Cause Of Lower Limb Amputation Research Articles

Histone modifications and their roles in macrophage-mediated inflammation: a new target for diabetic wound healing.

Impaired wound healing is one of the main clinical complications of type 2 diabetes (T2D) and a major cause of lower limb amputation. Diabetic wounds exhibit a sustained inflammatory state, and reducing inflammation is crucial to diabetic wounds management. Macrophages are key regulators in wound healing, and their dysfunction would cause exacerbated inflammation and poor healing in diabetic wounds. Gene regulation caused by histone modifications can affect macrophage phenotype and function during diabetic wound healing. Recent studies have revealed that targeting histone-modifying enzymes in a local, macrophage-specific manner can reduce inflammatory responses and improve diabetic wound healing. This article will review the significance of macrophage phenotype and function in wound healing, as well as illustrate how histone modifications affect macrophage polarization in diabetic wounds. Targeting macrophage phenotype with histone-modifying enzymes may provide novel therapeutic strategies for the treatment of diabetic wound healing.

1141 Mortality and Re-Amputation Rates Following Below Knee Amputation: A Systematic Review and Meta-Analysis

Abstract Aim Below knee amputation (BKA) is undertaken in patients with diabetes or peripheral vascular disease, when limb sparing medical optimisation or vascular interventions are no longer feasible. Mortality and proximal re-amputation rates are poorly defined in the literature. We sought to perform a systematic review to examine mortality and reputation rates across the current literature. Method A systematic search was performed of the MEDLINE (via Pubmed), EMBASE, Cochrane and clinicaltrials.gov databases from inception to August 25th, 2022. Articles were screened by two independent reviewers with conflicts reserved by a third party. Inclusion criteria were all non-traumatic causes of lower limb amputation. Outcomes of interest included Mortality and occurrence of more proximal amputation. Results Studies from 12 countries encompassing a total of 41832 patients were included for analysis. Study dates ranged from 1987 to 2019. Of the total patient number, 38577 (92.2%) were from the USA, with 2599 (6.2%) from Europe and 656 (1.6%) remainder. The mean age at BKA was 70.46 years (Range 62-86). Weighted mortality was 37% (Range 4%-29%) at 1 year, 58% (Range 12% - 60%) at 2 years, 65% (range 19% - 81%) at 5 years and 84% (Range 71-96%) at 10 years. Five studies reported re-amputation rate at any time point (13% Range 1.16- 22%). Conclusions Mortality following BKA is still poor, even in contemporary studies. The few large multicentre studies are US based and in military veteran populations. More robust UK focused studies are needed to accurately inform clinical decision making for patients and clinicians.

An Evaluation of Phantom Pain among Traumatic Lower Limb Amputees in Lahore

Background: Amputation is the surgical removal of all or part of an irreparably damaged limb due to injury or disease. Trauma is the leading cause of lower limb amputation in Pakistan. Phantom limb pain (PLP) is a common and distressing complication following amputation, affecting the quality of life and functional outcomes. Objective: The primary objective of this study was to assess the occurrence and intensity of phantom limb pain in patients who had undergone lower limb amputation due to traumatic causes in Pakistan. Methods: A descriptive cross-sectional study was conducted over six months, involving 73 patients who had undergone lower limb amputation due to trauma. The study was carried out in Ghurki Trust Teaching Hospital, Sheikh Zayed Hospital, and Mayo Hospital. Patients aged 20-45 years, with amputations performed within one year, were included. Exclusion criteria were non-traumatic amputations and amputations older than one year. Non-probability convenience sampling was used. Participants were divided into three groups based on the level of amputation: hip disarticulation (n=12), transfemoral (n=28), and transtibial (n=33). Phantom limb pain was assessed using the Numeric Pain Rating Scale (NRPS), an 11-item scale ranging from 0 (no pain) to 10 (severe pain). Data were analyzed using SPSS version 25, and descriptive statistics were presented in tables and graphs. Ethical approval was obtained from the Ethics Committee of Lahore College of Physical Therapy (ERC-LCPT/298/2019). Written informed consent was obtained from all participants. Results: The study found that 83.6% of the participants experienced phantom limb pain. Among the hip disarticulation group, 91.7% reported PLP, with a mean NRPS score of 7.3. In the transfemoral group, 89.3% experienced PLP, with a mean NRPS score of 6.8. In the transtibial group, 75.8% reported PLP, with a mean NRPS score of 5.4. The association between the level of amputation and the presence of PLP was significant, with p-values of 0.003 for hip disarticulation, 0.000 for transfemoral, and 0.001 for transtibial amputations. Conclusion: Phantom limb pain is a prevalent and significant issue among patients with traumatic lower limb amputations in Pakistan, with varying intensity across different levels of amputation. These findings underscore the need for targeted pain management strategies and comprehensive rehabilitation programs to address PLP and improve the quality of life for amputees.

