Incidence Of Lower Limb Amputations Research Articles

The profile of people undergoing lower limb amputations at Groote Schuur Hospital.

The annual incidence of lower limb amputations (LLA) at Groote Schuur Hospital is rising gradually. However, little is known about the sociodemographic and clinical profiles of people undergoing these limb amputations. To collect and analyse data to describe the sociodemographic, health and amputation profiles of people who have undergone LLA at Groote Schuur Hospital. A descriptive retrospective chart review was conducted using a sample of 107 participants who had undergone LLA at Groote Schuur Hospital between January 2019 and July 2020. A customised assessment tool was used to extract data on the sociodemographic, health and amputation profiles of patients who had LLA. Data were analysed descriptively. Sixty per cent of the patients who had undergone LLA at Groote Schuur Hospital were women. Most of the patients were over the age of 60 years and had not completed school and were pensioners or unemployed, with very low income and multiple co-morbidities including poorly controlled diabetes. Complications because of uncontrolled diabetes were the primary indication for LLAs at Groote Schuur Hospital. Therefore, health literacy projects are indicated to address chronic diseases of lifestyle, which, in turn, may reduce the overall burden of LLA, particularly on the South African under-resourced healthcare system. The results of this study may help us identify key factors that predispose patients to LLAs. Consequently, this may help us identify key areas for prevention and better management of diseases that can result in complications that indicate the need for amputation.

Efeitos das tecnologias educativas na prevenção e tratamento da úlcera diabética: revisão sistemática e metanálise

Objective: to analyze the effects of educational technologies in the prevention and treatment of diabetic ulcers. Method: a systematic review conducted in seven databases, a bibliographic index, an electronic library and the Gray Literature. The sample consisted of 11 randomized controlled clinical trials. The synthesis of the results was descriptive and through meta-analysis. Results: the predominant educational technologies were training sessions and verbal guidelines, with soft-hard technologies standing out. When compared to usual care, the educational technologies presented a protective factor to prevent the incidence of diabetic ulcers (RR=0.40; 95% CI=0.18-0.90; p=0.03) and the certainty of the evidence assessment was low. The educational technologies also had a protective factor to prevent the incidence of lower limb amputations (RR=0.53; 95% CI=0.31-0.90; p=0.02) and certainty of the evidence was very low. Conclusion: soft-hard educational technologies such as structured verbal guidelines, educational games, lectures, theoretical-practical training sessions, educational videos, folders, serial albums and playful drawings, and hard technologies such as therapeutic footwear, insoles, infrared digital thermometer, foot care kits, Telemedicine app and mobile phone use, were effective for the prevention and treatment of diabetic ulcers, although more robust studies are required.

Effects of educational technologies on the prevention and treatment of diabetic ulcers: A systematic review and meta-analysis.

to analyze the effects of educational technologies in the prevention and treatment of diabetic ulcers. a systematic review conducted in seven databases, a bibliographic index, an electronic library and the Gray Literature. The sample consisted of 11 randomized controlled clinical trials. The synthesis of the results was descriptive and through meta-analysis. the predominant educational technologies were training sessions and verbal guidelines, with soft-hard technologies standing out. When compared to usual care, the educational technologies presented a protective factor to prevent the incidence of diabetic ulcers (RR=0.40; 95%CI=0.18-0.90; p=0.03) and the certainty of the evidence assessment was low. The educational technologies also had a protective factor to prevent the incidence of lower limb amputations (RR=0.53; 95%CI=0.31-0.90; p=0.02) and certainty of the evidence was very low. soft-hard educational technologies such as structured verbal guidelines, educational games, lectures, theoretical-practical training sessions, educational videos, folders, serial albums and playful drawings, and hard technologies such as therapeutic footwear, insoles, infrared digital thermometer, foot care kits, Telemedicine app and mobile phone use, were effective for the prevention and treatment of diabetic ulcers, although more robust studies are required.

Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

Editor's Choice – Incidence of Lower Limb Amputations in Sweden from 2008 to 2017

This study examined the recent national and regional incidence of lower limb amputations (LLAs) in Sweden and their annual changes. This was an observational study using Swedish national register data. All initial amputations were identified in Sweden from 2008 to 2017 in individuals 18 years or older using the national inpatient register. The amputations were categorised into three levels: high proximal (through or above the knee joint), low proximal (through the tibia to through the ankle joint), and partial foot amputations. To examine the national and regional incidence and annual changes, the age, sex, and region specific population count each year was used as the denominator and Poisson regression or negative binomial regression models were used to estimate incidence rate ratios (IRRs) and 95% confidence intervals (CIs) adjusted for age and sex. The national annual incidence of LLAs was 22.1 per 100 000 inhabitants, with a higher incidence in men (24.2) than in women (20.0). The incidence of LLAs (all levels combined) declined during the study period, with an IRR of 0.984 per year (95% CI 0.973 - 0.994). This was mainly due to a decrease in high proximal amputations (0.985, 95% CI 0.974 - 0.995) and low proximal amputations (0.973, 95% CI 0.962 - 0.984). No change in the incidence of partial foot amputations was observed (0.994, 95% CI 0.974 - 1.014). Such declines in LLA incidence (all levels combined) were observed in nine of the 21 regions. Compared with the national average and with adjustment for age, sex, diabetes, and artery disease, the regional IRR varied from 0.85 to 1.36 for all LLAs, from 0.67 to 1.61 for high proximal amputations, from 0.50 to 1.51 for low proximal amputations, and from 0.13 to 3.68 for partial foot amputations. The incidence of LLAs has decreased in Sweden. However, regional variations in incidence, time trends, and amputation levels warrant further research.

Abstract P155: Differential Incidence Trends In Non-traumatic Lower Limb Amputations In The Province Of Quebec, Canada: Does The Reduction Applies Equally In Both Sexes?

Introduction: Non-traumatic lower limb amputations (LLA) represent an important complication of diabetes (DM) and peripheral arterial disease (PAD). In Quebec, Canada, the latest data between 1996 to 2004 suggested a reduction in the incidence of LLA while other Canadian provinces observed a recent increase between 2010 and 2016. Our objective was to update the incidence trends of LLA in Quebec from fiscal years 2006 to 2019. Methods: Age-standardized incidence of LLA among individuals ≥40 years was assessed using the Quebec Integrated Chronic Disease Surveillance System (n=4,527,533 in 2019). The mean age of incident cases and the presence / duration of DM and/or PAD was collected. Estimations were presented for all, by sexes and by types of LLA (minor: below the knee; major: knee and above), with 99% confidence intervals (CI). Results: Between 2006 and 2019, incident cases of LLA increased from 818 to 1,099 but age-standardized incidence remained stable (Figure 1) for both sexes. Men had a higher age-standardized incidence of LLA then women (32.7 per 100,000 [99% CI: 29.7-35.9] vs 12.9 per 100,000 [11.2-14.9] in 2019). From 2006 to 2019, the age-standardized incidence of major LLA showed a relative decrease of 48% while minor LLA remained stable (Figure 1). Reduction in age-standardized incidence of major LLA was attributable to men (3.8 per 100,000 [2.7-5.3] to 1.7 per 100,000 [1.1-2.6]). The mean age of incident cases went from 68.2 to 69.5 years from 2006 to 2019 (72.4 for women and 68.3 for men in 2019). Ninety-eight percent of LLA had DM, while 95% had PAD and 95% had both in 2019. Between 2006 and 2019, the average time between the first LLA and DM diagnosis increased from 7.0 to 14.7 years and from 2.0 to 2.6 years for PAD. Conclusions: Although the age-standardized incidence of LLA is stable, men remain at higher risk then women. The portrait of incident cases is changing towards an older average age, longer DM duration and a reduction of major LLA. These results emphasize the importance to improve further preventive care of LLA in Quebec.

The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study

To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.

What happens to our amputees? The Darling Downs experience.

Major lower limb amputation is occasionally required in the management of end-stage pathology where other treatment options have failed. The primary aim of this study was to determine the 30-day and 1-year mortality rates of patients undergoing nontraumatic major lower limb amputation. Secondary aims were to investigate risk factors for poor outcomes, incidence of previous minor amputation, and the rate of subsequent major amputation. All nontraumatic, major lower limb amputations performed at Toowoomba Hospital during an 18-year period were retrospectively reviewed. Mortality data were obtained from the Queensland Registry of Births, Deaths and Marriages. Kaplan-Meier analysis was performed to determine survival after amputation. A total of 147 patients were included in the study, with 104 undergoing below knee and 43 undergoing above knee amputations. Ten patients identified as having an Aboriginal and Torres Strait Islander background. For all patients, the 30-day mortality was 4.1% and 1-year mortality was 21.1%. For Indigenous patients, 30-day mortality was 10%. Previous minor amputation had occurred in 40 patients. Twenty-nine patients underwent further minor surgery after their initial major amputation, with thirteen requiring subsequent major amputation. Factors that increased mortality risk were the presence of peripheral vascular disease, an American Society of Anesthesiologists score of four and age greater than 65 years. The morbidity and mortality following major lower limb amputation is significant. The findings of this study highlight the importance of preventative measures to minimize the incidence of lower limb amputations in the future.

