Incidence Of Amputations In Patients Research Articles

Streamlined Clinical Management Pathways May Reduce Major Amputations in Patients with Chronic Limb Threatening Ischaemia: A Prospective Cohort Study with Historical Controls

Patient characteristics and patterns of disease in chronic limb threatening ischaemia (CLTI) have changed markedly in recent years. Urgent specialist referral and timely revascularisation are recommended in international guidelines. UK guidelines now recommend revascularisation within 5 days of referral for inpatients and 2 weeks in outpatients. This study compared the contemporary one year major amputation incidence in patients with CLTI with a historical cohort at a single UK centre. This was a single centre, observational cohort study with historical controls. A prospective cohort was recruited between May 2019 and March 2022. A historical cohort presenting between 2013 and 2015 inclusive was identified retrospectively. Significant changes in management pathways, including establishing a rapid access limb salvage clinic, occurred between these periods aiming to expedite time from referral to revascularisation. The one year primary outcome was major amputation, and the secondary outcome was death. Major amputation was analysed by Fine-Gray competing risks models (death as the competing risk), presented as subdistribution hazard ratios (SHRs). One year mortality was analysed by Cox regression, presented as hazard ratios. Analyses were adjusted for propensity score. A total of 928 patients were included (432 prospective and 496 historical). Proportions of patients presenting with tissue loss (72.2% vs. 71.6%; p = .090) were similar in both cohorts. At one year, 48 patients (11.1%) in the prospective cohort and 124 patients (25.0%) in the historical cohort had undergone a major amputation (p < .001). Risk of major amputation was 57.0% lower in the prospective cohort compared with the historical cohort after adjustment for propensity score (SHR 0.43, 95% confidence interval 0.29 - 0.63; p < .001). An encouraging reduction in major amputation incidence was observed after improvements to CLTI management pathways, but residual confounding is likely. The generalisability of these results is uncertain.

Comorbid status in patients with osteomyelitis is associated with long-term incidence of extremity amputation

IntroductionOsteomyelitis is associated with significant morbidity, including amputation. There are limited data on long-term amputation rates following an osteomyelitis diagnosis. We sought to determine the incidence of amputation in patients...

Extra-Anatomic Bypass and Excision is Superior to Graft Salvage Attempts with Antibiotic Beads to Treat Vascular Graft Infections in the Groin

This study aimed to determine if conventional extra-anatomic bypass and graft removal versus aggressive attempts at graft preservation have better survival and limb salvage in patients with localized groin wound infections of vascular grafts. We conducted a retrospective review of 53 consecutive patients with vascular graft infections presenting in the groin. Treatment groups consisted of group 1 (extra-anatomic bypass and graft excision, n=22) and group 2 (initial graft preservation attempts with utilization of antibiotic beads, n=31). In group 2, patients underwent serial debridement and placement of antibiotic beads until culture-negative wounds were achieved. Significantly more patients underwent muscle flap coverage in group 2 (27/31) compared with group 1 (7/22; P<0.001). Data collected included demographics, comorbidities, intraoperative details, and outcomes, including patency, limb salvage, mortality, and number of procedures. Continuous variables were examined with Student's t-test, and dichotomous variables were examined with chi-squared test. Linear and logistic regressions were used to analyze factors associated with outcomes, in addition to Kaplan-Meier analysis with log rankfor actuarial analysis. Both groups were similar with respect to demographics. The overall Kaplan-Meier 1- and 3-year survival rates were 66.2% and 34.1%, with no statistically significant difference between groups. The Kaplan-Meier 1- and 3-year limb salvage rates were 68.8% and 36.6% for group 1 vs. 58.5% and 38.7% for group 2 (P=not significant [NS]). The 1- and 3-year primary patency rates were 71% and 71% in traditional group 1 vs. 72% and 56% in group 2 (P=NS). One-year and 3-year secondary patency rates in traditional group 1 were 83% and 71% vs. 85% and 61% in group 2 (P=NS). Patients in group 1 underwent fewer total procedures when compared with group 2 (2.3±0.2 vs. 5.1±0.7, P=0.03). The late reinfection rate was significantly less in group 1 (4.5%) compared with group 2 (26%; P=0.04). Freedom from reinfection at 1 and 3 years were 94% and 94% in traditional group 1 vs. 74% and 62% in group 2 (P=0.03). Multivariable analysis showed a higher incidence of amputation in patients who suffered reinfection (n=13, P=0.049). There was a higher mortality in patients with septic shock (n=10, P=0.007) and reinfection (n=13, P=0.036). Reinfection was associated with the highest mortality (P=0.03). Conventional graft excision with extra-anatomic bypass resulted in similar mortality when compared with aggressive attempts at graft preservation and trended toward improved limb salvage and patency. However, attempts at graft preservation with antibiotic beads resulted in a significantly higher reinfection rate and greater number of procedures, and therefore, this approach should be used very selectively.

