Lower Extremity Amputation In People Research Articles

Excess risk of lower extremity amputations in people with type 1 diabetes compared with the general population: amputations and type 1 diabetes

ObjectiveThis study investigates how the excess risk of lower extremity amputations (amputations) in people with type 1 diabetes mellitus (DM) differs from the general population by diabetes duration, glycemic control,...

Decreasing rates of major lower-extremity amputation in people with diabetes but not in those without: a nationwide study in Belgium

Aims/hypothesisThe reduction of major lower-extremity amputations (LEAs) is one of the main goals in diabetes care. Our aim was to estimate annual LEA rates in individuals with and without diabetes in Belgium, and corresponding time trends.MethodsData for 2009–2013 were provided by the Belgian national health insurance funds, covering more than 99% of the Belgian population (about 11 million people). We estimated the age–sex standardised annual amputation rate (first per year) in the populations with and without diabetes for major and minor LEAs, and the corresponding relative risks. To test for time trends, Poisson regression models were fitted.ResultsA total of 5438 individuals (52.1% with diabetes) underwent a major LEA, 2884 people with above- and 3070 with below-the-knee major amputations. A significant decline in the major amputation rate was observed in people with diabetes (2009: 42.3; 2013: 29.9 per 100,000 person-years, 8% annual reduction, p < 0.001), which was particularly evident for major amputations above the knee. The annual major amputation rate remained stable in individuals without diabetes (2009: 6.1 per 100,000 person-years; 2013: 6.0 per 100,000 person-years, p = 0.324) and thus the relative risk reduced from 6.9 to 5.0 (p < 0.001). A significant but weaker decrease was observed for minor amputation in individuals with and without diabetes (5% and 3% annual reduction, respectively, p < 0.001).Conclusions/interpretationIn this nationwide study, the risk of undergoing a major LEA in Belgium gradually declined for individuals with diabetes between 2009 and 2013. However, continued efforts should be made to further reduce the number of unnecessary amputations.

Lower-extremity amputations in people with and without diabetes in Germany, 2008-2012 - an analysis of more than 30 million inhabitants.

Background and purposeLower-extremity amputations (LEAs) in people with diabetes are associated with reduced quality of life and increased health care costs. Detailed knowledge on amputation rates (ARs) is of utmost importance for future health care and economics strategies. We conducted the present cohort study in order to estimate the incidences of LEA as well as relative and attributable risk due to diabetes and to investigate time trends for the period 2008–2012.MethodsOn the basis of the administrative data from three large branches of German statutory health insurers, covering ~34 million insured people nationwide (about 40% of the German population), we estimated age-sex-standardized AR (first amputation per year) in the populations with and without diabetes for any, major, and minor LEAs. Time trends were analyzed using Poisson regression.ResultsA total of 108,208 individuals (diabetes: 67.3%; mean age 72.6 years) had at least one amputation. Among people with diabetes, we observed a significant reduction in major and minor ARs during 2008–2012 from 81.2 (95% CI 77.5–84.9) to 58.4 (55.0–61.7), and from 206.1 (197.3–214.8) to 177.0 (169.7–184.4) per 100,000 person-years, respectively. Among people without diabetes, the major AR decreased significantly from 14.3 (13.9–14.8) to 11.6 ([11.2–12.0], 12.0), whereas the minor AR increased from 15.8 (15.3–16.3) to 17.0 (16.5–17.5) per 100,000 person-years. The relative risk (RR) comparing the diabetic with the nondiabetic populations decreased significantly for both major and minor LEAs (4% and 5% annual reduction, respectively).ConclusionIn this large nationwide population, we still found higher major and minor ARs among people with diabetes compared with those without diabetes. However, AR and RR of major and minor LEAs in the diabetic compared with the nondiabetic population decreased significantly during the study period, confirming a positive trend that has been observed in smaller and regional studies in recent years.

Comorbid depression and risk of lower extremity amputation in people with diabetes: systematic review and meta-analysis

ObjectiveTo compare the risk of lower extremity amputation (LEA) in people with diabetes with and without comorbid depression.Research design and methodsA systematic review of the published literature was conducted. Six...