Treatment of necrotizing infection in patients with chronic arterial insufficiency of the lower extremities

To analyze the effectiveness of complex therapy of necrotizing infection using the original method of stimulation of angiogenesis in patients with chronic arterial insufficiency of the lower extremities. In 53 patients, operations were performed using the proposed technologies for stimulation of angiogenesis. A control group consisting of 56 patients was formed to compare the results of treatment. They had standard vascular therapy for the correction of ischemia. Morphological studies of the muscles of the lower extremities included assessment of capillary bed density and spatial orientation of the capillaries before and after treatment. Computed angiography of the lower extremities followed by calculation of perfusion index was performed to assess changes in the microvasculature. Clinical evaluation of the results was carried out using R. Rutherford scale. Revascularization resulted significant augmentation of capillary bed density and the number of functioning capillaries in muscular tissue. This was accompanied by increased perfusion index and TcPO2 values. The effect of treatment is observed in 12-14 days after surgery and persists for a long time. The best outcomes are found in patients with ischemia grade IIb-III. Incidence of lower limb amputations was more than 2 times lower in the main group compared with the control group. Combined stimulation of angiogenesis including mechanical tunneling of the muscles of the affected limb and administration of platelet rich plasma is effective procedure. This method does not require complex equipment and may be used in the treatment of patients with complications of chronic lower limb ischemia and contraindicated direct arterial reconstruction.

Association of Diuretics Use and Amputations in Patients with Type 2 Diabetes—A Hypothesis Driven from Canvas Warning?

Clinical trials in patients with type 2 diabetes (T2D) showed that the incidence of lower limb amputations (LLA) was doubled in patients in canagliflozin arm compared with placebo. Whether hypovolemia favored by SGLT2 inhibition-induced diuresis could be associated with a reduced lower extremity perfusion is a potential explanation. Although we cannot test this hypothesis directly, a similar side-effect of diuretics would be a supportive argument. We tested the association between use of diuretics (recorded at baseline) and risk of LLA (any LLA occurring during follow-up) in patients with T2D from the SURDIAGENE French cohort. Unadjusted and adjusted cox models were used. Among 1468 participants (Male 58%, age 65±11 years, known diabetes duration 15±10 years), 670 (46%) were on treatment with diuretics. LLA occurred in 79 (5.4%) patients during 5.8±3.2 years of follow-up: 51 (3.5%) among diuretics users and 28 (1.9%) in non-users (p<0.001). In the unadjusted model, the risk of amputation was higher in diuretics users (hazard ratio (HR), 2.52; 95% CI, 1.59-4.02; P<0.0001). The risk remained significantly higher after adjustment for confounding variables (age, sex, BMI, HbA1c at baseline, systolic blood pressure, diabetes duration, current smoking status, cholesterol-lowering drugs use and urinary albumin to creatinine ratio): HR 2.51 (95% CI, 1.50-4.22; P=0.0005). Higher risk of LLA during follow-up was also independently associated with male sex (HR 1.80; 95% CI, 1.1-1.41; P<0.0001), higher systolic blood pressure (HR 1.02; 95% CI, 1.00-1.03; P=0.01), and higher albuminuria (HR 1.33; 95% CI, 1.18-1.50; P<0.0001). Lower risk of LLA was associated with the use of fibrate (HR 0.23; 95% CI, 0.06-0.95; P=0.04). In our prospective observational study, the use of diuretics was the highest risk factor for LLA in patients with T2D. The result supports the role of hypovolemia in the amputation risk in T2D, a potential under-recognized effect of canagliflozin. Disclosure L. Potier: Consultant; Self; Sanofi, Novo Nordisk A/S, Eli Lilly and Company. Board Member; Self; Merck Sharp & Dohme Corp. K. Mohammedi: Speaker's Bureau; Self; Novo Nordisk Inc.. Other Relationship; Self; Novo Nordisk Inc.. Speaker's Bureau; Self; Sanofi. Other Relationship; Self; Sanofi, Takeda Development Centre Europe Ltd., Boehringer Ingelheim Pharmaceuticals, Inc.. A.K. Moutairou: None. A. Bumbu: Other Relationship; Self; Sanofi, Novo Nordisk A/S. O. Matar: None. F. Schneider: None. M. Marre: Board Member; Self; Abbott. Consultant; Self; AstraZeneca. Board Member; Self; Intarcia Therapeutics, Inc.. Consultant; Self; Eli Lilly and Company. Board Member; Self; Merck Sharp & Dohme Corp., Novo Nordisk A/S. Research Support; Self; Sanofi. Board Member; Self; Servier. P. Saulnier: None. G. Velho: None. R. Roussel: Advisory Panel; Self; AbbVie Inc., Abbott, Eli Lilly and Company, Sanofi, Novo Nordisk A/S, AstraZeneca. Speaker's Bureau; Self; Servier. Consultant; Self; Bayer AG. Advisory Panel; Self; Merck Sharp & Dohme Corp.. Research Support; Self; Amgen Inc., Sanofi, Novo Nordisk A/S, Danone Research. Stock/Shareholder; Self; Iriade. Advisory Panel; Self; Physiogenex S.A.S. S. Hadjadj: Consultant; Self; Abbott, Novo Nordisk A/S, Servier, AstraZeneca, Merck Sharp & Dohme Corp.. Board Member; Self; Valbiotis. Consultant; Self; Sanofi, Eli Lilly and Company.

