Risk Of Amputation In Patients Research Articles

Validity of Wagner, SINBAB, PEDIS, and WIFI Scoring Systems to Assess Risk of Amputation in Patients with Diabetic Foot Ulcers

Aim: This study aims to determine validity of the Wagner, SINBAD, PEDIS, and WIFI scoring systems in assessing the risk of amputation in patients with diabetic foot ulcers at Prof. dr. I.G.N.G. Ngoerah General Hospital, Denpasar. Methods: This research is an observational study of diagnostic tests with a cross-sectional design. The sample in this study was selected by consecutive sampling from 1 January 2022 to 31 December 2022 with total of 72 respondents.Results: Wagner score test obtained sensitivity 77.2%, specificity 80.0%, PPV 93.6%, NPV 48%, accuracy 77.7%, and RR 1.8. PEDIS score test results obtained sensitivity 82.5%, specificity 86.7%, PPV 95.9%, NPV 56.5%, accuracy 83.3%, and RR 2.2. The results of the SINBAD test score obtained sensitivity 78.9%, specificity 66.7%, PPV 90.0%, NPV 45.5%, accuracy 76.3%, and RR 1.6. WIFI score test obtained sensitivity 89.5%, specificity 66.7%, PPV 91.1%, NPV 62.5%, accuracy 84.7%, and RR 2.4. Conclusion: The WIFI score has better sensitivity and accuracy compared to score Wagner, SINBAD, and PEDIS so it is recommended to use the WIFI score to assess the risk of amputation in diabetic foot ulcer patients.

Competing risk analysis to estimate amputation incidence and risk in lower-extremity peripheral artery disease.

Background: Patients with peripheral artery disease face high amputation and mortality risk. When assessing vascular outcomes, consideration of mortality as a competing risk is not routine. We hypothesize standard time-to-event methods will overestimate major amputation risk in chronic limb-threatening ischemia (CLTI) and non-CLTI. Methods: Patients undergoing peripheral vascular intervention from 2017 to 2018 were abstracted from the Vascular Quality Initiative registry and stratified by mean age (⩾ 75 vs < 75 years). Mortality and amputation data were obtained from Medicare claims. The 2-year cumulative incidence function (CIF) and risk of major amputation from standard time-to-event analysis (1 - Kaplan-Meier and Cox regression) were compared with competing risk analysis (Aalen-Johansen and Fine-Gray model) in CLTI and non-CLTI. Results: A total of 7273 patients with CLTI and 5095 with non-CLTI were included. At 2-year follow up, 13.1% of patients underwent major amputation and 33.4% died without major amputation in the CLTI cohort; 1.3% and 10.7%, respectively, in the non-CLTI cohort. In CLTI, standard time-to-event analysis overestimated the 2-year CIF of major amputation by 20.5% and 13.7%, respectively, in patients ⩾ 75 and < 75 years old compared with competing risk analysis. The standard Cox regression overestimated adjusted 2-year major amputation risk in patients ⩾ 75 versus < 75 years old by 7.0%. In non-CLTI, the CIF was overestimated by 7.1% in patients ⩾ 75 years, and the adjusted risk was overestimated by 5.1% compared with competing risk analysis. Conclusions: Standard time-to-event analysis overestimates the incidence and risk of major amputation, especially in CLTI. Competing risk analyses are alternative approaches to estimate accurately amputation risk in vascular outcomes research.