National trends in incidence and outcomes in lower extremity amputations in people with and without diabetes in Spain, 2001–2012

AimsTo describe trends in the incidence and outcomes of lower-extremity amputations (LEAs) in patients with T1DM and T2DM in Spain, 2001–2012. MethodsWe used national hospital discharge data. Incidence of discharges attributed to LEA procedures were calculated stratified by diabetes status and type of LEA. Joinpoint log-linear regression for incidence trends and logistic regression for factors associated with in-hospital mortality were used. ResultsFrom 2001 to 2012, 73,302 minor LEAs and 64,710 major LEAs were performed. We found that incidence of minor LEA procedures in T1DM patients decreased by 9.84% per year from 2001 to 2008 and then remained stable through 2012. In T2DM patients, LEA increased by 1.89% per year over the entire study period. Among patients with T1DM, major LEA incidence rate decreased by 10.5% from 2001 to 2012. In patients with T2DM, it increased by 4.29% from 2001 to 2004, and then decreased by 1.85% through 2012. In-hospital mortality after major or minor LEAs was associated with older age in all groups and with being female in T2DM and in people without diabetes. ConclusionsOur national data show a decrease in the incidence of minor LEAs in patients with diabetes and in major LEAS in patients with T1DM over the period of study. In patients with T2DM, we found a decrease between 2004 and 2012. An additional improvement in preventive care, such as the introduction of diabetes foot units in hospitals, is necessary.

Temporal trends in initial and recurrent lower extremity amputations in people with and without diabetes in Western Australia from 2000 to 2010

AimsTo examine temporal trends in lower extremity amputations in people with type 1 diabetes, type 2 diabetes and cardiovascular disease (CVD) without diabetes in Western Australia (WA) from 2000 to 2010. MethodsWe used linked health data to identify all non-traumatic lower extremity amputations in adults aged ≥20years with diabetes and/or CVD from 2000 to 2010 in WA. Annual age- and sex-standardised rates of total, initial and recurrent amputations, stratified by major and minor status, were calculated for type 1 and type 2 diabetes, and CVD without diabetes, from the at-risk population for each group. Age- and sex-adjusted trends were estimated from Poisson regression models. Results5891 lower extremity amputations were identified. Peripheral vascular disease (71%), hypertension (70%) and chronic kidney disease (60%) were highly prevalent. Average annual rates of total amputations were 724, 564 and 66 per 100,000 person-years in type 1, type 2 diabetes and CVD without diabetes respectively. Rates of initial amputations fell significantly by 2.4%/year (95% CI −3.5, −1.4) in type 2 diabetes, with similar declines for type 1 diabetes and CVD without diabetes (interaction p=0.96), driven by large falls in major amputations. There was limited improvement in recurrence rates overall, with recurrent minor amputations increasing significantly in type 2 diabetes (+3.5%/year, 95% CI +1.3%, +5.7%). ConclusionLower extremity amputation rates have declined at a population level in people with diabetes and CVD without diabetes, suggesting improvements in prevention and management for this high-risk patient group, however limited declines in recurrent amputations requires further investigation.

Incidence and risk factors of lower extremity amputations in people with type 2 diabetes in Taiwan, 2001-2010.

Diabetic patients have an increased risk of lower extremity amputations (LEAs). In the present study we analyzed the incidence of LEA in patients with type 2 diabetes mellitus (T2DM) in Taiwan from 2001 to 2010, and determined risk factors for LEA. Data from the Taiwan National Health Insurance Research Database collected between 1 January 2001 and 31 December 2010 were analyzed. First, the incidence of LEA in the diabetic population was calculated. Subsequently, patients with new-onset T2DM during the study period were selected, and Cox's proportional hazards model was used to identify factors associated with LEA. The characteristics of patients who underwent major and multiple amputations were also analyzed. From 2001 to 2010, 1588 non-traumatic LEAs were performed among the study subjects; 776 (48.9%) were minor and 812 (51.1%) were major LEAs. Over the period in question, the incidence of LEAs decreased from 3.08 to 1.65 per 1000 person-years. Factors associated with LEA included peripheral arterial occlusive disease (hazard ratio [HR] 4.134; 95% confidence interval [CI] 2.72-6.29), diabetic neuropathy (HR 2.34; 95% CI 1.62-3.38), diabetic retinopathy (HR 2.07; 95% CI 1.12-3.82), heart failure (HR 2.13; 95% CI 1.45-3.15), male gender (HR 1.64; 95% CI 1.24-2.18), and adult onset diabetes (HR 1.02; 95% CI 1.01-1.04). Patients with a history of stroke were more likely to undergo major and multiple amputations (P < 0.001 and P < 0.01, respectively). The incidence of LEA in the Taiwan diabetic population decreased over the study period. The results indicate that efforts to improve diabetic care should be supported and sustainable, especially for those at high risk.