Systematic review and meta-analysis of skin substitutes in the treatment of diabetic foot ulcers: Highlights of a Cochrane systematic review.

Skin substitutes are increasingly used in the treatment of various types of acute and chronic wounds. The aim of this study was to perform a systematic review and meta-analysis to evaluate the effectiveness of skin substitutes on ulcer healing and limb salvage in the treatment of diabetic foot ulcers. Randomized clinical trials were searched and assessed following the methodology of The Cochrane Collaboration. We included 17 trials, totaling 1655 randomized participants. Risk of bias was variable among included trials. Thirteen trials compared the skin substitutes with standard care. The pooled results showed that that skin substitutes can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone after 6-16 weeks (risk ratio 1.55, 95% confidence interval [CI] 1.30-1.85). Four of the included trials compared two types of skin substitutes but no particular product showed a superior effect over another. Two trials reported on total incidence of lower limb amputations. Pooling the results of these two trials yielded a statistically significantly lower amputation rate among patients treated with skin substitutes (risk ratio 0.43, 95% CI 0.23-0.81), although the absolute risk difference was small (-0.06, 95% CI -0.10 to -0.01). This systematic review provides evidence that skin substitutes can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone in the treatment of diabetic foot ulcers. However, effectiveness on the long term, including lower limb salvage and recurrence, is currently lacking and cost-effectiveness is unclear.

Skin grafting and tissue replacement for treating foot ulcers in people with diabetes.