Elevated Composite Inflammatory Markers are Associated with Clinical Severity and Long-term Amputation Risk in Patients with Critical Limb Ischemia after Percutaneous Transluminal Angioplasty

Elevated Composite Inflammatory Markers are Associated with Clinical Severity and Long-term Amputation Risk in Patients with Critical Limb Ischemia after Percutaneous Transluminal Angioplasty

The association of comorbid depression with mortality and amputation risk in patients with chronic limb-threatening ischemia

The association of comorbid depression with mortality and amputation risk in patients with chronic limb-threatening ischemia

Abstract 18259: Overestimation of Major Amputation Risk in Patients Undergoing Peripheral Vascular Intervention for Peripheral Artery Disease When Not Accounting for Mortality Risk

Background: Endovascular peripheral vascular intervention (PVI) is intended to improve symptoms and functioning, and avoid limb amputation in patients with chronic limb threatening ischemia (CLTI). CLTI is associated with high mortality risk, which differs across age groups. We aimed to offset mortality vs. amputation risks by age groups in patients with CLTI using competing risk modeling. Methods: Patients with CLTI underwent PVI in 2017-2018 in the Vascular Quality Initiative registry were included. Mortality and major amputation outcomes over 3 years were derived from Medicare data. The cumulative incidence (CIF) of both outcomes in age groups &lt;65 and ≥65 years, was calculated by Aalen-Johansen (AJ), taking mortality into account, and compared with corresponding CIF calculated by Kaplan-Meier (KM). The major amputation risk in &lt;65 vs ≥65 years was estimated using a Fine and Gray competing risk model (sHR) and Cox regression (HR) adjusted for patients’ baseline characteristics. Results: A total of 10,114 patients were included: 22% &lt;65 years; 59% male and 19% Black. The cumulative incidence of death without major amputation increased with age (32% in &lt;65 vs. 46% ≥65 years) and was higher than that of major amputation (26% in &lt;65 vs. 15% in ≥65 years). By ignoring competing risk, both death without major amputation and major amputation was overestimated by a relative difference of 25.4% and 14.3% in &lt;65 years and by 13.8% and 21.2% in ≥65 years. The adjusted major amputation risk in &lt;65 vs. ≥65 years estimated by Cox regression was HR 1.30 95%CI 1.16-1.56 vs. FG model sHR = 1.75 95%CI 1.57-1.95. (Table) Conclusions: Longer term mortality following PVI is high, especially among elderly with CLTI. To derive accurate risk estimates for amputation across age groups, advanced methods that can accommodate the competing risk of mortality are needed to better inform clinicians and patients as they face CLTI treatment decisions.

Abstract 18280: Five-Year Major Amputation Risk in Patients Undergoing Lower Extremity Bypass Taking into Account All-Cause Mortality Risk and Age Groups

Background: Selecting good lower extremity bypass (LEB) surgery candidates for chronic limb threatening ischemia (CLTI) is important to optimize risk-benefit ratios for amputation and death. As mortality risks may be different across age groups, we aimed to examine whether amputation risks across age groups differ by their differential competing risk of death. Methods: Individuals with CLTI undergoing infrapopliteal LEB from 2014 to 2019 in the Medicare linked Vascular Quality Initiative registry were included. The cumulative incidence Function (CIF) for 5-year mortality and major amputation in age groups &lt;65 and ≥65 years, was calculated by Aalen-Johansen, taking mortality into account, and compared against the CIF derived from a traditional Kaplan-Meier, not accounting for competing death. The major amputation risk by age groups was estimated using a Fine and Gray competing risk model (sHR) accounting for competing death and traditional Cox regression (HR) not accounting for competing death. Results: A total of 2,105 patients were included (22% aged &lt;65 years; 70% male, 7% Hispanic, and 18% black). Amputation rates in &lt; 65 vs. ≥65 years were 35.2% and 19.2%; for mortality 34.4% and 44.6%, respectively. In those &lt;65 years, death without amputation was over-estimated by a relative difference of 42%; and major amputation by 16%. Death without amputation in the ≥65 years group was over-estimated by 18%; amputation risk was over-estimated by 23%. When not accounting for competing death risk, adjusted amputation risk for &lt;65 vs ≥65 years was HR 1.17 95%CI 0.90 -1.50 vs. sHR = 1.26 95%CI 0.97-1.62 in the competing risk model. (Table) Conclusions: Younger individuals with CLTI have the highest amputation vs. mortality risk; for those older than 65 years it is the other way around. Collapsing estimates across age groups, while not incorporating competing death risk overestimates amputation risk and can mislead the interpretation of therapeutic benefits of CLTI interventions.