IJCM_121A: Assessment of risk of foot ulcer in patients with diabetes according to the risk classification consensus of International Working Group on Diabetic Foot (IWGDF) in Ernakulam District, Kerala; a community based cross sectional study

Background: The International Diabetes Federation states that India accounts for 1 in 7 of all adults living with diabetes worldwide. Diabetic foot disease is among the most serious complications of diabetes mellitus as it is a source of major suffering and financial burden for the patient, healthcare professionals and the society in general. The leading cause of lower-limb amputations is diabetes and 40%–85% of these are preventable Objective: Assessment of diabetic foot ulcer risk factors according to International Working Group on the Diabetic Foot (IWGDF) consensus. Methodology: A community based cross-sectional study was done in Ernakulam district involving 600 individuals with diabetes mellitus. The study gathered information on sociodemographic factors, anthropometric details and a detailed foot examination was performed with a IWGDF checklist. The collected data were entered into MS Excel, and the analysis was carried out using SPSS 21.0. Results: Mean age of patients in the study was 61.48 yrs±10.24 years.371 patients (61.83%) were females and 229(38.17%) were males.108 patients (18%) had disturbed sense of vibration (128 Hz). 90 patients (15%) had decreased sensitivity to 10-gram monofilaments. Peripheral arterial disease was present in 47 patients (7.83). 20 patients (3.33%) had history of previous ulcer. 11(1.83%) patients had lower extremity amputation. Patients were classified into four risk groups according to IWGDF criteria. Four hundred and fifty-five patients (75.83%) were in group 0, fifty-five patients (9.1%) in group 1, sixty-six patients (11%) in group 2 and twenty-four patients (4%) in group 3 of IWGDF criteria Conclusion: Routine foot examination in patients with diabetes as per IWGDF guidelines for each risk category will help in prevention of diabetic foot ulcers.

Factors associated with diabetic foot ulcers and lower limb amputations in type 1 and type 2 diabetes supported by real-world data from the German/Austrian DPV registry.

Diabetic foot ulcer (DFU) is a leading cause of lower limb amputations in people with diabetes. This study was aimed to retrospectively analyze factors affecting DFU using real-world data from a large, prospective central-European diabetes registry (DPV [Diabetes-Patienten-Verlaufsdokumentation]). We matched adults with type 1 (T1D) or type 2 diabetes (T2D) and DFU to controls without DFU by diabetes type, age, sex, diabetes duration, and treatment year to compare possible risk factors. Cox regression was used to calculate hazard ratios for amputation among those with DFU. In our cohort (N = 63 464), male sex, taller height, and diabetes complications such as neuropathy, peripheral artery disease, nephropathy, and retinopathy were associated with DFU (all p < .001). Glycated hemoglobin (HbA1c) was related to DFU only in T1D (mean with 95% confidence interval [CI]: 7.8 [6.9-9.0] % vs 7.5 [6.8-8.5] %, p < .001). High triglycerides and worse low-density lipoprotein/high-density lipoprotein ratio were also associated with DFU in T1D, whereas smoking (14.7% vs 13.1%) and alcohol abuse (6.4% vs 3.8%, both p < .001) were associated with DFU in T2D. Male sex, higher Wagner grades, and high HbA1c in both diabetes types and insulin use in T2D were associated with increased hazard ratios for amputations. Sex, body height, and diabetes complications were associated DFU risk in adults with T1D and T2D. Improvement in glycemic control and lipid levels in T1D and reduction of smoking and drinking in T2D may be appropriate interventions to reduce the risk for DFU or amputations.

