical examination was performed to classify ulcers as neuropathic or neuroischemic, microvascular and macrovascular complications, as well as laboratory tests that were reviewed from medical records.

Results. Patients with diabetes with and without foot ulcers did not differ significantly in terms of age, sex, smoking habits, glycemic control, and prevalence rates of hypertension, dyslipidemia, and cerebrovascular disease. Known duration of diabetes was longer (P < 0.001), while the values of body mass index (P = 0.03) and creatinine clearance (P = 0.003) were lower in the patients with foot ulcers than in those without ulcers. In addition, prevalence rates of coronary artery disease (P = 0.005), lower extremity arterial disease (P < 0.001), retinopathy (P < 0.001), and nephropathy (P = 0.04), were higher in the patients with foot ulcers compared to those without ulcers. Additionally, duration of diabetes was longer and the prevalence rates of microvascular and macrovascular complications as well as hypertension, dyslipidemia, and smoking were much higher in the patients with neuroischemic ulcers in comparison to those with neuropathic ulcers.

Conclusion. The high mortality rates in patients with diabetes and foot ulcers may be due to the high prevalence rates of comorbid conditions, especially coronary artery disease and nephropathy.
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Old 18th November 2008, 03:14 PM
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Default Re: Mortality and diabetes related amputations

Mortality Rates and Diabetic Foot Ulcers
Is it Time to Communicate Mortality Risk to Patients with Diabetic Foot Ulceration?

Jeffrey M. Robbins, Gerald Strauss, David Aron, Jodi Long, Jennifer Kuba, and Yelena Kaplan
Journal of the American Podiatric Medical Association; Volume 98 Number 6 489-493 2008
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Five-year mortality rates after new-onset diabetic ulceration have been reported between 43% and 55% and up to 74% for patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin’s disease. These alarmingly high 5-year mortality rates should be addressed more aggressively by patients and providers alike. Cardiovascular diseases represent the major causal factor, and early preventive interventions to improve life expectancy in this most vulnerable patient cohort are essential. New-onset diabetic foot ulcers should be considered a marker for significantly increased mortality and should be aggressively managed locally, systemically, and psychologically.
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Old 23rd December 2008, 04:11 AM
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Default Re: Mortality and diabetes related amputations

Mortality of first-time amputees in diabetics: A 10-year observation.
Izumi Y, Satterfield K, Lee S, Harkless LB, Lavery LA.
Diabetes Res Clin Pract. 2008 Dec 19. [Epub ahead of print]
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AIMS: We analyze mortality of first-time diabetic amputees by stratifying by level of amputation, differentiating short-term and long-term mortality.

METHODS: We evaluated 277 diabetic patients who received their first lower extremity amputation (LEA) during 1993-97. Subjects were followed until December 2003, and categorized by level of amputation. We compared the mortality difference by level for 0-10 years, 0-10 months, and 10 months-10 years, and examined the association of comorbid conditions and death for each level.

RESULTS: We found a significant difference in mortality by amputation level for 0-10 years (p<0.05) and <10 months (p<0.01) survival, but not for the one of 10 months-10 years. For major amputees deceased within 10 months, sepsis was as frequent a cause of death as cardiovascular disease. In distal amputees, CVD, CAD and ESRD were strongly associated with death, but only CAD was associated death among major amputees.

CONCLUSION: For diabetic patients undergoing first LEAs, the mortality of major amputees was worse than that of minor amputees due to the difference in first 10-month mortality. The history of comorbid conditions in first-time major amputees was less important than in minor amputees since sepsis was the frequent cause of death in major amputees in this early period.
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Old 31st March 2009, 03:37 PM
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Default Re: Mortality and diabetes related amputations

Mortality after major amputation in diabetic patients with critical limb ischemia who did and did not undergo previous peripheral revascularization Data of a cohort study of 564 consecutive diabetic patients.
Faglia E, Clerici G, Caminiti M, Curci V, Clerissi J, Losa S, Casini A, Morabito A.
J Diabetes Complications. 2009 Mar 26. [Epub ahead of print]
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BACKGROUND: To evaluate the survival after major lower limb amputation, at a level either below (BKA) or above (AKA) the knee, in diabetic patients admitted to hospital because of critical limb ischemia (CLI).

METHODS: From January 1999 to December 2003, 564 diabetic patients were consecutively admitted to our Foot Center because of CLI and followed up until December 2005. A revascularization procedure was performed in 537 patients (95.2%): in 420 with peripheral angioplasty, in 117 with peripheral bypass graft. Neither endoluminal nor surgical revascularization was practicable in 27 (4.8%) patients.

RESULTS: Major amputation was performed in a total of 55 (9.8%) patients. Among the clinical and demographic variables evaluated, age was significantly lower (67.3+/-10.1 vs. 76.7+/-10.4, P<.001), duration of diabetes was higher (17.1+/-11.1 vs. 13.4+/-10.0, P=.013), and current smoking was more frequent (38.5% vs. 25.0%, P<.001) in revascularized amputees. The amputation free median time for revascularized patients was 5.11 months, and for nonrevascularized patients, 0.33 months. The log-rank test for equality of survivor function without amputation between amputees with or without revascularization was 31.76 (P<.001). Among the 55 amputees, 11 (28.2%) out of the 39 revascularized patients and 13 (81.2%) out of the 16 nonrevascularized patients died. The log-rank test for equality of survivor function was 6.83 (P=.009). The Cox model performed to evaluate the association between the recorded variables and the mortality showed a significant hazard ratio only with age (hazard ratio for 1 year 1.11, P=.003, confidence interval 1.04-1.19).