Lower Extremity Amputation in People with Diabetes as a Marker of Quality of Diabetes Care

Diabetes is a common chronic disease, which can lead to a number of complications including lower extremity amputation (LEA). On-going management of diabetes requires the provision of good quality care. Assessing the quality of diabetes care is difficult. Measurement of quality has been described in terms of structures, processes and outcomes. This article focuses on the long-term clinical outcome of LEA, as an indicator of the quality of diabetes care.

Timing of access to secondary healthcare services for diabetes management and lower extremity amputation in people with diabetes: a protocol of a case–control study

BackgroundLower extremity amputation (LEA) is a complication of diabetes and a marker of the quality of diabetes care. Clinical and sociodemographic determinants of LEA in people with diabetes are well...

Concordance studies between hospital discharge data and medical records for the recording of lower extremity amputation and diabetes in the Republic of Ireland.

BackgroundHospital discharge data have been used to study trends in Lower Extremity Amputation (LEA) rates in people with and without diabetes. The aim of this study was to assess the reliability of routine hospital discharge data in the Republic of Ireland (RoI) for this purpose by determining the level of agreement between hospital discharge data and medical records for both the occurrence of LEA and diagnosis of diabetes.MethodsTwo concordance studies between hospital discharge data (HIPE) and medical records were performed. To determine the level of agreement for LEA occurrence, HIPE records were compared to theatre logbooks in 9 hospitals utilising HIPE over a two-year period in a defined study area. To determine the level of agreement for diabetes diagnosis, HIPE records were compared to laboratory records in each of the 4 largest hospitals utilising HIPE over a one week period in the same study area. The proportions of positive and negative agreement and Cohen’s kappa statistic of agreement were calculated.ResultsDuring a two-year study period in 9 hospitals, 216 LEAs were recorded in both data sources. Sixteen LEAs were recorded in medical records alone and 25 LEAs were recorded in hospital discharge records alone. The proportion of positive agreement was 0.91 (95% CI 0.88-0.94), the proportion of negative agreement was 0.99 (95% CI 0.98-0.99) and the kappa statistic was 0.91 (95% CI 0.88-0.94).During a one-week study period in 4 hospitals, 49 patients with diabetes and 716 patients without diabetes were recorded in both data sources. Eighteen patients had diabetes in medical records alone and 2 patients had diabetes in hospital discharge records alone. The proportion of positive agreement was 0.83 (95% CI 0.76-0.9), the proportion of negative agreement was 0.99 (95% CI 0.98-0.99) and the kappa statistic was 0.82 (95% CI 0.75-0.89).ConclusionsThis study detected high levels of agreement between hospital discharge data and medical records for LEA and diabetes in a defined study area. Based on these findings, we suggest that HIPE is sufficiently reliable to monitor trends in LEAs in people with and without diabetes in the RoI.

Does contact with a podiatrist prevent the occurrence of a lower extremity amputation in people with diabetes? A systematic review and meta-analysis

ObjectiveTo determine the effect of contact with a podiatrist on the occurrence of Lower Extremity Amputation (LEA) in people with diabetes.Design and data sourcesWe conducted a systematic review of available...