Increasing prevalence of diabetic peripheral angiopathy and complications in hospitalized patients in the United States

Abstract Objectives We aim to assess prevalence of diabetes related peripheral arterial disease and associated outcomes in hospitalized patients in the United States. Methods Trends in hospitalizations in diabetic patients with PAD were determined using the 2003–2017 National Inpatient Sample database. Hospital outcomes including diabetic ulcer incidence, amputations, and revascularizations were analyzed. Results The analysis included 10,303,673 hospitalizations in diabetic patients with PAD (DMPAD) during the study period. Prevalence of PAD among patients with diabetes increased over time (p&amp;lt;0.001). The prevalence of foot ulcers in diabetics have also increased over time (p&amp;lt;0.001). The incidence of amputations in patients with diabetes showed a decreasing trend with increasing prevalence of revascularizations from 2003 to 2009. Since 2010 however, rising rates of amputations, both minor and major are seen, especially in younger populations (age 18–49). Hospital costs for amputations have increased ($6.6 billion in 2003 vs $ 14.8 billion in 2017) as well as the costs for revascularization (6.1 billion in 2003 vs $13 billion in 2017) during the study period (p&amp;lt;0.001). Conclusions In this analysis of patients with DMPAD, an alarming rate of disease prevalence and in-hospital limb outcomes, including costs, are realized in the current era. Funding Acknowledgement Type of funding sources: None.

Low-intensity pulsed ultrasound decreases major amputation in patients with critical limb ischemia: 5-year follow-up study.

Various therapeutic strategies for angiogenesis are performed to improve symptoms in patients with critical limb ischemia (CLI). Pre-clinical studies have shown that low-intensity pulsed ultrasound (LIPUS) exposure induces angiogenesis. LIPUS may be a new stratergy for treatment of CLI. The purpose of this pilot trial was to evaluate outcomes in patients with CLI who were treated with LIPUS. Fourteen patients with CLI, who were not candidates for angioplasty or surgical revascularization, were enrolled in this study. Historical control data were obtained from the Hiroshima University PAD database. The primary endpoints were major amputation and death. The outcomes were compared in 16 lower limbs of the 14 patients with CLI who were treated with LIPUS and in 14 lower limbs of 14 patients with CLI as historical controls. All patients were followed for after 5 years after treatment with LIPUS. The mean duration of LIPUS exposure in the LIPUS group was 381± 283 days. During the 5-year follow-up periods, there were 3 major amputations and 7 deaths in the LIPUS group and there were 14 major amputations and 7 deaths in the historical control group. The overall amputation-free survival rate was significantly higher in patients who were treated with LIPUS than in historical controls. There was no significant difference between overall mortality-free survival rates in the LIPUS group and historical control group. LIPUS is a noninvasive option for therapeutic angiogenesis with the potential to reduce the incidence of major amputations in patients with CLI.

CEPT1-Mediated Phospholipogenesis Regulates Endothelial Cell Function and Ischemia-Induced Angiogenesis Through PPARα.