CONCLUSIONS: Our data suggest that the revascularization allows to postpone the major amputation, and that the survival of revascularized amputees is better than that of nonrevascularized amputated patients. All these data offer further encouragement to revascularize all diabetic patients with CLI.
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Old 30th April 2009, 02:38 PM
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Default Re: Mortality and diabetes related amputations

Mortality Risk of Charcot Arthropathy Compared With That of Diabetic Foot Ulcer and Diabetes Alone
Diabetes Care 32:816-821, 2009
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OBJECTIVE— The purpose of this study was to compare mortality risks of patients with Charcot arthropathy with those of patients with diabetic foot ulcer and those of patients with diabetes alone (no ulcer or Charcot arthropathy).

RESEARCH DESIGN AND METHODS— A retrospective cohort of 1,050 patients with incident Charcot arthropathy in 2003 in a large health care system was compared with patients with foot ulcer and those with diabetes alone. Mortality was determined during a 5-year follow-up period. Patients with Charcot arthropathy were matched to individuals in the other two groups using propensity score matching based on patient age, sex, race, marital status, diabetes duration, and diabetes control.

RESULTS— During follow-up, 28.0% of the sample died; 18.8% with diabetes alone and 37.0% with foot ulcer died compared with 28.3% with Charcot arthropathy. Multivariable Cox regression shows that, compared with Charcot arthropathy, foot ulcer was associated with 35% higher mortality risk (hazard ratio 1.35 [95% CI 1.18–1.54]) and diabetes alone with 23% lower risk (0.77 [0.66–0.90]). Of the patients with Charcot arthropathy, 63% experienced foot ulceration before or after the onset of the Charcot arthropathy. Stratified analyses suggest that Charcot arthropathy is associated with a significantly increased mortality risk independent of foot ulcer and other comorbidities.

CONCLUSIONS— Charcot arthropathy was significantly associated with higher mortality risk than diabetes alone and with lower risk than foot ulcer. Patients with foot ulcers tended to have a higher prevalence of peripheral vascular disease and macrovascular diseases than patients with Charcot arthropathy. This finding may explain the difference in mortality risks between the two groups
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Old 5th September 2009, 02:35 PM
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Default Re: Mortality and diabetes related amputations

A History of Foot ulcer increases Mortality among Persons with Diabetes. 10-year Follow-up of the Nord-Trondelag Health Study, Norway.
Iversen MM, Tell GS, Riise T, Hanestad BR, Ostbye T, Graue M, Midthjell K.
Diabetes Care. 2009 Sep 3. [Epub ahead of print]
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Objective - To compare mortality rates for persons with diabetes with and without a history of foot ulcer (HFU) and with the non-diabetic population.

Research design and methods- This population-based study included 155 diabetic persons with a HFU, 1,339 diabetic persons without a HFU, and 63,632 non-diabetic persons who were all followed for 10 years with mortality as the end point.

Results - During the follow-up period, a total of 49.0% of diabetic persons with a HFU died, compared to 35.2% of diabetic persons without a HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having a HFU was associated with more than a twofold (2.29 [95% CI 1.82-2.88]) hazard risk for mortality compared to the non-diabetic group. In corresponding analyses comparing diabetic persons with and without a HFU, a HFU was associated with 47% increased mortality (1.47 [1.14-1.89]). Significant covariates were older age, being male and current smoking. After also including HbA(1c), insulin use, microalbuminuria, cardiovascular disease and depression scores in the model, each was significantly related to life expectancy.

Conclusions - A HFU increased mortality risk among community-dwelling adults and elderly people with diabetes. The excess risk persisted after adjusting for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among persons with a HFU, who may be particularly vulnerable to adverse outcomes.
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Old 25th November 2009, 02:59 PM
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Default Re: Mortality and diabetes related amputations

History of Foot Ulcer Increases Mortality Among Individuals With Diabetes
Diabetes Care December 2009 vol. 32 no. 12 2193-2199
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OBJECTIVE To compare mortality rates for individuals with diabetes with and without a history of foot ulcer (HFU) and with that for the nondiabetic population.

RESEARCH DESIGN AND METHODS This population-based study included 155 diabetic individuals with an HFU, 1,339 diabetic individuals without an HFU, and 63,632 nondiabetic individuals who were all followed for 10 years with mortality as the end point.

RESULTS During the follow-up period, a total of 49.0% of diabetic individuals with an HFU died, compared with 35.2% of diabetic individuals without an HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having an HFU was associated with more than a twofold (2.29 [95% CI 1.82–2.88]) hazard risk for mortality compared with that of the nondiabetic group. In corresponding analyses comparing diabetic individuals with and without an HFU, an HFU was associated with 47% increased mortality (1.47 [1.14–1.89]). Significant covariates were older age, male sex, and current smoking. After inclusion of A1C, insulin use, microalbuminuria, cardiovascular disease, and depression scores in the model, each was significantly related to life expectancy.

CONCLUSIONS AN HFU increased mortality risk among community-dwelling adults and elderly individuals with diabetes. The excess risk persisted after adjustment for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among individuals with an HFU, who may be particularly vulnerable to adverse outcomes.
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Old 27th February 2010, 04:03 PM
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Default Re: Mortality and diabetic foot related complications

MORTALITY ASSOCIATED WITH ACUTE CHARCOT FOOT AND NEUROPATHIC FOOT ULCERATION.
van Baal J, Hubbard R, Game F, Jeffcoate W.
Diabetes Care. 2010 Feb 25. [Epub ahead of print]
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Objective - To compare the mortality of patients with an acute Charcot foot with a matched population with uninfected neuropathic foot ulcers (NFU)

Research design and methods - Data were extrated from a specialist departmental database, supplemented by hospital records. The findings were compared with the results of earlier populations with Charcot foot and uninfected NFU managed from 1980. Finally, the results of all patients with acute Charcot foot and all controls managed between 1980 and 2007 were compared with normative mortality data for the UK population.