Investigating Weekend Effect in the Management of Upper and Lower Extremity Degloving Injuries.

Weekend presentation has been associated with adverse outcomes in emergent conditions, including stroke, myocardial infarction, and critical limb ischemia. We examine whether a weekend effect exists in the management of and outcomes after extremity degloving injuries. The cohort included adults presenting with open extremity degloving injuries to a tertiary level one trauma center between June 2018 and May 2022. We collected demographics, comorbidities, injury information, interventions, and complications. Propensity score weighting was used to minimize confounding differences between those presenting on weekends (Sat-Sun) versus weekdays (Mon-Fri). Weighted regressions were used to examine differences in interventions by day of presentation. Multivariable weighted regressions accounting for differences in interventions received were used to examine whether weekend presentation was associated with amputation risk, complications, or functional deficits. Ninety-five patients with 100 open extremity degloving injuries were included. In total, 39% of injuries were weekend-presenting. There was a higher rate of noninsulin-dependent diabetes among patients presenting on weekends (P = 0.03). Weekend-presenting injuries had higher median Injury Severity Scores (P = 0.04). Propensity-weighted regression analysis revealed differences in interventions received on weekends, including lower rates of pedicled and free flaps and bone graft, and increased rates of negative-pressure wound therapy (P ≤ 0.02). Multivariable regression analysis revealed weekend presentation was a significant independent risk factor for amputation of the affected extremity [odds ratio 2.27, 95% CI (1.01-5.33), P = 0.05]. Weekend presentation may impact interventions received and amputation risk in patients presenting with open extremity degloving injuries.

The association of comorbid depression with mortality and amputation risk in patients with chronic limb-threatening ischemia

ObjectiveThere is increasing evidence that depression is a risk factor for worse outcomes in patients with peripheral artery disease. The association of depression in patients with chronic limb-threatening ischemia (CLTI) is not well described, nor is the impact of medical treatment for depression in this patient population. The objective of this study was to investigate the prevalence of depression in patients with CLTI, its association on major amputation and all-cause mortality, and whether medical antidepressant treatment is associated with improvement in these outcomes in patients with depression. MethodsA retrospective review of all adult patients (≥18 years old) diagnosed with CLTI from January 1, 2007, to December 31, 2018, at a single academic medical center was performed. Collected data included patient demographics, comorbidities, and diagnosis of depression within 6 months of initial CLTI diagnosis. We also collected data on use of antidepressant medications. Outcomes evaluated were need for major lower extremity amputation and all-cause mortality. Multivariable logistic regression models estimated the adjusted effects of comorbid depression and antidepressant medication use on major amputation and all-cause mortality. Kaplan-Meier survival curves illustrated the probabilities of survival and limb salvage over time, stratified by diagnosis of comorbid depression. Multivariable Cox proportional hazards models estimated the adjusted effects of comorbid depression on time to major amputation and all-cause mortality, and the adjusted effect of antidepressant treatment on time to all-cause mortality. ResultsA total of 2987 patients with CLTI were identified. Mean age was 68.6 years (standard deviation, 12.9 years); 56.5% were male, and 43.5% were female. Comorbid depression within 6 months of CLTI diagnosis was present in 7.1% of the cohort (212 patients). In multivariable analysis, comorbid depression was associated with a 68% increase in the odds of major amputation (adjusted odds ratio [aOR], 1.68; 95% confidence interval [CI], 1.19-2.37; P < .01), a 164% increase in the odds of all-cause mortality among patients not taking antidepressants (aOR, 2.64; 95% CI, 1.31-5.32; P = .03), and only a 6% increase in the odds of all-cause mortality among patients taking antidepressants (aOR, 1.06; 95% CI, 0.72-1.55; P = .99). The effect of comorbid depression on mortality varied significantly by whether or not the patient was taking an antidepressant medication (P = .02). ConclusionsComorbid depression in the patient population with CLTI is associated with a worse prognosis for major lower extremity amputation overall, and a worse prognosis for all-cause mortality among patients not taking an antidepressant. Furthermore, antidepressant treatment in the presence of comorbid depression in this patient population is associated with an improvement in the odds of all-cause mortality, illustrating the potential importance of medical management of depression.