Reduced Incidence of Lower-Extremity Amputations in People With Diabetes in Scotland

OBJECTIVETo establish the incidence of nontraumatic lower-extremity amputation (LEA) in people with diabetes in Scotland.RESEARCH DESIGN AND METHODSThis cohort study linked national morbidity records and diabetes datasets to establish the number of people with diabetes who underwent nontraumatic major and minor LEA in Scotland from 2004 to 2008.RESULTSTwo thousand three hundred eighty-two individuals with diabetes underwent a nontraumatic LEA between 2004 and 2008; 57.1% (n = 1,359) underwent major LEAs. The incidence of any LEA among persons with diabetes fell over the 5-year study period by 29.8% (3.04 per 1,000 in 2004 to 2.13 per 1,000 in 2008, P < 0.001). Major LEA rates decreased by 40.7% from 1.87 per 1,000 in 2004 to 1.11 per 1,000 in 2008 (P < 0.001).CONCLUSIONSThere has been a significant reduction in the incidence of LEA in persons with diabetes in Scotland between 2004 and 2008, principally explained by a reduction in major amputation.

PS11 Does Contact with a Podiatrist Prevent The Occurrence of a Lower Extremity Amputation in people with Diabetes? A Systematic Review and Meta-Analysis

BackgroundDiabetes is associated with a significant risk of LEA (lower extremity amputation). LEA rates vary between communities, 46–9,600 per 105 people with diabetes, for many reasons. The effects of clinical...

Trends in the Incidence of Lower Extremity Amputations in People with and without Diabetes over a Five-Year Period in the Republic of Ireland

AimsTo describe trends in the incidence of non-traumatic amputations among people with and without diabetes and estimate the relative risk of an individual with diabetes undergoing a lower extremity amputation compared to an individual without diabetes in the Republic of Ireland.MethodsAll adults who underwent a nontraumatic amputation during 2005 to 2009 were identified using HIPE (Hospital In-patient Enquiry) data. Participants were classified as having diabetes or not having diabetes. Incidence rates were calculated using the number of discharges for diabetes and non-diabetes related lower extremity amputations as the numerator and estimates of the resident population with and without diabetes as the denominator. Age-adjusted incidence rates were used for trend analysis.ResultsTotal diabetes-related amputation rates increased non-significantly during the study period; 144.2 in 2005 to 175.7 in 2009 per 100,000 people with diabetes (p = 0.11). Total non-diabetes related amputation rates dropped non-significantly from 12.0 in 2005 to 9.2 in 2009 per 100,000 people without diabetes (p = 0.16). An individual with diabetes was 22.3 (95% CI 19.1–26.1) times more likely to undergo a nontraumatic amputation than an individual without diabetes in 2005 and this did not change significantly by 2009.DiscussionThis study provides the first national estimate of lower extremity amputation rates in the Republic of Ireland. Diabetes-related amputation rates have remained steady despite an increase in people with diabetes. These estimates provide a base-line and will allow follow-up over time.

Trends in Lower-Extremity Amputations in People With and Without Diabetes in Spain, 2001–2008

OBJECTIVETo examine trends in nontraumatic lower-extremity amputations (LEAs) over an 8-year period in patients with and without diabetes in Spain.RESEARCH DESIGN AND METHODSWe identified all patients who underwent an LEA using national hospital discharge data. Discharges were grouped by diabetes status: type 1 diabetes, type 2 diabetes, and no diabetes. The incidence of discharges attributed to amputations were calculated overall and stratified by diabetes status and year. We calculated length of stay and in-hospital fatality stratified by diabetes status and type of LEA.RESULTSFrom 2001 to 2008, 46,536 minor LEAs and 43,528 major LEAs were performed. In patients with type 1 diabetes, the incidence of minor and major amputations decreased significantly from 2001 to 2008 (0.88–0.43 per 100,000 inhabitants and 0.59–0.22 per 100,000 inhabitants, respectively). In patients with type 2 diabetes, the incidence of minor and major LEAs increased significantly (9.23–10.9 per 100,000 inhabitants and 7.12–7.47 per 100,000 inhabitants). Hospital stay was similar among type 1 diabetic and type 2 diabetic subjects, according to the type of LEA. Only in-hospital mortality for minor LEAs among type 1 diabetic subjects decreased significantly (4.0% in 2001 vs. 1.6% in 2008).CONCLUSIONSOur national data show a decrease in the incidence of major and minor LEAs in patients with type 1 diabetes and an increase among patients with type 2 diabetes. Further improvement is necessary in the preventive care and early treatment of patients with diabetes. The management of foot lesions, especially among type 2 diabetic patients, is particularly urgent.