De novo phospholipogenesis, mediated by choline-ethanolamine phosphotransferase 1 (CEPT1), is essential for phospholipid activation of transcription factors such as peroxisome proliferator-activated receptor α (PPARα) in the liver. Fenofibrate, a PPARα agonist and lipid-lowering agent, decreases amputation incidence in patients with diabetes. Because we previously observed that CEPT1 is elevated in carotid plaque of patients with diabetes, we evaluated the role of CEPT1 in peripheral arteries and PPARα phosphorylation (Ser12). CEPT1 was found to be elevated in diseased lower-extremity arterial intima of individuals with peripheral arterial disease and diabetes. To evaluate the role of Cept1 in the endothelium, we engineered a conditional endothelial cell (EC)-specific deletion of Cept1 via induced VE-cadherin-CreERT2-mediated recombination (Cept1Lp/LpCre +). Cept1Lp/LpCre + ECs demonstrated decreased proliferation, migration, and tubule formation, and Cept1Lp/LpCre + mice had reduced perfusion and angiogenesis in ischemic hind limbs. Peripheral ischemic recovery and PPARα signaling were further compromised by streptozotocin-induced diabetes and ameliorated by feeding fenofibrate. Cept1 endoribonuclease-prepared siRNA decreased PPARα phosphorylation in ECs, which was rescued with fenofibrate but not PC16:0/18:1. Unlike Cept1Lp/LpCre + mice, Cept1Lp/LpCre + Ppara -/- mice did not demonstrate hind-paw perfusion recovery after feeding fenofibrate. Therefore, we demonstrate that CEPT1 is essential for EC function and tissue recovery after ischemia and that fenofibrate rescues CEPT1-mediated activation of PPARα.

Amputations and foot ulcers in patients newly diagnosed with Type 2 diabetes mellitus and observed for 19 years. The role of age, gender and co‐morbidity

To determine the prevalence of foot ulcers and the incidence of amputations in patients with Type 2 diabetes observed for 19 years after diagnosis. We investigated the role of gender, age and co-morbidities. From the Diabetes Care in General Practice study, 1381 patients were included and examined at diabetes diagnosis, at 6 years and at 14 years after diagnosis. Register-based follow-up was for 19 years. Foot ulcers and amputations were related to gender, age and co-morbidities by odds and hazard ratios from logistic and Cox regression models, respectively. The incidence of any amputation and major amputation was 400 (95% CI 307-512) and 279 (95% CI 203-375) per 100,000 patient-years, respectively. At the three observation points, the foot ulcer prevalences were 2.76% (95% CI 1.89-3.63), 2.93% (95% CI 1.86-4.00) and 4.96% (95% CI 3.10-6.82). Multivariate analyses showed associations between foot ulcers and peripheral neuropathy, peripheral arterial disease, male gender, retinopathy and myocardial infarction. After multivariate adjustment, significant predictors (hazard ratio; 95% CI) of any amputation were peripheral neuropathy (hazard ratio 2.09; 95% CI 1.19-3.69), peripheral arterial disease (hazard ratio 3.43; 95% CI 1.65-7.12), microalbuminuria (hazard ratio 2.11; 95% CI 1.21-3.67), retinopathy (hazard ratio 6.42; 95% CI 2.59-15.90), impaired vision (hazard ratio 6.92; 95% CI 2.35-20.38) and male gender (hazard ratio 2.40; 95% CI 1.31-4.41). For women, the risk of amputation increased with age, but for men the risk was higher when diagnosed with diabetes at a younger age. Despite improved treatment regimens, the incidence of amputations is still high in this population-based patient sample. Men diagnosed with diabetes before age 65 years and patients with diabetes-related co-morbidities are at particularly high risk of foot ulcers and amputations.

Does Gender Influence the Incidence of Lower Extremity Amputation in Patients with Critical Limb Ischemia?

Does Gender Influence the Incidence of Lower Extremity Amputation in Patients with Critical Limb Ischemia?

Negative-Pressure Wound Therapy and Diabetic Foot Amputations

This study was undertaken to assess the benefits of negative-pressure wound therapy (NPWT) versus traditional wound therapies in reducing the incidence of lower-extremity amputations in patients with diabetic foot ulcers. Administrative claims data for patients with diabetic foot ulcers from commercial payers (n=3,524) and Medicare (n=12,795) were retrospectively analyzed. Patients were divided into NPWT and control/traditional therapy groups on the basis of administrative codes. Risk-adjustment procedures were then performed to match patient risk categories (through total treatment costs) and wound severities (through debridement depth). The incidence of amputations in the NPWT groups was lower than that in the control groups. For the cost-based risk-adjustment analysis, amputation incidences with NPWT versus traditional therapy were 35% lower in the Medicare sample (10.8% versus 16.6%; P=.0077) and 34% lower in the commercial payer sample (14.1% versus 21.4%; P=.0951). Whereas overall amputation rates increased progressively with increasing wound debridement depth in both control groups, the same increasing trend did not occur in the NPWT groups. Patients with diabetic foot ulcers in the Medicare sample treated with NPWT had a lower incidence of amputations than those undergoing traditional wound therapy; this finding was evident in wounds of varying depth in both populations studied.