The Role Played by Novel Inflammatory Markers in Assessment of Peripheral Artery Disease.

Background and Objectives: Atherosclerosis is a multifactorial process in which inflammatory markers have both therapeutic and prognostic roles. Recent studies bring into question the importance of assessing new inflammatory markers in relation to the severity of peripheral artery disease (PAD), such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and lymphocyte-to-C-reactive protein ratio (LCR). Materials and Methods: We conducted a retrospective and descriptive study including 652 patients with PAD, who were divided into two groups according to the severity of the ankle-brachial index value: mild and moderate obstruction (257 patients) and severe obstruction (395 patients). We evaluated demographics, anthropometric data and clinical and paraclinical parameters in relation to the novel inflammatory biomarkers mentioned above. Results: Weight (p = 0.048), smoking (p = 0.033), the number of cardiovascular risk factors (p = 0.041), NLR (p = 0.037), LCR (p = 0.041) and PLR (p = 0.019), the presence of gangrene (p = 0.001) and the number of lesions detected via peripheral angiography (p < 0.001) were statistically significant parameters in our study. For the group of patients with severe obstruction, all three inflammatory biomarkers were statistically significantly correlated with a serum low-density lipoprotein-cholesterol level, the number of cardiovascular risk factors, rest pain, gangrene and a risk of amputation. In addition, directly proportional relationships were found between NLR, PLR and the number of stenotic lesions (p = 0.018, p = 0.016). Also, NLR (area under the curve <AUC> = 0.682, p = 0.010) and PLR (AUC = 0.692, p = 0.006) were predictors associated with a high risk of amputation in patients with an ABI < 0.5. Conclusions: in our study, we demonstrated the importance of assessing inflammatory markers in relation to the presence of cardiovascular risk factors through the therapeutic and prognostic value demonstrated in PAD.

A practical nomogram for predicting amputation rates in acute compartment syndrome patients based on clinical factors and biochemical blood markers

BackgroundAmputation is a serious complication of acute compartment syndrome (ACS), and predicting the risk factors associated with amputation remains a challenge for surgeons. The aim of this study was to analyze the risk factors for amputation in patients with ACS and develop a nomogram to predict amputation risk more accurately.MethodsThe study population consisted of 143 patients (32 in the amputation group and 111 in the limb preservation group) diagnosed with ACS. LASSO and multivariate logistic regression were used to screen predictors and create a nomogram. The model’s accuracy was assessed by receiver operating characteristic (ROC) curves, C-index, calibration curves, and decision curve analysis (DCA).ResultsThe predictors included cause of injury, vascular damage, shock, and fibrinogen in the nomogram. The C-index of the model was 0.872 (95% confidence interval: 0.854–0.962), and the C-index calculated by internal validation was 0.838. The nomogram’s area under the curve (AUC) was 0.849, and the calibration curve demonstrated a high degree of agreement between the nomogram’s predictions and actual observations. Additionally, the DCA indicated good clinical utility for the nomogram.ConclusionThe risk of amputation in ACS patients is associated with the cause of injury, vascular damage, shock, and fibrinogen. Our nomogram integrating clinical factors and biochemical blood markers enables doctors to more conveniently predict the risk of amputation in patients with ACS.