Results - 70 patients with presented with an acute Charcot foot (mean age 57.4+/-12.0; 48 (68.6%) male) between 2001 and 2007; there were 66 matched controls. By 1 October 2008, 13 (18.6%; 8 male) patients with a Charcot foot had died, after a median of 2.1 (IQR 1.1-3.3) years. 22 (33.3%; 20 male) controls had also died, after a median of 1.3 (IQR 0.6-2.5) years. There was no difference in survival between the two groups (log rank p>0.05). Median survival of all 117 patients with acute Charcot foot managed between 1980 and 2007 was 7.88 (IQR 4.0-15.4) years and was not significantly different from the control NFU patients: 8.43 (IQR 3.4-15.8) years . When compared to normative UK population data, life expectancy in the two groups was reduced by 14.4 and 13.9 years, respectively.

Conclusions - These data confirm that the mortality in patients presenting to our unit with either an acute Charcot foot and an uninfected neuropathic ulcer was unexpectedly high.
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Old 5th March 2010, 07:19 AM
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Default Re: Mortality and diabetic foot related complications

LONG TERM OUTCOMES OF DIABETIC PATIENTS WITH CRITICAL LIMB ISCHEMIA FOLLOWED IN A THERTIARY REFERRAL DIABETIC FOOT CLINIC.
Uccioli L, Gandini R, Giurato L, Fabiano S, Pampana E, Spallone V, Vainieri E, Simonetti G.
Diabetes Care. 2010 Mar 3. [Epub ahead of print]
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Objectives. We describe the long term outcomes of 510 diabetic patients with Critical Limb Ischemia(CLI), seen at the University Hospital of Rome Tor Vergata, a tertiary care clinic, and an active foot ulcer or gangrene.

Methods. These patients were seen between 11/02 and 11/07 (mean FU 20+/-13mo.1-66). The Texas Wound Classification(TWC) was used to grade these wounds that were either class C(ischemia) and D(ischemia+infection) and grade 2-3(deep-very deep). This comprehensive treatment protocol includes rapid and extensive initial debridment, aggressive use of peripheral Percutaneous Angioplasty (PA), empiric IV antibiotic therapy and strict follow-up.

Results. The protocol was totally applied in 456(89.4%)(PA+) and partially(without PA) in 54(10.6%) patients(PA-). Outcomes for whole and PA+ve and PA-ve patients are respectively n(%): Healing: 310(60.8), 284(62.3), 26(48.1); Major amputation: 80(15.7), 67(14.7) 13(24.1); Death: 83(16.27), 68(14.9), 15(27.8); Nonhealing(NH): 37(7.25), 37(8.1), 0(0);(chi(2)<0.0009). Predicting variables at multivariate analysis: Healing: ulcer dimension, infection and ischemic heart disease; Major amputation: ulcer dimension, number of minor amputations and age. Additional predicting variables for PA+ patients: Healing: DeltaTcPO2; Major amputation: Basal TcPO(2), basal HbA1c, DeltaTcPO(2) and PA technical failure.

Conclusion. The early diagnosis of CLI, the aggressive treatment of infection, extensive use of PA in ischemic affected ulcers offers improved outcome for many previously at risk limbs. Ulcer size>5cm(2) indicates reduced chance of healing and increased risk of major amputation. It was felt that all ulcers warrant aggressive treatment including PA and that treatment should be considered even in the presence of small ischemic ulcers.
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Old 20th March 2010, 02:50 PM
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Default Re: Mortality and diabetic foot related complications

Comparison of post amputation outcome in patients with type 2 diabetes from specialized foot care centres in three developing countries.
Viswanathan V, Wadud JR, Madhavan S, Rajasekar S, Kumpatla S, Lutale JK, Abbas ZG.
Diabetes Res Clin Pract. 2010 Mar 16. [Epub ahead of print]
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OBJECTIVE: To evaluate post amputation outcome and associated complications in type 2 diabetic patients who had undergone major amputations in developing countries.

PATIENTS AND METHODS: A total of 526 (M:F; 369:157) subjects from three centers [India (IND), n=194, Bangladesh (BAN) n=177 and Tanzania (TAN) n=155 who had undergone amputation and subsequently visited the hospital were included in this analysis. Details on foot problems and associated complications were recorded.

RESULTS: The prevalence of amputations was similar in all centres. The history of minor amputation and foot deformity was high in BAN. Recurrence of foot ulceration was more in TAN (30%) than in IND (9%) and BAN (11%). Re-amputation rate was similar in all groups (3%). The use of artificial limb was most in BAN (97%). Myocardial infarction was more prevalent in IND (15%). In Tanzania, 31% had died during the follow-up period and it was 16% and 5% in IND and BAN. The causes of death were infection due to septicemia and cardiovascular events which finally led to multisystem organ failure.

CONCLUSION: The outcome following a major diabetic foot amputation was compared in three developing countries. Recurrence of foot infection was common in Tanzania. The most frequent causes of death were infection and cardiovascular events
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Old 24th April 2010, 02:34 PM
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Default Re: Mortality and diabetic foot related complications

Trends in lower extremity amputations in people with and without diabetes in England, 1996-2005.
Vamos EP, Bottle A, Majeed A, Millett C.
Diabetes Res Clin Pract. 2010 Feb;87(2):275-82.
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AIMS: To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England.