Effectiveness of mirror therapy for amputation patients at National Authority of Prosthesis and Orthosis in Sudan

Introduction. Mirror Therapy (MT) seems to be a promising strategy in amputation rehabilitation by creating a visual representation of the missing limb. The study exploring the effect of MT and conventional rehabilitation in the treatment of post-amputation phantom lower limp pain in National Authority of Prosthesis and Orthosis (NAPO). Method. An experimental study was done on 20 patients that were found for the study (these were the only available cases with phantom lower limb pain), was divided into: Group (A) conventional rehabilitation, Group (B) MT, 10 patients were selected randomly in each group. Questioner with sixteen close end questions was distributed to the patients of the two groups for post rehabilitation assessment to reassess the effect of each treatment for post amputated phantom lower limp pain. Results. There were 50% of the participants were above 60 years old and 60% of participants had Trans – Femoral amputation. Diabetic was the major cause of Amputation (55%). According to participants perception, 40% of participants undergone MT thing it is effective in reducing phantom lower pain while only 10% of participants undergone conventional therapy think it is effective in reducing phantom lower pain. Conclusion. As known, diabetes is still the major cause of lower limb amputation in Sudan. Both conventional therapy and MT are found to be effective in the treatment of phantom lower limb pain, but MT is shown to be more effective compared to conventional therapy.

Association Between Lipid Profile and Diabetic Foot Ulcer

Diabetic foot ulcer is a serious disabling consequence of Diabetes Mellitus. They are characterized by the breakdown of skin and underlying tissues in the feet, and are a major cause of lower limb amputations. Various risk factors have been identified for the development of diabetic foot ulcers, including poor glycemic control, peripheral neuropathy, peripheral arterial disease, and impaired wound healing. it is considered that the lipid profile is one of many factors that contribute to the formation and progression of diabetic foot ulcers. To stratify the incidence of diabetic foot ulcers (DFUs), biomarkers are required. The aim of this review is to assess the relationship between the risk of DFU and lipid profile in diabetic patients.

Implementing Effective Care Through Utilization of Diabetes-Focused "Right Care" Visits in a Suburban Primary Care Setting.

Background: Diabetes is the seventh leading cause of death in the United States and the leading cause of lower limb amputations, adult-onset blindness, and renal failure. It is estimated that 34.2 million Americans have a diabetes diagnosis, and the prevalence of this condition has continually increased over the last two decades. This study includes patients at a large, suburban primary care practice in southwest Ohio who were considered to have uncontrolled diabetes based on their last Hemoglobin A1c of greater than 9%. Compliance with recommended annual screenings among this population was 15%. Objectives: The aim of this project was to improve glycemic control and increase the number of patients who received the recommended annual screenings through the implementation of nurse practitioner-driven, diabetes-focused "Right Care" visits.C Methods: This quality improvement pilot study consisted of interventions implemented over the four plan-do-study-act cycles. Each cycle included a test of change that was identified based on data from previous cycles to ensure continuous improvement throughout project implementation. Four interventions were evaluated including the utilization of a diabetes registry, implementation of a "Right Care" checklist during "Right Care" visits, use of a patient engagement tool with a focus on individualizing diabetes medication regimens, and implementation of a team-engagement plan. Results: Average Hemoglobin A1c reduction was 2.4% post-"Right Care" visit. Compliance with the annual screening bundle increased to 44% over 8 weeks. Utilization of the patient/provider relationship increased visit compliance by 18%, and the team engagement plan decreased work-related stress by 12%. Conclusions: The implementation of "Right Care" visits led to improved glycemic control and increased compliance with the recommended annual screenings among patients with an A1c greater than 9%. The patient engagement tool identified key factors related to diabetes medication adherence and team engagement decreased work-related stress and improved annual fundoscopic exam screening compliance. Implications for Nursing: Nurse practitioner-led "Right Care" visits utilize the knowledge and skills of advanced practice registered nurses to improve glycemic control in patients with uncontrolled diabetes.