Glucagon-like peptide-1 treatment reduces the risk of diabetes-type 2 related amputations: A cohort study in Denmark

AimsTo assess the impact of Glucagon-like peptide-1 (GLP-1) agonists on the risk of lower extremity amputations in patients with type 2 diabetes mellitus (DM2). MethodsWe conducted a cohort study on 309,116 patients with DM2 using Danish National Register and Diabetes Database. We tracked the GLP-1 agonists over time along with the medication dose. Time-varying models are used to assess the risk of amputation for patients with/without GLP-1 treatment. ResultsPatients on GLP-1 treatment experience a notable reduction in the risk of amputation compared to those without the treatment with a hazard ratio (HR) of 0.5, 95% CI [0.54–0.74], indicating a statistically significant difference (p <.005). This risk reduction was consistent across different age groups, but notably most pronounced among middle income patients. The findings were further validated by using time-varying Cox models, which considered the patient’s comorbidity history. ConclusionsOur analysis reveals compelling evidence of a reduced risk of amputation among patients receiving GLP-1 therapy, an effect dominated by liraglutide, compared to those without the treatment, even after adjusting for various socio-economic factors. However, further investigation is required to identify and account for any other potential confounding variables that may impact the outcome.

Association Between Primary Care Utilization and Amputation Risk for Patients with Peripheral Arterial Disease

Association Between Primary Care Utilization and Amputation Risk for Patients with Peripheral Arterial Disease

Conditional Effect of Race on Primary Care Utilization and Amputation Risk for Patients With Peripheral Arterial Disease

Conditional Effect of Race on Primary Care Utilization and Amputation Risk for Patients With Peripheral Arterial Disease

Interruption of Insurance Coverage and the Risk of Amputation in Patients with Pre-Existing Commercial Health Insurance and Peripheral Artery Disease

Peripheral artery disease (PAD) is linked with an increased risk of lower extremity amputation and multiple socioeconomic factors attenuate this risk. Prior studies have demonstrated increased rates of amputation in PAD patients with suboptimal or no insurance coverage. However, the impact of insurance loss in PAD patients with pre-existing commercial insurance coverage is unclear. In this study, we evaluated the outcomes of PAD patients who lose commercial insurance coverage. The Pearl Diver all-payor insurance claims database was used to identify adult patients (>18years) with a PAD diagnosis from 2010 to 2019. The study cohort included patients with pre-existing commercial insurance and at least 3years continuous enrollment after diagnosis of PAD. Patients were stratified based on whether they had an interruption of commercial insurance coverage over time. Patients who transitioned from commercial insurance to Medicare and other government-sponsored insurance during follow up were excluded. Adjusted comparison (1:1 ratio) was performed using propensity matching for age, gender, the Charlson Comorbidity Index (CCI), and relevant comorbidities. The main outcomes were major amputation and minor amputation. Cox proportional hazards ratios and Kaplan-Meier estimate were used to examine the association between loss of insurance and outcomes. Among the 214,386 patients included, 43.3% (n=92,772) had continuous commercial insurance coverage and 56.7% (n=121,614) had interruption of coverage (transition to uninsured or Medicaid coverage) during follow up. In the crude cohort and matched cohort, interruption of coverage was associated with lower major amputation-free survival on Kaplan Meier estimate (P<0.001). In the crude cohort, interruption of coverage was associated with 77% increased risk of major amputation (OR 1.77, 95% CI 1.49-2.12) and a 41% high risk of minor amputation (OR 1.41, 95% CI 1.31-1.53). In the matched cohort, interruption of coverage was associated with 87% increased risk of major amputation (OR 1.87, 95% CI 1.57-2.25) and a 104% increased risk of minor amputation (OR 1.47, 95% CI 1.36-1.60). Interruption of insurance coverage in PAD patients with pre-existing commercial health insurance was associated with increased risks of lower extremity amputation.