METHODS: All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004.

RESULTS: There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004.

CONCLUSIONS: While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.
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Old 23rd March 2011, 12:14 PM
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Default Re: Mortality and diabetic foot related complications

Assessing the Long-Term Outcomes of Minor Lower Limb Amputations: A 5-Year Study.
Uzzaman MM, Jukaku S, Kambal A, Hussain ST.
Angiology. 2011 Mar 18. [Epub ahead of print]
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Our aim was to assess the long-term outcome for minor forefoot amputations. A retrospective study of 126 patients who had such amputations between 1999 and 2004 was performed. Patients were divided into 2 groups, diabetic (group A: 79 patients) and nondiabetic (group B: 47 patients). Angiograms were requested in 45 patients in group A compared with 31 patients in group B (P = ·77). In group A, 11 patients underwent further ipsilateral amputations compared with 30 patients in group B (P = ·02.). The 2 groups were equally likely to have vascular reconstruction (35% vs 37%). The overall 5-year mortality was 27%, with 58% of deaths occurring within the first year. This study shows that foot amputees have high mortality and reintervention rates. Adequate utilization of vascular services, extra vigilance in the prevention of complications, and risk factor modifications are required to improve postoperative outcomes.
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Old 13th April 2011, 03:41 PM
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Default Re: Mortality and diabetic foot related complications

History of foot ulcers increases mortality among patients with diabetes in Northern Thailand.
Junrungsee S, Kosachunhanun N, Wongthanee A, Rerkasem K.
Diabet Med. 2011 May;28(5):608-11. doi: 10.1111/j.1464-5491.2011.03262.x.
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Aims  Studies within the Caucasian population with diabetes showed an increased mortality in patients with diabetic foot ulcers. However, there were no such studies based on Asian populations. We therefore designed our study on the association of foot ulcer with mortality within the Asian population.

Methods  Ninety-seven Asian individuals with diabetes who had previously participated in the 'Multidisciplinary Diabetic Foot Protocol' between 2005 and 2007 at our centre were followed up in 2010 to ascertain their mortality rate. Cox proportional-hazard regression analyses were used to estimate hazard ratios.

Results  Forty-seven patients had a history of foot ulcer (group 1), while 50 had none (group 2). The mean follow-up was 43.74 months. Twenty-one patients died during this period (21.65%). The mortality rates in group 1 and group 2 were 15 (31.92%) and six (12.00%), respectively. Patients with a history of foot ulcer had higher mortality rates than those without (hazard ratio 3.51, 95% CI 1.03-11.96, P = 0.04).

Conclusions  Our study showed that history of foot ulcer increased mortality. This association appeared to be stronger in younger Asian patients than those in the Caucasian populations.
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Old 6th July 2011, 12:56 PM
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Default Re: Mortality and diabetic foot related complications

Minor amputation in patients with diabetes mellitus and severe foot ulcers achieves good outcomes.
Svensson H, Apelqvist J, Larsson J, Lindholm E, Eneroth M.
J Wound Care. 2011 Jun;20(6):261-74.
Quote:
Objective: To analyse the outcome of minor amputations (through, or distal to, the ankle joint) in patients with diabetes.

Method: All diabetic patients in a defined population undergoing one or more minor amputation between 1982 and 2006 were investigated according to a standardised protocol and were followed until final outcome (healing or death). A total of 410 consecutive amputations in 309 patients with a median age of 73 (32-93) years were identified.

Results: In 94% of amputations, deep infection (39%) and/or gangrene (55%) was present. Severe peripheral vascular disease or critical limb ischaemia was present in 61% of amputations. 261/410 (64%) of the amputations healed at a level below the ankle joint; 69/410 (17%) healed after a re-amputation above the ankle joint; in 76/410 of amputations (19%), the patient died before healing could occur. In surviving patients, 79% of the amputations healed below the ankle. Median healing time for amputations that healed below the ankle was 26 (2-250) weeks; 21% of amputations required a re-amputation above the ankle. None of the analysed parameters excluded the possibility of healing below the ankle.

Conclusion: In this population-based survey, the goal of avoiding major amputation was achieved in almost two thirds of minor amputations, but at the price of long healing times. In almost all amputations, the patient had deep infection and/or gangrene. In spite of this, 64% of all amputations, and 79% of amputations in surviving patients, healed at a level below the ankle. This indicates that minor amputations in these patients are worthwhile.
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Old 3rd February 2012, 03:58 PM
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Default Re: Mortality and diabetic foot related complications

Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do?
Kristensen MT, Holm G, Kirketerp-Møller K, Krasheninnikoff M, Gebuhr P.
Interact Cardiovasc Thorac Surg. 2012 Jan 31
Quote:
The aim of this retrospective study was to evaluate factors potentially influencing short- and long-term mortality in patients who had a non-traumatic lower limb amputation in a university hospital. A consecutive series of 93 amputations (16% toe/foot, 33% trans-tibial, 9% through knee and 42% trans-femoral) were studied. Their mean age was 75.8 years; 21 (23%) were admitted from a nursing home and 87 (92%) were amputated due to a vascular disease and/or diabetes. Thirty days and 1-year mortality were 30 and 54%, respectively. Cox regression analysis demonstrated that the 30-day mortality was associated with older age (P = 0.01), and the number of co-morbidities (P = 0.04), when adjusted for gender, previous amputations, cause of and amputation level, and residential status. Thus, a patient with 4 or 5 co-morbidities (n = 20) was seven times more likely to die within 30 days, compared with a patient with 1 co-morbidity (n = 16). Further, the risk of not surviving increased with 7% per each additional year the patient got older. Of concern, almost one-third of patients died within 1 month. This may be unavoidable, but a multidisciplinary, optimized, multimodal pre- and postoperative programme should be instituted, trying to improve the outcome.
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Old 21st July 2012, 12:54 PM
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Default Re: Mortality and diabetic foot related complications