Immersion of debrided diabetic foot ulcer tissue in electrochemically generated pH neutral hypochlorous acid significantly reduces the microbial bioburden: whole-genome sequencing of Staphylococcus aureus, the most prevalent species recovered

Diabetic foot ulcer infections (DFUIs) are the leading cause of lower-limb amputations, mediated predominantly by Staphylococcus aureus. pH-neutral electrochemically generated hypochlorous acid (anolyte) is a non-toxic, microbiocidal agent with significant potential for wound disinfection. To investigate both the effectiveness of anolyte for microbial bioburden reduction in debrided ulcer tissues and the population of resident S.aureus. Fifty-one debrided tissues from 30 people with type II diabetes were aliquoted by wet weight and immersed in 1- or 10-mL volumes of anolyte (200parts per million) or saline for 3min. Microbial loads recovered were determined in colony forming units/g (cfu/g) of tissue following aerobic, anaerobic and staphylococcal-selective culture. Bacterial species were identified and 50S.aureus isolates from 30 tissues underwent whole-genome sequencing (WGS). The ulcers were predominantly superficial, lacking signs of infection (39/51, 76.5%). Of the 42/51 saline-treated tissues yielding ≥105cfu/g, a microbial threshold reported to impede wound-healing, only 4/42 (9.5%) were clinically diagnosed DFUIs. Microbial loads from anolyte-treated tissues were significantly lower than saline-treated tissues using 1mL (1065-fold, 2.0 log) and 10mL (8216-fold, 2.1 log) immersion volumes (P<0.0005). S.aureus was the predominant species recovered (44/51, 86.3%) and 50 isolates underwent WGS. All were meticillin susceptible and comprised 12 sequence types (STs), predominantly ST1, ST5 and ST15. Whole-genome multi-locus sequence typing identified three clusters of closely related isolates from 10 patients indicating inter-patient transmission. Short immersions of debrided ulcer tissue in anolyte significantly reduced microbial bioburden: a potential novel DFUI treatment.

KNOWLEDGE AND PRACTICE REGARDING DIABETIC FOOT CARE AMONG DIABETIC PATIENTS ATTENDING OUTPATIENT DEPARTMENT IN MINISTRY OF NATIONAL GUARD HEALTH AFFAIRS AL-AHSA, KINGDOM OF SAUDI ARABIA

Background; Diabetic foot ulcer is a major cause of lower limb amputation. Diabetic foot problems and amputation can be prevented by proper foot care. Patient's awareness is important in reducing the incidence of foot ulcers and complication. Education of the Patient with diabetes will lower the rate of foot complications and subsequent amputations. Guidelines regarding proper foot care should be provided to the diabetic patients is vital important. The study aim was to determine the knowledge and practice regarding diabetic foot care among diabetic patients. Methodology; The present study is a cross-sectional descriptive study was carried out among 288 patients attending OPD in ministry of National Guard health Affairs Al-Ahsa, kingdom of Saudi Arabia. Samples were selected from December 2019 to March 2020. Systematic random sampling technique was done to collect the data. The data was collected after obtaining consent from all subjects. Information related to demographic variables and knowledge, practice questionnaire survey was collected using interview technique. There were 10 items inclusive of each knowledge and practice components regarding diabetes foot care was selected. SPSS version 20 was used for analysis. Results; The study report showed that 53.8% of patients had adequate level of knowledge regarding diabetes, 43.5% of patients had intermediate level of knowledge and 2.8% of patients had inadequate level of knowledge.ly 30.6% of patients had good practice and 51% of patients had very fair practice and also 18.4% of patients doing poor practice.

Bacterial isolates from diabetic foot ulcers and their antimicrobial resistance profile from selected hospitals in Addis Ababa, Ethiopia.