Evaluation of Lower Extremity Calcium Score as a Measure of Peripheral Arterial Disease Burden and Amputation Risk

The ankle-brachial pressure index (ABI) and toe-brachial pressure index (TBI) are commonly used diagnostic tools for peripheral artery disease (PAD) that are unreliable in the presence of calcified vessels. In this study, we aimed to demonstrate the utility of the lower extremity calcium score (LECS) in addition to ABI and TBI in measuring disease burden and predicting the risk of amputation in patients with PAD. Patients who were evaluated in the vascular surgery clinic at Emory University for PAD and who underwent noncontrast computed tomography of the aorta and lower extremities were included in the study. Aortoiliac, femoral-popliteal, and tibial calcium scores were measured using the Agatston method. ABI and TBI that were obtained within 6months of the computed tomography scan were noted and divided into categories of PAD severity. Associations between ABI, TBI, and LECS of each anatomic segment were evaluated. Univariate and multivariate ordinal regression analyses were performed to predict the outcome of amputation. Receiver operating characteristic analysis was performed to compare LECS with other variables in its ability to predict amputation. Fifty patients included in the study cohort were divided into LECS quartiles, with 12-13 patients in each quartile. The highest quartile tended to be older (P=0.016), had a higher percentage of diabetics (P=0.034), and had a higher frequency of major amputations (P=0.004) compared to the other quartiles. Patients in the highest quartile of tibial calcium score were more likely to have stage 3 chronic kidney disease (CKD) or greater (P=0.011) and also had a higher frequency of amputation (P<0.005) and mortality (P=0.041). We found no significant association between each anatomic LECS and ABI/TBI categories. On univariate analysis, CKD (Odds Ratio [OR] 12.92 (95% CI 2.01 to 82.83), P=0.007), diabetes mellitus (OR 5.47 (95% CI 1.27 to 23.64), P=0.023), tibial calcium score (OR 6.62 (95% CI 1.79 to 24.54), P=0.005), and total bilateral calcium score (OR 6.32 (95% CI 1.18 to 33.78), P=0.031) were associated with increased risk of amputation. On multivariate stepwise ordinal regression, TBI and tibial calcium score were identified as important predictors of amputation, with hyperlipidemia and CKD increasing the overall prediction of the model. On Receiver operating characteristic analysis, the addition of the tibial calcium score (area under the curve 0.94, standard error 0.048) significantly improved the prediction of amputation compared to hyperlipidemia, CKD, and TBI alone (area under the curve 0.82, standard error 0.071, P=0.022). The addition of tibial calcium score to other known PAD risk factors may improve the prediction of amputation in patients with PAD.

The Mangled Extremity Severity Score (MESS) does not predict amputation in popliteal artery injury

PurposeVascular injuries in lower extremity trauma, especially with involvement of the popliteal artery, are associated with considerably high rates of limb loss, especially with blunt trauma mechanisms. The aim of this study was to evaluate the risk of amputation in patients with traumatic popliteal artery lesions with special focus on the validity of the Mangled Extremity Severity Score (MESS).MethodsIn this retrospective study, all patients treated for isolated lesions of the popliteal artery following trauma between January 1990 and December 2020 at a high-volume level I trauma center were included. Primary outcome was limb salvage dependent on MESS and the influence of defined parameters on limb salvage was defined as secondary outcome. The extent of trauma was assessed by the MESS.ResultsA total of 50 patients (age 39.2 ± 18.6 years, 76% male) with most blunt injuries (n = 47, 94%) were included. None of the patients died within 30 days and revascularization was attempted in all patients with no primary amputation and the overall limb salvage rate was 88% (44 patients). A MESS ≥ 7 was observed in 28 patients (56%) with significantly higher rates of performed fasciotomies (92.9% vs. 59.1%; p < 0.01) in those patients. MESS did not predict delayed amputation within our patient cohort (MESS 8.4 ± 4.1 in the amputation group vs. 8.1 ± 3.8 in the limb salvage group; p = 0.765).ConclusionRevascularization of limbs with isolated popliteal artery injuries should always be attempted. MESS did not predict delayed amputation in our cohort with fasciotomy being an important measure to increase limb salvage rates.