Long-Term Prognosis of Diabetic Foot Patients and Their Limbs: Amputation and death over the course of a decade.
Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT, Klemp U, Roden T, Icks A, Haastert B, Rümenapf G, Abbas ZG, Bharara M, Armstrong DG.
Diabetes Care. 2012 Jul 18.
Quote:
OBJECTIVE
There is a dearth of long-term data regarding patient- and limb survival in patients with diabetic foot ulcers (DFUs). The purpose of our study was therefore to prospectively investigate the limb and person survival of DFU patients during a follow-up period of more than 10 years.

RESEARCH DESIGN AND METHODS
Two hundred forty-seven patients with DFUs and without previous major amputation consecutively presenting to a single diabetes center between June 1998 and December 1999 were included in this study and followed up until May 2011. Mean patient age was 68.8 ± 10.9 years, 58.7% were male, and 55.5% had peripheral arterial disease (PAD). Times to first major amputation and to death were analyzed with Kaplan-Meier curves and Cox multiple regression.

RESULTS
A first major amputation occurred in 38 patients (15.4%) during follow-up. All but one of these patients had evidence of PAD at inclusion in the study, and 51.4% had severe PAD [ankle-brachial pressure index ≤0.4]). Age (hazard ratio [HR] per year, 1.05 [95% CI, 1.01-1.10]), being on dialysis (3.51 [1.02-12.07]), and PAD (35.34 [4.81-259.79]) were significant predictors for first major amputation. Cumulative mortalities at years 1, 3, 5, and 10 were 15.4, 33.1, 45.8, and 70.4%, respectively. Significant predictors for death were age (HR per year, 1.08 [95% CI, 1.06-1.10]), male sex ([1.18-2.32]), chronic renal insufficiency (1.83 [1.25-2.66]), dialysis (6.43 [3.14-13.16]), and PAD (1.44 [1.05-1.98]).

CONCLUSIONS
Although long-term limb salvage in this modern series of diabetic foot patients is favorable, long-term survival remains poor, especially among patients with PAD or renal insufficiency.
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Old 7th August 2012, 12:46 PM
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Default Re: Mortality and diabetic foot related complications

Nontraumatic Amputation : Incidence and Cost Analysis.
Jindeel A, Narahara KA.
Int J Low Extrem Wounds. 2012 Aug 2
Quote:
Lower extremity amputation (LEA) is devastating for those affected and a significant factor in health care costs. Although the overall incidence of amputation has been declining, the decline is not universal. The objectives of this study were to identify patients with nontraumatic amputation at Harbor-UCLA Medical Center (HUMC) from January 2000 to January 2007, to calculate their 1-year and 5-year mortality rates after amputation and to estimate the financial cost of those amputations. The authors searched the HUMC electronic database by ICD codes (84.10-84.18) to identify patients with LEA and subsequently searched the National Death Index database for deaths in study subjects to calculate mortality rates. HUMC is a Los Angeles County tertiary teaching medical center that provides medical care to a large percentage of the Los Angeles County population, especially those without health insurance. There were 1169 admissions in 847 patients with nontraumatic LEA with a 1-year mortality rate of 9.1% and 5-year mortality rate of 25.6%. Only major amputation and increasing age were independent risk factors for 1-year mortality rate. At 1 year, the re-amputation rate for nontraumatic LEA was 26.7%. African American and Hispanic females had a significantly higher percentage of major amputations than corresponding males and white females. The average length of hospital stay was more than double for patients with nontraumatic amputation than for all other admissions (12.7 vs 5.3 days). There were 14 846 hospital days for 1169 nontraumatic amputation admissions with an estimated cost of $47 033 767. Amputation remains common at HUMC and the associated mortality rates and economic costs are high. In the authors' opinion, a coordinated and serious campaign by all involved in the health care system is urgently needed to implement proven and effective measures such as establishing multidisciplinary foot care clinics to reduce amputation.
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Old 15th August 2012, 04:33 AM
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Default Re: Mortality and diabetic foot related complications

The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis.
Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK, Hinchliffe RJ.
Diabetologia. 2012 Aug 14.
Quote:
AIMS/HYPOTHESIS:
It is well established that diabetes mellitus increases the risk of cardiovascular disease (CVD) and all-cause mortality. Observational studies suggest that a history of diabetic foot ulceration (DFU) may increase this risk further still. We sought to determine to what extent DFU is associated with excess risk over and above diabetes.

METHODS:
We identified studies reporting on associations of DFU with CVD and all-cause mortality. We obtained data on incident events of all-cause mortality, fatal myocardial infarction and fatal stroke. Study-specific estimates were pooled using a random-effects meta-analysis and the statistical heterogeneity of included studies was assessed using the I (2) statistic.

RESULTS:
The eight studies included reported on 3,619 events of all-cause mortality during 81,116 person-years of follow-up. DFU was associated with an increased risk of all-cause mortality (RR 1.89, 95% CI 1.60, 2.23), fatal myocardial infarction (2.22, 95% CI 1.09, 4.53) and fatal stroke (1.41, 95% CI 0.61, 3.24). CVD mortality accounted for a similar proportion of deaths in DFU and non-DFU patients.