IntroductionInfected diabetic foot ulcer (IDFU) is a worldwide problem associated with diabetes mellitus. It could lead from soft tissue infection to bone infection and is a leading cause of lower limb amputation. Gram-negative and Gram-positive bacteria, including anaerobic bacteria and fungi, are considered potential causes of infection. The early diagnosis of DFU infection and appropriate treatment based on the identification of the pathogens and their antimicrobial susceptibility pattern is important for good prognosis. Therefore, the purpose of this study was to isolate the bacteria that infect foot ulcers in selected Hospitals and determine their antimicrobial resistance profile.MethodAn institutional-based multicenter, cross-sectional study was conducted in selected Hospitals in Addis Ababa, Ethiopia, from November 2020 to May 2021. A sterile swab was used to collect samples from the foot ulcer and a sterile needle to collect pus. Isolates were identified by culture, Gram-staining, and a series of biochemical tests. For each bacterial species identified, the antibiotic profiling was determined by the Kirby-Bauer disk diffusion method.Resultsone hundred and twenty-seven pathogenic bacteria were isolated from samples taken from 130 patients with a diabetic foot ulcer. Sixty-eight percent had growth of multiple microorganisms. Two-thirds (66.7%) of the isolates were gram-negative bacteria. The predominant bacterial species were S. aureus 25.19% (32/127), Pseudomonas species 18.89% (24/127), and Escherichia coli 16.53% (21/127). Overall, 92.9% (118/127) of the isolates were identified as multi-drug resistant. Gram-positive isolates were susceptible to chloramphenicol, clindamycin, and amikacin. Gram-negative isolates were also sensitive to chloramphenicol, aztreonam, and amikacin.ConclusionThe majority of bacteria isolated from patients presenting with Diabetic foot ulcer infections were found to be multi-drug resistant in the study sites of the current study. The results demonstrate the importance of timely identification of infection of diabetic foot ulcers, proper sample collection for identification of the pathogens and for determining their antibiotic susceptibility pattern before initiating antimicrobial treatment

770 Reprogramming of diabetic wounds by SOX2 triggers a pro-healing transcriptional signature

Diabetic foot ulcers (DFUs) are a severe complication of diabetes and a common cause of lower limb amputations and are associated with a high mortality rate. We previously demonstrated that the transcription factor SOX2 establishes a transcriptional network that primes the oral epithelium for rapid wound repair and reprogrammed cutaneous keratinocytes to present accelerated wound resolution both in vitro and in vivo. However, the mechanisms by which SOX2 reverses effects of diabetes during wound healing are not known.

Stress-Reducing Psychological Interventions as Adjuvant Therapies for Diabetic Chronic Wounds.

Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus and a leading cause of lower limb amputation. Interventions to reduce psychological stress may have the potential to improve self-care and greatly reduce the morbidity and mortality associated with DFU. This review is focused on the consequences of psychological stress in wound healing and reflects on the effects of currently used psychological stress-reducing interventions in patients with DFU, proposing new applications for currently used stress-reduction interventions. Stress is a natural and fundamental survival mechanism that becomes harmful when chronic. DFU is associated with high levels of anxiety and chronic psychological stress. Chronic stressinduced cortisol and adrenaline release impair wound healing, independently of the stressor. Psychological stress-reducing interventions, such as relaxation with guided imagery, biofeedback-assisted relaxation, mindfulness-based strategies, and hypnosis, can lead to a reduction in perceived stress and improve wound healing by reducing wound inflammation and pain while improving glycemic control. All stress reduction interventions also lead to pain relief and improved patient's quality of life. Psychological stress-reducing interventions are promising adjuvant therapies for DFU. Their clinical application can improve self-care by tackling patient's expectations, anxieties, and fears. They can also help patients manage stress and pain while reducing wound inflammation and improving wound healing.

Through-knee versus above-knee amputation for vascular and non-vascular major lower limb amputations.

Diabetes and vascular disease are the leading causes of lower limb amputation. Currently, 463 million adults are living with diabetes, and 202 million with peripheral vascular disease, worldwide. When a lower limb amputation is considered, preservation of the knee in a below-knee amputation allows for superior functional recovery when compared with amputation at a higher level. When a below-knee amputation is not feasible, the most common alternative performed is an above-knee amputation. Another possible option, which is less commonly performed, is a through-knee amputation which may offer some potential functional benefits over an above-knee amputation. To assess the effects of through-knee amputation compared to above-knee amputation on clinical and rehabilitation outcomes and complication rates for all patients undergoing vascular and non-vascular major lower limb amputation. The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.govtrials register to 17 February 2021. We undertook reference checking, citation searching, and contact with study authors to identify additional studies. Published and unpublished randomised controlled trials (RCTs) comparing through-knee amputation and above-knee amputation were eligible for inclusion in this study. Primary outcomes were uncomplicated primary wound healing and prosthetic limb fitting. Secondary outcomes included time taken to achieve independent mobility with a prosthesis, health-related quality of life, walking speed, pain, and 30-day survival. Two review authors independently reviewed all records identified by the search. Data collection and extraction were planned in line with recommendations outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We planned to assess the certainty of evidence using the GRADE approach. We did not identify RCTs that met the inclusion criteria for this review. No RCTs have been conducted to determine comparative clinical or rehabilitation outcomes of through-knee amputation and above-knee amputation, or complication rates. It is unknown whether either of these approaches offers improved outcomes for patients. RCTs are needed to guide practice and to ensure the best outcomes for this patient group.