Foot ulceration is a major problem in people with diabetes and is the leading cause of hospitalisation and limb amputations. Skin grafts and tissue replacements can be used to reconstruct skin defects for people with diabetic foot ulcers in addition to providing them with standard care. Skin substitutes can consist of bioengineered or artificial skin, autografts (taken from the patient), allografts (taken from another person) or xenografts (taken from animals). To determine the benefits and harms of skin grafting and tissue replacement for treating foot ulcers in people with diabetes. In April 2015 we searched: The Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched clinical trial registries to identify ongoing studies. We did not apply restrictions to language, date of publication or study setting. Randomised clinical trials (RCTs) of skin grafts or tissue replacements for treating foot ulcers in people with diabetes. Two review authors independently extracted data and assessed the quality of the included studies. We included seventeen studies with a total of 1655 randomised participants in this review. Risk of bias was variable among studies. Blinding of participants, personnel and outcome assessment was not possible in most trials because of obvious differences between the treatments. The lack of a blinded outcome assessor may have caused detection bias when ulcer healing was assessed. However, possible detection bias is hard to prevent due to the nature of the skin replacement products we assessed, and the fact that they are easily recognisable. Strikingly, nearly all studies (15/17) reported industry involvement; at least one of the authors was connected to a commercial organisation or the study was funded by a commercial organisation. In addition, the funnel plot for assessing risk of bias appeared to be asymmetrical; suggesting that small studies with 'negative' results are less likely to be published.Thirteen of the studies included in this review compared a skin graft or tissue replacement with standard care. Four studies compared two grafts or tissue replacements with each other. When we pooled the results of all the individual studies, the skin grafts and tissue replacement products that were used in the trials increased the healing rate of foot ulcers in patients with diabetes compared to standard care (risk ratio (RR) 1.55, 95% confidence interval (CI) 1.30 to 1.85, low quality of evidence). However, the strength of effect was variable depending on the specific product that was used (e.g. EpiFix® RR 11.08, 95% CI 1.69 to 72.82 and OrCel® RR 1.75, 95% CI 0.61 to 5.05). Based on the four included studies that directly compared two products, no specific type of skin graft or tissue replacement showed a superior effect on ulcer healing over another type of skin graft or tissue replacement.Sixteen of the included studies reported on adverse events in various ways. No study reported a statistically significant difference in the occurrence of adverse events between the intervention and the control group.Only two of the included studies reported on total incidence of lower limb amputations. We found fewer amputations in the experimental group compared with the standard care group when we pooled the results of these two studies, although the absolute risk reduction for amputation was small (RR 0.43, 95% CI 0.23 to 0.81; risk difference (RD) -0.06, 95% CI -0.10 to -0.01, very low quality of evidence). Based on the studies included in this review, the overall therapeutic effect of skin grafts and tissue replacements used in conjunction with standard care shows an increase in the healing rate of foot ulcers and slightly fewer amputations in people with diabetes compared with standard care alone. However, the data available to us was insufficient for us to draw conclusions on the effectiveness of different types of skin grafts or tissue replacement therapies. In addition, evidence of long term effectiveness is lacking and cost-effectiveness is uncertain.

Healthcare Utilization Disparity between Caucasian and African-American Patients with Diabetes from 2006-2008 and 2009-2011

Objective: Type II Diabetes Mellitus has attached concern worldwide because of its impact on those with the disease, the growing costs to health systems, and chronic complications and comorbidities of the disease. The purpose of this study was to identify disparity of utilization of healthcare services among African Americans and Caucasians in the United States from 2006-2008 and 2009 and 2011. Design: Retrospective demographic data was acquired from the Medicare database via the Center for Medicare and Medicaid Services (CMS) from 2006- 2011 using files derived from inpatient charts and insurance carrier data was analyzed by independent t-test. Subjects: The sample from 2006-2008 included men and women; 181,857 Caucasians and 29,527 African Americans. The sample from 2009-2011, included 140,172 Caucasians and 23,898 African Americans. Main Outcome Measures: Number of hospital stays, length of hospital stay, number of physician office visits, number of physical therapy visits, and incidence of lower limb amputations. Results: An analysis of temporal changes in these populations revealed that the mean number of hospital stays decreased from 3.05 to 2.05 for African Americans and from 2.63 to 1.86 for Caucasians, P<0.001. The length of hospital stays decreased for African Americans from 21.11 to 15.61 days and in Caucasians from 13.87 to 11.01 days. The number of lower limb amputations decreased for both groups, but African Americans saw a more significant drop from 1.6% to 0.7%. The mean number of doctor visits for African Americans decreased from 21.28 to 8.91 and Caucasians from 24.72 to 9.59. The mean number of physical therapy visits in African Americans decreased 19.56 to 17.19 and Caucasians 25.15 to 20.91. Conclusion: Health care disparities in the utilization of health care for DMII exist between African Americans and Caucasians. Caucasians are more likely to visit physicians and physical therapists while African Americans are more likely to go to hospitals, stay longer in hospitals, and have lower limb amputations. The causes of these disparities between African Americans and Caucasians require further investigation for complete understanding.

Ethnicity and risk of lower limb amputation in people with Type 2 diabetes: a prospective cohort study.