CONCLUSIONS/INTERPRETATION:
Patients with DFU have an excess risk of all-cause mortality, compared with patients with diabetes without a history of DFU. This risk is attributable, in part, to a greater burden of CVD. If this result is validated in other studies, strategies should evaluate the role of further aggressive CVD risk modification and ulcer prevention in those with DFU.
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Old 10th October 2012, 01:09 PM
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Default Re: Mortality and diabetic foot related complications

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The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis.
Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK, Hinchliffe RJ.
Diabetologia. 2012 Aug 14.
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Researchers link diabetic foot ulcers with higher risk of death, heart attack and stroke
10 October 2012
Quote:
People with diabetes who develop foot ulcers are at more risk of dying prematurely than those without the complication, finds a new large-scale study. The researchers say the findings highlight the potential need for improved detection and management of those with diabetes and foot ulcers.

The study, which is the largest analysis of diabetes into the link between foot ulcers and the condition, is published in the latest edition (November) of the journal Diabetologia.

About 3.7million people in the UK have diabetes, including an estimated 850,000 people who have the condition but do not know it. Diabetes can damage a person’s blood vessels and nerves, especially if their blood sugar is poorly controlled.

Poor circulation and nerve damage in the feet makes people vulnerable to unnoticed cuts or other injuries and progress into poorly healing ulcers, or sores. In severe cases, this can lead to foot or leg amputation.

In a study of 17,830 patients with diabetes – 3,095 diagnosed with foot ulceration and 14,735 without – researchers from St George’s, University of London investigated how diabetic foot ulcers affected a person’s risk of dying earlier. They found that those with a history of foot ulceration had a higher death rate than those without. There were an extra 58 deaths per 1,000 people each year with diabetic foot ulcers.

The investigators analysed patient records from eight studies, conducted in Europe, America, Australasia and South-East Asia, published between 2006 and 2011. The length of time the health of participants was followed for varied between an average of two and 10 years for each of the studies.

People with foot ulcers and diabetes showed more cardiovascular risk factors, such as high blood pressure, and were more likely to die from cardiovascular causes. Approximately half of the additional mortalities were due to cardiovascular disease, such as heart attack or stroke.

The cause of non-cardiovascular deaths was not studied as part of this investigation but the researchers say this is potentially linked to infections and complications of foot ulceration, such as blood poisoning.

Robert Hinchliffe from St George’s, University of London, who co-led the study, said:

“Our research, which is the largest and therefore most reliable study to date, shows that people with diabetes who have foot ulcers are at considerably higher risk of an earlier death compared to those patients without. We suspect that this may be due in part to the effect of infections among those with foot ulcers and the greater co-existence of cardiovascular disease and foot ulcers with diabetes although the reasons are not entirely clear.”

The researchers say these results underline the importance of a two-pronged approach for people with diabetes: enhanced foot ulceration screening as early detection and treatment may help reduce some of the complications; and more intensive control of blood pressure and cholesterol among those diagnosed with foot ulcers as they are at higher cardiovascular risk.

Currently, experts already recommend that people with diabetes undertake a number of precautions to prevent foot ulcers including blood sugar control, wearing socks to prevent cuts, self-checking for abrasions and getting a complete foot examination at least once a year.

Existing guidelines to prevent cardiovascular disease include healthy diet choices, regular exercise, a medical check-up at least once a year and, often, medically prescribed drug treatment.

Professor Kausik Ray, who also co-led the study, said:

“Our results warrant further investigation as to whether even greater control of risk factors such as blood pressure, blood glucose and early preventative screening can further reduce mortality among those with foot ulcers. There is likely an unmet potential to reduce deaths in this group.”

The full journal article, ‘The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis’, is available on the Diabetologia website [ to journal subscribers only] at http://www.springerlink.com/content/m773660227386615/
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Old 14th February 2013, 03:02 PM
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Default Re: Mortality and diabetic foot related complications

The impact of metabolic control and QTc prolongation on all-cause mortality in patients with type 2 diabetes and foot ulcers.
Fagher K, Löndahl M.
Diabetologia. 2013 Feb 12.
Quote:
AIMS/HYPOTHESIS:
The increased all-cause mortality in patients with chronic diabetic foot ulcers cannot fully be explained by traditional cardiovascular risk factors. The significance of heart-rate-corrected QT (QTc) prolongation, a finding often seen in these patients, is unknown. Recently, the importance of metabolic control and hypoglycaemia has been discussed. The aim of this study was to evaluate the impact of different HbA(1c) levels and QTc prolongation on all-cause mortality in the high-risk population of patients with type 2 diabetes mellitus and foot ulcers.

METHODS:
All patients with type 2 diabetes, younger than 80 years, visiting our diabetes foot unit, with a foot ulcer duration >4 weeks, were screened for participation. Patients on dialysis were excluded. Patients were grouped according to HbA(1c) level and QTc time ≤ or > 440 ms.

RESULTS:
Patients (n = 214, median age 69.1 years) were grouped according to HbA(1c) level (HbA(1c) < 7.5% [<58 mmol/mol] n = 81, 7.5-8.9% [58-74 mmol/mol] n = 70, >8.9% [>74 mmol/mol] n = 63). Baseline characteristics, including use of potential hypoglycaemic drugs, were similar between groups. During the 8 years of follow-up 151 patients died (70.6%) and HbA(1c) < 7.5% (<58 mmol/mol) was strongly associated with increased mortality. The highest mortality was seen in patients with a combination of HbA(1c) < 7.5% (<58 mmol/mol) and QTc prolongation, with an 8 year mortality of 92.1% as compared with 48.8% in those with HbA(1c) < 7.5% (<58 mmol/mol) but without QTc prolongation.