Risk assessment of amputation in patients with diabetic foot.

The prevalence of diabetes has increased dramatically over the past decade, especially in developing countries, reaching pandemic proportions. Although has been the most important factor influencing the prevalence of type 2 diabetes, the prevalence of type 2 diabetes is on the increase among younger adults. The subsequent rate of increase with age is variable, which is more evident in societies where the general prevalence of the disease is higher. Based on clinical and statistical data obtained from the patients who were admitted to The First and Second Surgery Wards in the Sibiu County Emergency University Clinical Hospital (Sibiu, Romania) and the Proctoven Clinic (Sibiu, Romania) between January 2018 and December 2020, the present study attempted to devise a risk score that can be applied for the benefit of patients. The ultimate aim was that this risk score may be eventually applied by diabetologists and surgeons to assess the risk of amputation in patients with diabetic foot lesions. An important part in the therapeutic management of diabetic foot injuries is the assessment of risk factors. Using this risk score system devised, the risk factors that were found to exert influence in aggravating diabetic foot injuries are smoking, obesity, dyslipidaemia, unbalanced diabetes mellitus (glycated haemoglobin ≥7.5%), duration of diabetes >5 years, hepatic steatosis and the co-existence of various heart diseases. To conclude, all these risk factors aforementioned can decrease the effectiveness of treatment and can have a significant impact on the quality of life, if they are not well known.

Abstract 11756: Tracking High-Density Lipoprotein Functionality in Diabetic and Non-Diabetic Patients With Toe Amputations

Introduction: High-density lipoprotein cholesterol (HDL-c) levels have an established inverse association with cardiovascular event risk. More recently, the focus has shifted to HDL functionality as an improved metric of its predictive value and is impaired in patients with coronary arterial disease. HDL-c levels have been reported to inversely associate with the risk of amputation in patients with diabetic foot ulcers (DFUs), but whether HDL functionality is predictive of wound closure success is currently unknown. Methods: Eighteen diabetic and eight non-diabetic patients with toe/s amputations had blood collected at: (1) the time of surgery, (2) four weeks and (3) six months post-amputation. Wound areas were tracked until closure by 3D camera. Blood was collected from 20 healthy age and gender-matched participants. From blood, HDL was isolated and its functionality tested via (1) cholesterol efflux from macrophages, and (2) anti-inflammatory and (3) pro-angiogenic effects in endothelial cells. Results: Wound closure was faster in non-diabetic than diabetic amputation patients at four weeks (186.6%, P =0.12). Diabetic HDL promoted less cholesterol efflux at four-weeks (37.8%, P &lt;0.05) and six-months (45.6%, P &lt;0.01) post-amputation, compared to non-diabetic HDL. Incubation of non-diabetic HDL with endothelial cells caused greater reductions in inflammatory markers RELA (51.4%, P &lt;0.01), CCL5 (46.9%, P &lt;0.01), CCL2 (15.3%, P &lt;0.05) and ICAM-1 (33.1%, P &lt;0.05) than non-diabetic HDL. Non-diabetic HDL elicited greater endothelial cell angiogenesis with increased Matrigel tubule number at four weeks post amputation (46.15%, P &lt;0.05), compared to diabetic HDL. There were significant correlations between the rate of wound closure and HDL-c levels (R 2 = +0.62, P &lt;0.05), CCL2 (R = -0.64, P &lt;0.05) and ICAM-1 (R = -0.71, P &lt;0.05). Conclusion: In toe amputation patients, HDL-c levels and inflammatory HDL functionality markers associate with the rate of wound closure. HDL from diabetic patients had impaired cholesterol efflux capacity, reduced anti-inflammatory effects and was less able to promote angiogenesis, compared to non-diabetic HDL.