Lower limb amputation is a serious complication of diabetic foot disease and there are unexplained ethnic variations in incidence. This study investigates the risk of amputation among different ethnic groups after adjusting for demographic, socio-economic status and clinical variables. We used primary care data from a large national multi-ethnic cohort of patients with Type 2 diabetes in New Zealand and linked hospital records. The primary outcome was time from initial data collection to first lower limb amputation. Demographic variables included age of onset and duration since diabetes diagnosis, gender, ethnicity and socio-economic status. Clinical variables included smoking status, height and weight, blood pressure, HbA1c , total cholesterol/HDL ratio and albuminuria. Cox proportional hazards models were used. There were 892 lower limb amputations recorded among 62 002 patients (2.11 amputations per 1000 person-years), followed for a median of 7.14 years (422 357 person-years). After adjusting for demographic and socio-economic variables and compared with Europeans, Māori had the highest risk [hazard ratio (HR) 1.84 (95%CI:1.54-2.19)], whereas East Asians [HR 0.18, (0.08-0.44)] and South Asians [HR 0.39 (0.22-0.67)] had the lowest risk. Adjusting for available clinical variables reduced the differences but they remained substantial [HR 1.61 (1.35-1.93), 0.23 (0.10-0.56) and 0.48 (0.27-0.83), respectively]. Ethnic groups had significantly different risk of lower limb amputation, even after adjusting for demographic and some major clinical risk factors. Barriers to care should be addressed and intensive prevention strategies known to reduce the incidence of lower limb amputations could be prioritized to those at greatest risk.

Treatment of the diabetic foot - to amputate or not?

BackgroundDiabetic foot infections are a frequent clinical problem. About 50% of patients with diabetic foot infections who have foot amputations die within five years. Properly managed most can be cured, but many patients needlessly undergo amputations because of improper diagnostic and therapeutic approaches.DiscussionThe article debates the pros and cons of amputation of the diabetic foot. The thesis is that if the guidelines on the management of the diabetic foot are followed primary amputation is only necessary for the unsalvageable diabetic foot. This approach would reduce the incidence of lower limb amputations in diabetic patients.SummaryWe favour the argument that a structured clinical and vascular assessment would help clinical decision- making as to which patients to hospitalize, which to send for imaging, or for whom to recommend surgical interventions. Endovascular procedures are the future in the treatment of diabetic arterial disease and hence the diabetic foot.

Incidence of lower limb amputation in Australian hospitals from 2000 to 2010

Contemporary literature reports that the incidence of lower limb amputation has declined in many countries. This impression may be misleading given that many publications only describe the incidence of lower limb amputations above the ankle and fail to include lower limb amputations below the ankle. To describe trends in the incidence of different levels of lower limb amputation in Australian hospitals over a 10-year period. Descriptive. Data describing the age-standardised incidence of lower limb amputation were calculated from the Australian National Hospital Morbidity database and analysed for trends over a 10-year period. The age-standardised incidence of lower limb amputation remained unchanged over time (p = 0.786). A significant increase in the incidence of partial foot amputations (p = 0.001) and a decline in the incidence of transfemoral (p = 0.00) and transtibial amputations (p = 0.00) were observed. There are now three lower limb amputations below the ankle for every lower limb amputation above the ankle. While the age-standardised incidence of all lower limb amputation has not changed, a shift in the proportion of lower limb amputations above the ankle and lower limb amputations below the ankle may be the result of improved management of precursor disease that makes partial foot amputation a more commonly utilised alternative to lower limb amputations above the ankle. Clinical relevance This article highlights that although the incidence of lower limb amputation has remained steady, the proportion of amputations above the ankle and below the ankle has changed dramatically over the last decade. This has implications for how we judge the success of efforts to reduce the incidence of lower limb amputation and the services required to meet the increasing proportion of persons with amputation below the ankle.

Comparative Study of Different Treatment Options of Grade III and IV Diabetic Foot Ulcers to Reduce the Incidence of Amputations.