Autologous Platelet Rich Plasma Promotes the Healing of Non-Ischemic Diabetic Foot Ulcers. A Randomized Controlled Trial

DFU (diabetic foot ulcer) represents a major global health and socioeconomic problem and a leading cause of lower limb amputation. Although many therapies have been tested, none has been proposed as a dominant wound healing treatment. We performed a prospective randomized controlled study in order to assess the role of autologous platelet rich plasma (PRP) for the promotion of non-ischemic DFU healing. After full vascular assessment, a total of 80 patients were randomized in 1:1 ratio to receive either PRP injection in the healing edge and the floor of the targeted DFU (Group A), or have usual standard care with moist dressing with or without collagenase ointment (Group B). We calculated the total surface area (TSA) for the ulcer in both groups (cm2) before, after treatment and every week up to 12 weeks of follow-up. A total of 4 patients (10%) experienced major amputation in group B, while no major amputation was performed in patients of Group A (P< 0.001). A ≥ 50% reduction in TSA occurred earlier in Group A (at 2.5 weeks), compared to Group B (4.5 weeks); P < 0.001. Complete wound healing rate was 95% (n=38) and it was achieved earlier (6th week) for patients of group A, contrary to 77.8% (n=28) of patients (9th week) for Group B (P < 0.001). Superficial wound infection was noted in 10% (n=4) of the cases in the PRP arm, while in group B, 45% (n=18) of cases had a variable degree of infection ranging from superficial to deep wound infection and cellulites (P < 0.001). PRP treatment was cost-effective, with 247.50$ vs. 437.50$ for the total cost of treatment for patients of Group B. PRP is a cost-beneficial novel modality of treatment that can accelerate wound healing and decrease the rate of local infection in DFU, compared to other conventional treatment modalities.

Microbiota of diabetic foot infections in a University Hospital in Bogotá, Colombia

The presence of infection in diabetic foot ulcers (DFU) is one of the main causes of lower limb amputation in the world. The presence of polymicrobial infections is usually the standard for isolation in such lesions, with Gram Positive (GP) germs being the main organisms involved, as is described in the global literature. However, some studies indicate a greater number of isolates with Gram Negative (GN) germs, reported mainly in the literature of Middle Eastern countries and in the tropics.

General estimates of the energy cost of walking in people with different levels and causes of lower-limb amputation: a systematic review and meta-analysis.

Energy cost of walking (ECw) is an important determinant of walking ability in people with a lower-limb amputation. Large variety in estimates of ECw has been reported, likely because of the heterogeneity of this population in terms of level and cause of amputation and walking speed. To assess (1) differences in ECw between people with and without a lower-limb amputation, and between people with different levels and causes of amputation, and (2) the association between ECw and walking speed. Systematic review and meta-analysis. We included studies that compared ECw in people with and without a lower-limb amputation. A meta-analysis was done to compare ECw between both groups, and between different levels and causes of amputation. A second analysis investigated the association between self-selected walking speed and ECw in people with an amputation. Out of 526 identified articles, 25 were included in the meta-analysis and an additional 30 in the walking speed analysis. Overall, people with a lower-limb amputation have significantly higher ECw compared to people without an amputation. People with vascular transfemoral amputations showed the greatest difference (+102%) in ECw. The smallest difference (+12%) was found for people with nonvascular transtibial amputations. Slower self-selected walking speed was associated with substantial increases in ECw. This study provides general estimates on the ECw in people with a lower-limb amputation, quantifying the differences as a function of level and cause of amputation, as well as the relationship with walking speed.