CONCLUSION/INTERPRETATIONS:
HbA(1c) < 7.5% (<58 mmol/mol) in a high-risk population of patients with type 2 diabetes and foot ulcers is associated with a significantly higher mortality, particularly in patients with QTc prolongation.
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Old 4th May 2013, 07:37 AM
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Default Re: Mortality and diabetic foot related complications

Outcome of Ischemic Foot Ulcer in Diabetic Patients Who Had no Invasive Vascular Intervention
Elgzyri T., Larsson J., Thörne J., Eriksson K.-F., Apelqvist J.
Eur. J. Vasc. Endovasc. Surg. 2013
Quote:
Objective/background: There is limited information regarding outcome in patients not available for revascularisation. Our aim was to identify factors related to ulcer healing in diabetic patients with severe peripheral arterial disease who were not available for revascularisation.

Methods: Diabetic patients with a foot ulcer, consecutively presenting at a multidisciplinary foot centre with systolic toe pressure <45 all="" an="" ankle="" continuous="" death.="" excluded.="" follow-up="" had="" healing="" included.="" mmhg="" or="" p="" patients="" pressure="" prospectively="" received="" revascularisation="" until="" were="" who="">Results: Out of 602 patients (median age: 76 years) included in this study, 50% healed either primarily (76%) or with a minor amputation (24%). Seventeen percent of patients healed after major amputation and 33% died unhealed. By regression analysis, rest pain, impaired renal function, ischemic heart disease, cerebral vascular disease, extent of tissue destruction, and ankle pressure >50 mmHg affected the outcome of the ulcers.

Conclusion: Diabetic patients with ischemic foot ulcers not available for revascularisations are not excluded from healing without major amputation. Factors strongly related to outcome were co-morbidity, severity of peripheral arterial disease, and extent of tissue destruction. Our findings reinforce the need for a classification system considering these factors at decision-making for vascular intervention.
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Old 9th May 2013, 08:24 AM
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Default Re: Mortality and diabetic foot related complications

Heart failure in hospitalized patients with diabetic foot ulcers: clinical characteristics and its relationship to prognosis.
Xu L, Qian H, Gu J, Shi J, Gu X, Tang Z.
J Diabetes. 2013 May 8.
Quote:
BACKGROUND:
In the present study, we evaluated the incidence of heart failure (HF) in diabetic foot ulcer (DFU) patients, investigated clinical characteristics and its relationship to prognosis in such a population.

METHODS:
Clinical characteristics of 330 consecutive Chinese subjects (137 males and 193 females) hospitalized for diabetic foot ulcers were collected. Clinical characteristics were assessed to determine the effects about the presence of HF on DFU. All the subjects were followed up for 3 months. Rates of healing, new ulcers, amputations and mortality were calculated at the end of the follow-up to analyze the effect of heart failure on the prognosis of diabetic foot ulcer.

RESULTS:
HF accounted for 64.3% of the patients with ulcers, and the rate would increase from Wagner 1 to Wagner 5 ( 42.4% vs.59.1%vs. 64.7% vs. 73.3% vs. 87.0%), higher than 33.6% for diabetes(Wagner 0). Factors associated with high risk for HF were plasma albumin level, creatine clearance rate, NYHA grade, and neutrophil count. And HF conferred a greater increase in relative risk of worse prognosis when compared with non-HF. The 3-month healing rates of diabetic foot ulcer were 60.3% vs. 75.7% between HF and non-HF patients. More frequent recurrences and amputations were detected in HF when compared with non-HF counterparts (13.2% vs. 7.5%, 28.6% vs. 20.0%, respectively, P<0.05). All-cause mortality occurred in 14 of 126 HF subjects compared with 3 of 70 non-HF subjects (11.1% vs. 4.3%, P<0.05).

CONCLUSIONS:
The prevalence of HF was high in Chinese inpatient with DFU, and the presence of HF indicated a worse prognosis.
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Old 19th June 2013, 01:43 PM
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Default Re: Mortality and diabetic foot related complications

In-hospital mortality and length of stay in patients with diabetes having foot disease.
Nirantharakumar K, Saeed M, Wilson I, Marshall T, Coleman JJ.
J Diabetes Complications. 2013 Jun 14.
Quote:
OBJECTIVE:
We aimed to determine whether in-patient mortality and length of stay were greater in diabetes patients with foot disease compared to those without foot disease.
METHODS:
Retrospective data analysis of admissions over four years (2007-2010) to University Hospital Birmingham. Based on discharge diagnostic codes we grouped admissions into those 1) with amputation, 2) with foot disease and 3) without foot disease. Inpatient mortality and length of stay were compared between the three groups, adjusting for confounders.
RESULTS:
We identified 25,118 admissions with diabetes of which 1149 admissions (4.6%) had foot disease and another 195 (0.8%) had a code for lower limb amputation. When compared to those without foot disease the adjusted odds ratio for inpatient mortality was 1.31 (95% CI 1.04-1.65 P=0.02) in the foot disease group, and 1.02 (95% CI 0.56-1.85 P=0.95) in the amputation group; and the adjusted relative ratio for length of stay was 2.01 (95 CI 1.86-2.16 P<0.001) in the foot disease group and 3.08 (95% CI 2.60-3.65 P<0.001) in the amputation group.
CONCLUSION:
Foot disease in hospitalised patients with diabetes is associated with increased length of stay and inpatient mortality. Our study adds to evidence on excess mortality associated with diabetic foot disease and to evidence on excess mortality observed in people with diabetes admitted to hospitals.
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Old 21st September 2013, 12:06 PM
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Default Re: Mortality and diabetic foot related complications