This study aims to compare the efficacy of antiseptic dressings, hyperbaric oxygen therapy, and recombinant human platelet derived growth factor (rhPDGF) for two reasons: i) to reduce the incidence of lower limb amputations in diabetic foot ulcer; ii) to limit the duration of stay in the hospital. A prospective randomized trial was conducted on 60 patients with stage III and IV diabetic foot ulcers (International Association of Enterostomal Therapy classification) and patients were divided randomly in three different therapy groups - antiseptics, hyperbaric oxygen therapy, recombinant platelet derived growth factor, with 20 patients in each group. Patients were managed initially on inpatient and then on outpatient basis till the ulcer healed completely. Results among three groups were compared using unpaired T test and the level of significance was set at P<0.05 using ANOVA. This study compares the efficacy of hyperbaric oxygen therapy, antiseptic dressings, and rhPDGF in grade III and IV diabetic foot ulcers. P value (0.0348) was significant for complete wound contraction while p value healing time (0.6534) and ulcer size (0.0593) in the groups was not significant. PDGF is safe, effective and easy to apply. Results are comparable with hyperbaric oxygen (HBO) therapy and cost of treatment is lower than other therapies. Diabetic foot ulcer management requires multidisciplinary and aggressive approach. PDGF should be recommended for all grade III and IV diabetic foot ulcer at least 8 weeks old. HBO is equally good an option but has limitations and side effects.

Incidence of lower limb amputations in individuals with and without diabetes mellitus in Andalusia (Spain) from 1998 to 2006

AimsWe studied the changes in the incidence of lower limb amputation (LLA) in Andalusia from 1998 to 2006 in the population with and without diabetes. MethodsWe undertook a retrospective study of all LLA performed in Andalusia in people aged 30 years old, with or without diabetes, between 1 January 1998 and 31 December 2006. We obtained the crude and standardized incidence rates by year, and sex for three periods: 1998–2000, 2001–2003 and 2004–2006 and calculated the RR of requiring LLA in patients with diabetes. To test for time trend, Poisson regression models were fitted. ResultsA total of 16,210 LLA were carried out in Andalusia, 72.6% in patients with diabetes mellitus and 66.4% in men. In the population with diabetes the standardized incidence of all LLA was found to be 344.0 per 100,000 (95% CI, 315.4–372.4) in 2004–2006. There was an estimated incidence increase for all LLA by 14% and for minor LLA by 13.6% in 2004–2006. In people with diabetes the RR increased by 31.6% as compared to the first period. ConclusionsDespite the implementation of a care plan for patients with diabetes, the incidence of LLA has not fallen in Andalusia in recent years.