899Stepping up: identifying small-area variation in diabetes-related lower limb amputations

Abstract Background Diabetes-related foot disease is the leading cause of lower limb amputations in Queensland. Amputations can be either minor (below the ankle joint) or major (above the ankle joint). Minor amputations may be performed to prevent major amputations prophylactically, but how these forms of amputations interrelate, and where their interrelationships are weakest and strongest, is unknown. Knowledge of small-area variation in interrelations between minor and major amputations is relevant to prevention and improved management of foot disease. Methods Data on lower limb amputations performed between 2014 and 2018 on patients aged 20+ years with diabetes were obtained from the Queensland Hospital Admitted Patient Data Collection. Rates were calculated using the number of people, rather than the number of amputation procedures. A Bayesian hierarchical spatial multivariate model was used to examine patterns over 516 populated statistical areas 2 in Queensland. Results During 2014 to 2018, 3,548 Queenslanders had at least one minor amputation, and 1,114 had at least one major amputation. Modelled amputation rates varied markedly across the State (standardised morbidity ratio (SMR) IQR: 0.67 to 1.22), with areas in far north Queensland having extremely high rates. There was consistently high area-level correlation between minor and major amputation rates. The highest SMRs for both minor and major amputations were in the Northern Peninsula. Conclusions Elevated rates of minor and major amputations in areas in Queensland, most noticeably the far north, indicate an urgent need for greater support for people with diabetes-related foot disease. Key messages Text: Large differences in minor and major amputation rates across Queensland indicate that certain regions require greater assistance in managing diabetes-related foot disease.

English

BACKGROUND Diabetic foot is the most common and most feared complication of diabetes and is more significant than nephropathy, retinopathy, heart attack, and stroke combined. Diabetes-associated problems are the second common cause of lowerlimb amputations in India. Foot disorders like ulcerations, infection, Gangrene are the leading causes of hospitalization in patients with diabetes mellitus in India.1 METHODS A prospective study, carried out on 100 diabetic patients with foot ulcers over a period of one year from April 2019 to March 2020 at Sri Venkateswara Medical College hospital. The extent of foot infection was assessed based on Wagner’s classification and were studied based on the culture and sensitivity obtained and the efficacy of the antibiotic used. RESULTS The data analysis of 100 patients has given the following results. 70 % (70 patients) of them were culture positive, and 30 % (30 patients) were culture negative. Culture positive patients were divided into two groups with 35 patients each. Group A started on empirical therapy, Group B on sensitive antibiotic therapy. Repeat swab taken on day 7 from the previously culture-positive patients (70 patients), it was found that 30 out of 35 patients of group-A (empirical therapy) were still culture positive with a similar or newer organism, only 5 patients were culture negative, whereas in 35 patients of Group-B (sensitive antibiotic therapy) only 5 patients were culture positive with a similar or newer organism, remaining 30 patients were culture negative. Sensitive antibiotic therapy was found to be effective than empirical therapy in treatment of diabetic foot ulcers. CONCLUSIONS Culture and sensitivity from the wounds play a critical role in prescribing appropriate antibiotic at the time of admission itself rather than starting the empirical treatment. KEYWORDS Diabetic Foot, Culture and Sensitivity, Empirical Antibiotic Therapy

Measurement properties of the L Test with fast walking speed in patients after lower limb amputation in initial prosthetic training phase

The L Test is a clinical mobility test used in patients after lower limb amputation. To assess dynamic balance, it should be performed with fast walking speed. Its measurement properties in the initial prosthetic training phase are not known yet. The objective of the study was to establish intra- and interrater reliability, concurrent and discriminant validity, minimal detectable change, effect size between the rehabilitation time points and ceiling effect of the L Test with fast walking speed in patients after lower limb amputation in initial prosthetic training phase. The study included 36 inpatients aged 19-86 years who were provided with a prosthesis for the first time. They were assessed repeatedly with the L Test, Ten-meter Walk Test and 6-min Walk Test. The intra- (ICC3, k = 0.94) and interrater reliability (ICC2, k = 0.96) of the L Test were excellent. Correlations with the walking tests were very good (r = 0.75-0.86). Regression analysis with respect to the level of lower limb amputation showed a linear relationship with other variables (R2 = 0.55). Influences of age, cause of lower limb amputation and walking aid were statistically significant. The L Test was responsive to change after two weeks of prosthetic training (Cohen's d = 1.21). No ceiling effect was identified. The L Test with fast walking speed is a feasible, reliable, valid, and responsive measure of basic mobility skills in patients after lower limb amputation in the initial prosthetic training phase.