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Objectives
The aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major amputations (below- and above-knee).
Methods
This is a prospective study of 202 patients treated in National University Hospital (NUH) during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for limb loss were determined using univariate and stepwise logistic regression analysis.
Results
One hundred ninety-two patients had Type 2 diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays (P=.0015) and Indians (P=.036) and significantly lower in Chinese (P<.05). Of patients, 72.8% had poor endocrine control (GHb level >7%), and 42.1% of patients had sensory neuropathy based on 5.07 Semmes–Weinstein Monofilament test.
Common DFP included gangrene (31.7%), infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcot's osteoarthropathy (2.0%).
Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in 6.9%).
Conclusions
This is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP. Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) <0.8, gangrene, infection, and pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression analysis, only PVD and infection were significant.
Risks of Nontraumatic Lower-Extremity Amputations in Patients with Type 1 Diabetes
A population-based cohort study in Sweden Diabetes Care 31:1536-1540, 2008
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OBJECTIVE—The purpose of this study was to estimate the risks of nontraumatic lower-extremity amputations (LEAs) in patients with type 1 diabetes.
RESEARCH DESIGN AND METHODS—We identified 31,354 patients with type 1 diabetes (15,001 women and 16,353 men) in the Swedish Inpatient Register between 1975 and 2004. The incidence of nontraumatic LEAs was followed up until 31 December 2004 by cross-linkage in the Inpatient Register and linkage to the Death and Migration registers. Poisson regression modeling was used to compare the risks of nontraumatic LEAs during different calendar periods of follow-up, with adjustment for both sex and attained age at follow-up. Standardized incidence ratios (SIRs) were used to estimate the relative risks (RRs) with the age-, sex-, and calendar period–matched general Swedish population as reference. The cumulative probability of nontraumatic LEAs was calculated by the Kaplan-Meier method.
RESULTS—In total, 465 patients with type 1 diabetes underwent nontraumatic LEAs. The risk was lower during the most recent calendar period (2000–2004) than during the period before 2000 (RR 0.6 [95% CI 0.5–0.8]). However, even in this most recent period, the risk for nontraumatic LEAs among these relatively young patients was 86-fold higher than that in the matched general population (SIR 85.8 [72.9–100.3]). By age 65 years, the cumulative probability of having a nontraumatic LEA was 11.0% for women with type 1 diabetes and 20.7% for men with type 1 diabetes.
CONCLUSIONS—Although the risks appeared to have declined in recent years, patients with type 1 diabetes still have a very high risk for nontraumatic LEAs.
PULSE PRESSURE AND PREDICTION OF INCIDENT FOOT ULCERS IN TYPE 2 DIABETES.
Monami M, Vivarelli M, Desideri CM, Colombi C, Marchionni N, Mannucci E. Diabetes Care. 2009 Feb 5. [Epub ahead of print]
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Objectives- To assess the relevance of pulse pressure (PP) as a predictor of foot ulcers in type 2 diabetes.
Research design and methods- A cohort study was performed on a consecutive series of 1,945 type 2 diabetic outpatients without foot ulcer at baseline. Incident foot ulcers were identified through the Regional Hospital Discharge system, which contains ICD codes of current diagnoses.
Results- During a mean follow-up of 4.2+/-2.2 years, 86 ulcers were observed. After adjusting for confounders, the highest quartiles of PP had a 2.39[1.14-5.02]-fold risk of foot ulcers. When ischemic ulcers were considered separately, the highest PP quartile was associated with an increased age- and sex-adjusted risk (2.08[1.02-4.24]), whereas no increase of risk was observed for neuropathic ulcers.
Conclusion- Elevated PP represents an independent predictor of foot ulcers in diabetic patients; this parameter should be considered for the stratification of risk of ischemic or neuroischemic ulcers
Incidence and characteristics of lower limb amputations in people with diabetes
S. Fosse, A. Hartemann-Heurtier, S. Jacqueminet, G. Ha Van, A. Grimaldi and A. Fagot-Campagna Diabetic Medicine Volume 26 Issue 4, Pages 391 - 396
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Aims To estimate the incidence, characteristics and potential causes of lower limb amputations in France.
Methods Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002–2003 databases.
Results In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes.
Conclusions We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.
Incidence and characteristics of lower limb amputations in people with diabetes.
Fosse S, Hartemann-Heurtier A, Jacqueminet S, Ha Van G, Grimaldi A, Fagot-Campagna A. Diabet Med. 2009 Apr;26(4):391-6.
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AIMS: To estimate the incidence, characteristics and potential causes of lower limb amputations in France.
METHODS: Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002-2003 databases.
RESULTS: In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes.
CONCLUSIONS: We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.
Predictors of amputation in diabetics with foot ulcer: Single center experience in a large Turkish cohort.
Yesil S, Akinci B, Yener S, Bayraktar F, Karabay O, Havitcioglu H, Yapar N, Atabey A, Kucukyavas Y, Comlekci A, Eraslan S. Hormones (Athens). 2009 Oct-Dec;8(4):286-95.
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OBJECTIVE: Prediction of diabetic foot ulcer outcome may be helpful for clinicians in optimizing and individualizing management strategy. The aim of the present study was to examine the possibility of predicting the outcome of patients with diabetic foot ulcers by using easily assessed clinical and laboratory parameters at baseline.
DESIGN: In this observational study, data were collected prospectively in 670 consecutive diabetic foot ulcer episodes in 510 patients examined between January 1999 and June 2008 and were used to evaluate potential predictors of amputation retrospectively. After exclusion of patients who did not come to the hospital for follow-up for a minimum of six months, data of 574 foot ulcer episodes were evaluated.
RESULTS: Limb ischemia, osteomyelitis and presence of gangrene and ulcer depth, determined by the Wagner classification system, were the major independent predictors of overall and major amputations. Older age, presence of coronary artery disease, smoking and ulcer size were found to be associated with either overall or major amputations. Baseline levels of acute phase reactants (white blood cell count, polymorphonuclear leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and albumin) and decreased hemoglobin levels were associated with amputation risk. Multivariate analysis showed that one standard deviation increase in baseline CRP and ESR levels were independent predictors of overall and major amputations, respectively.
CONCLUSIONS: The presence of limb ischemia, osteomyelitis, local and diffuse gangrene and ulcer depth were independent predictors of amputation. Baseline levels of ESR and CRP appeared to be helpful for clinicians in predicting amputation.
Risk factors for diabetes amputation
Linear Mode