Clinical outcomes of below knee amputations in diabetic foot patients.
Wong KL, Nather A, Liang S, Chang Z, Wong TT, Lim CT.
Ann Acad Med Singapore. 2013 Aug;42(8):388-94.
Quote:
Introduction: This study aims to evaluate the predictive factors affecting the clinical outcome of Below Knee Amputations (BKA) performed in diabetic foot patients admitted to National University Hospital (NUH) Multi-Disciplinary Diabetic Foot Team.

Materials and Methods: This is a prospective cohort study of 151 patients admitted to the Department of Orthopaedic Surgery, NUH, for Diabetic Foot Problems (DFP) from January 2006 to January 2010. All had undergone BKA performed by NUH Multi-Disciplinary Diabetic Foot Team. Statistical analyses (univariate and multivariate analysis with logistic regression) were carried out using SPSS version 18.0, for factors such as demographic data, diabetic duration and control, clinical findings and investigations, indications for surgery, preoperative investigations and evaluation, microbiological cultures, and these were compared to the clinical outcome of the patient. A good clinical outcome is defined as one not requiring proximal re-amputation and whose stump healed well within 6 months. The ability to ambulate with successful use of a prosthesis after 1 year was documented. Statistical significance was set at P <0.050.

Results: Mean age of study population was 55.2 years with a male to female ratio of about 3:2. Mean follow up duration was 36 months. Of BKAs, 73.5% gave a good outcome. Univariate analysis showed that smoking, previous limb surgery secondary to diabetes, high Total White Count (TW), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Urea, Creatinine (Cr), Neutrophils, absence of posterior tibial and popliteal pulses, low Ankle Brachial Index (ABI) and Toe Brachial Index (TBI) were associated with poor clinical outcome. Multivariate analysis showed that high CRP, ESR, Neutrophils, absence of popliteal pulse and low ABI were associated with poor clinical outcome. Of patients, 50.3% attained mobility with prosthesis after 1 year. Mortality rate was 21.2% within 6 months of operation, with sepsis being the most significant cause of death.

Conclusion: Success rate of BKA was 73.5%, with mortality rate being 21.2% within 6 months. In this cohort, 50.3% were able to attain eventual mobility with prosthesis after 1 year. Sepsis was the most significant cause of death. Markers of infection such as high CRP, ESR, neutrophils; and indicators of poor vascularity such as absence of popliteal pulse and low ABI were significantly associated with poor clinical outcome.
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Old 13th January 2014, 07:37 PM
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Default Re: Mortality and diabetic foot related complications

B-Type Natriuretic Peptide Predict Mortality in Diabetic Patients with Foot Ulcer
Ezio Faglia, Giacomo Clerici, Maurizio Caminiti, Curci Vincenzo, Alberto Morabito, Vincenzo Prisco, Marco Prisco, Rosaria Greco and Michael Edmonds
Volume 2013 (2013), Article ID 388970, Journal of Research in Diabetes
Quote:
The background of this article is to retrospectively investigate the role of B-type natriuretic peptide (BNP) levels as an independent prognostic marker for mortality in diabetic patients with foot ulcer.

In the period 1 January-30 June 2009, 279 diabetic patients were admitted to our foot center because of foot ulcer: neuroischemic in 182 (65.2%), neuropathic in 97 (34.8%), infected in 233 (83.5%). In all patients BNP (normal value: ≤ 100 pg/mL) was evaluated at admission.

Mortality from any cause was established and the relationship between the recorded variables and risk of death was evaluated by the survival Cox regression model. Kaplan-Meier analysis was performed. BNP was >100 pg/mL in 167 (59.9%) patients. 278 (99.6%) patients were followed to December 31, 2012 with a mean follow-up of 3.6  0.2 years.

Seventy-one/278 (25.5%) patients died. Of these, 61 (85.9%) had a BNP value >100 pg/mL. Forty-five/71 (63.4%) patients died from cardiac cause. The most frequent cause of death was heart disease: 45/71 (63.4%). Of these, 24 patients had no history of CAD.

Multivariate analysis showed the independent predictors of death to be BNP > 100 (hazard ratio 6.040; p <0.001; CI, 2.380-15.328), age (hazard ratio 1.043, p = 0.024, CI 1.001-1.082), and dialysis treatment (hazard ratio 3.145; p = 0.032; CI, 1.100-8.988).

In diabetic patients with foot ulcer an elevated BNP level is a strong predictor of the excess mortality, independent of history of cardiac disease.
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Old 18th February 2014, 02:01 PM
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Default Re: Mortality and diabetic foot related complications

Albuminuria is a predictive factor of in-hospital mortality in patients with diabetes admitted for foot disease.
Aragón-Sánchez J, Lázaro-Martínez JL, García-Álvarez Y, Morales EG, Hernández-Herrero MJ.
Diabetes Res Clin Pract. 2014 Jan 21
Quote:
Albuminuria has been previously reported as a risk factor for mortality in people with diabetes. In a retrospective series of 455 patients with diabetes and foot ulcers, albuminuria was a predictive factor of in-hospital mortality. Other predictive factors were: white blood cell count>12.9×109/L, haemoglobin<108g/L and age >75 years old.
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