Treatment of diabetic foot during the COVID-19 pandemic: A systematic review

Background:In the context of the novel coronavirus disease 2019 (COVID-19) pandemic, people have had to stay at home more and make fewer trips to the hospital. Furthermore, hospitals give priority to the treatment of COVID-19 patients. These factors are not conducive to the treatment of diabetic foot, and even increase the risk of amputation. Therefore, how to better treat patients with diabetic foot during the COVID-19 epidemic, prevent further aggravation of the disease and reduce the risk of amputation in patients with diabetic foot has become an urgent problem for doctors around the world.Methods:The researchers searched PubMed, the Cochrane Library, and the Embase database. The retrieval time was set from the database establishment to October 2021. All studies on treatment of diabetic foot in the COVID-19 pandemic were included in our study.Results:A total of 6 studies were included in this study. In the 6 protocols for treating patients with diabetic foot, the researchers classified patients according to the condition of their diabetic foot. Diabetic foot patients with general conditions received treatment at home, and doctors can guide the wound dressing change and medication treatment of patients through telemedicine. Patients with severe conditions of diabetic foot were admitted to hospital for treatment. Patients were screened for COVID-19 before hospitalization, those infected or suspected of COVID-19 were treated in isolation, and those not infected with COVID-19 were treated in a general ward.Conclusion:Through this systematic review, we proposed a new protocol for the treatment of patients with diabetic foot in the context of the COVID-19 pandemic. It provided reference for the treatment of diabetic foot in the context of COVID-19 epidemic. However, the global applicability of the treatment protocol for diabetic foot in the context of COVID-19 epidemic proposed in this study needs further clinical testing.

ERICVA Risk Scale simplified as a predictor of amputation in critical limb ischemia.

Demonstrate that simplified ERICVA (Valladolid Critical Limb Ischaemia Risk Scale) is useful in predicting amputation in chronic limb-threatening ischemia (CLI) after one year of revascularization. A retrospective cohort study was performed. We analyzed the medical records of 93 patients over the age of 35 with the diagnosis of CLI who were treated in the Department of Internal Medicine, Orthopedics or in the Cardiovascular Surgery Unit of the Víctor Lazarte Echegaray Hospital and the High Complexity Virgen de La Puerta Hospital during the period 2015-2018. The simplified ERICVA score was determined in patients before surgical and endovascular revascularization. We included 31 patients who scored 2 or more points in the exposed group and 62 patients who scored less than 2 points in the group not exposed to amputation risk. The collected data was analyzed with the statistical program SPSS where the Relative Risk and significance was obtained with Pearson's Chi-square. The multivariate analysis was also carried out in order to obtain the adjusted relative risk. It was identified that the simplified ERICVA score greater than or equal to 2 points was more frequent in those who underwent amputation (90.3%) compared to patients who did not undergo amputation (4.8%), increasing the risk of amputation in those patients with CLI who underwent revascularization (RR: 18.67, P<0.001). It was also possible to identify that within the group of patients that showed a high risk of amputation according to the ERICVA scale, they had a higher risk of major amputation (RR: 9.32, P<0.001) as opposed to the risk of minor amputation (RR: 1, 89, P=0.193). Among the items of the simplified ERICVA scale, the preoperative neutrophil-lymphocyte ratio and hematocrit were significantly higher in the group of amputated patients (P<0.001). In addition, it was possible to identify that the score greater than or equal to 2 was independently associated with the risk of amputation in patients revascularized with CLI (RR: 13.5, P<0.001). In our patient population, the simplified ERICVA scale is useful in predicting major and minor amputation in critical limb ischemia after revascularization. The present data showed that the patients who had a simplified ERICVA score greater than or equal to 2 had a higher risk of major amputation compared to the risk of minor amputation. However, it is important to highlight that the impact on the prediction of minor amputation is greater because in some circumstances major amputation can appear as a complication of CLI.