Using data to inform care needs planning for people with diabetes

Practice NursingVol. 22, No. 5 Diabetes Evidence-Based Management 31Using data to inform care needs planning for people with diabetesNaomi Holman, Anne PhillipsNaomi HolmanSearch for more papers by this author, Anne PhillipsSearch for more papers by this authorNaomi Holman; Anne PhillipsPublished Online:29 Sep 2013https://doi.org/10.12968/pnur.2011.22.5.258AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View articleReferencesCraig R, Hirani V, eds. (2009) Health Survey for England 2008. Volume 2. Methods and Documentation. The Information Centre, London Google ScholarFolsom AR, Szklo M, Stevens Jet al. (1997) A prospective study of coronary heart disease in relation to fasting insulin, glucose, and diabetes. The Atherosclerosis Risk in Communities (ARIC) Study. Diabetes Care 20(6): 935–42 Crossref, Google ScholarFolsom AR, Rasmussen ML, Chambless LEet al. (1999) Prospective associations of fasting insulin, body fat distribution, and diabetes with risk of ischemic stroke. Diabetes Care 22(7): 1077–83 Crossref, Google ScholarForouhi NG, Merrick D, Goyder E,et al. (2005) Diabetes prevalence in England, 2001. Estimates from an epidemiological model. Diabet Med 23(2): 189–97 Crossref, Google ScholarHolman N (2008) Diabetes attributable deaths: estimating the excess deaths among people with diabetes. Poster Presentation at the Diabetes UK Annual Professional Conference 2009, Glasgow Google ScholarHolman RR, Paul SK, Bethel MA, Neil HAW, Matthews DR (2008a) Long-term follow up after tight control of blood pressure in type 2 diabetes. N Engl J Med 359(15): 1565–76 Crossref, Google ScholarHolman RR, Paul SK, Bethel MA, Matthews DR, Neil HAW (2008b) 10 year follow-up of intevsive glucose control in type 2 diabetes. New Engl J Med 359(15): 1577–89 Crossref, Google ScholarHolman N, Forouhi NG, Goyder E, Wild S (2011) The APHO Diabetes Prevalence Model. Estimates of total diabetes prevalence 2010-2030. Diabet Med 28(5): 575–82 Crossref, Google ScholarJones S, Young R, Jeffcoate W, Holman N (2011) Variation in the incidence of lower limb amputations in adults with diabetes. Poster presentation at the Diabetes UK Annual Professional Conference 2011, London Google ScholarLusignan S, Khunti K, Belsey Jet al. (2010) A method of identifying and correcting miscoding, misclassification and misdiagnosis in diabetes: a pilot and validation study of routinely collected data. Diabet Med 27(2): 203–9 Crossref, Google ScholarInformation Centre for Health and Social Care (2010) Key findings about the quality of care for people with diabetes in England and Wales: Report for the audit period 2008/09 http://tiny.cc/t2mf4 (accessed 6 April 2011) Google ScholarMindell J, Zaninotto P (2006) Cardiovascular disease and diabetes. In: K, Mindell J, eds. Health Survey for England 2004: The health of ethnic minority groups. The Information Centre for Health and Social Care, Leeds Google ScholarNational Collaborating Centre for Chronic Conditions (2008) Type 2 Diabetes. National Clinical Guideline for Nanagement in Primary and Secondary Care (Update). [NICE clinical guideline 66.] Royal College of Physicians, London Google ScholarRetnakaran Ret al. (2006) Risk factors for renal dysfunction in type 2 diabetes: UK Prospective diabetes study 74. Diabetes 55(6): 1832–9 Crossref, Google ScholarRiste L, Khan F, Cruickshank K, (2001) High prevalence of type 2 diabetes in all ethnic groups, including Europeans, in a British Inner City: Relative poverty, history, inactivity or 21st centrury Europe? Diabetes Care 24(8): 1377–83 Crossref, Google ScholarSproston K, Mindell J, eds. (2006) Health Survey for England 2004: The health of ethnic minority groups Leeds: The Information Centre for Health and Social Care, Leeds Google ScholarThomson MJ, Biddulph JP, Cull CA, Holman RR (2005) Reporting of diabetes on death certificates using data from the UK Prospective Diabetes Study Diabetic Medicine 22: 1031–6 Crossref, Google ScholarUK Prospective Diabetes Study Group (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 352(9131): 837–53 Crossref, Google Scholar FiguresReferencesRelatedDetailsCited byThe importance of screening for Charcot neuroarthropathy29 September 2013 | Practice Nursing, Vol. 23, No. 8Identifying neuropathic presentations of diabetes29 September 2013 | Practice Nursing, Vol. 22, No. 12 1 May 2011Volume 22Issue 5ISSN (print): 0964-9271ISSN (online): 2052-2940 Metrics History Received 28 February 2011 Accepted 6 April 2011 Published online 29 September 2013 Published in print 1 May 2011 Information© MA Healthcare LimitedKeywordsdiabetesprevalenceneedsoutcomesPDF download

Incidence of Lower-limb Amputations in the Diabetic Compared to the Non-diabetic Population. Findings from Nationwide Insurance Data, Germany, 2005–2007

One major objective is to reduce the risk of lower limb amputation in diabetes mellitus. Nationwide data to incidences of amputations in the diabetic and non-diabetic populations in Germany as well as relative and attributable risks due to diabetes are lacking so far. Using data of a nationwide statutory health insurance (1.6 million members), we assessed all first non-traumatic lower-limb amputations between 2005 and 2007. We estimated sex-age-specific and standardized incidences of amputations in the diabetic and non-diabetic populations, and relative and attributable risks due to diabetes. Of all subjects with a first amputation in the study period 2005-2007 (n=994), 66% had diabetes, 76% were male, mean age (SD) was 67 (13) years. Incidences per 100 000 person years (standardized to the 2004 German population) in the diabetic and the non-diabetic populations: 176.5 (95% confidence interval 156.0-196.9) and 20.0 (17.0-23.1) in men, and 76.9 (61.9-91.8) and 13.4 (10.7-16.2) in women. Standardized relative risks: 8.8 (7.3-10.7) in men and 5.7 (4.3-7.6) in women. Attributable risks among exposed: 0.89 and 0.83 and population attributable risks 0.59 and 0.40, each in men and women, respectively. In our first German nationwide study, we found the relative risk of lower limb amputation in the diabetic compared to the non-diabetic to be lower than in earlier regional studies in Germany, supporting results of regional reductions of the excess amputation risk due to diabetes. A repetition of the study is warranted to further evaluate trends according to the St. Vincent goals.