The 25-Year Cumulative Incidence of Lower Extremity Amputations in People With Type 1 Diabetes

OBJECTIVETo examine the 25-year cumulative incidence of lower-extremity amputation (LEA) in people with type 1 diabetes.RESEARCH DESIGN AND METHODSCumulative incidence of LEA was ascertained in Wisconsin Epidemiologic Study of Diabetic Retinopathy participants (n = 943) using the Kaplan-Meier approach accounting for competing risk of death. Relationships of baseline characteristics with incidence of LEA were explored using a proportional hazards approach with discrete linear regression modeling.RESULTSThe overall 25-year incidence of LEA was 10.1%. In multivariate analyses (results reported as odds ratio; 95% CI), being male (3.90; 2.29–6.65), heavy smoking (2.07; 1.11–3.85), having hypertension (3.36; 1.91–5.93), diabetic retinopathy (2.62; 1.13–6.09), neuropathy (1.68; 1.02–2.76), and higher HbA1c (per 1% 1.40; 1.24–1.58) were independently associated with the incidence of LEA.CONCLUSIONSOur results show a high 25-year incidence of LEA and suggest that glycemic control and blood pressure control and preventing heavy smoking may result in reduction in its incidence.

Efforts to Decrease Diabetes-Related Amputations in African Americans by the Racial and Ethnic Approaches to Community Health Charleston and Georgetown Diabetes Coalition

Diabetes is the leading cause of amputation of the lower limbs. Yet, half of these amputations might be prevented through simple but effective foot care practices. This article describes the progress made in the reduction of lower extremity amputations in people with diabetes by the Racial and Ethnic Approaches to Community Health (REACH) Charleston and Georgetown Diabetes Coalition. The coalition's community action plan and interventions were based on an expanded Chronic Care Model that spawned changes in policies, health and education systems, and other community systems for people with diabetes and their support systems.

Trends in lower extremity amputations in people with and without diabetes in England, 1996–2005

Aims To examine trends in non-traumatic lower extremity amputations over a 10-year-period in people with and without diabetes (DM) in England. Methods All individuals admitted to NHS hospitals for non-traumatic amputations between 1996 and 2005 in England were identified using hospital activity data. Postoperative and 1-year mortality were examined between 2000 and 2004. Results There was a reduction in minor and major amputations during the study period. The number of type 1 DM- and non-DM-related minor amputations decreased by 11.4% and 32.4%, respectively, while the number of type 2 DM-related minor amputations almost doubled. The incidence of type 1- and non-DM-related minor amputations decreased from 1.5 to 1.2 and from 8.1 to 5.1/100,000 population, respectively, while type 2 DM-related amputations increased from 2.4 to 4.1/100,000 population. The number of type 1- and non-DM-related major amputations declined by 41% and 22%, respectively, whereas type 2 DM-related amputations increased by 43%. The incidence of type 2 DM-related amputations increased from 2.0 to 2.7/100,000 population. Overall perioperative and 1-year mortality did not significantly change between 2000 and 2004. Conclusions While several factors may explain the increase in type 2 DM-related LEAs, these findings highlight the importance of diabetes prevention strategies and controlling risk factors for LEAs in people with diabetes.

All-Cause Mortality After Diabetes-Related Amputation in Barbados: A Prospective Case-Control Study

Our report on diabetes-related amputation in Barbados (1), together with data from Morbach et al. (2), offers tentative evidence of a different hierarchy of mortality following lower-extremity amputation in people with diabetes in the developing world, with more deaths caused by overwhelming infection. In a recent Caribbean publication, septicemia was again the most common cause of postoperative mortality (3), contributing …

Predictive Value of Soluble CD14, Interleukin-6 and Procalcitonin For Lower Extremity Amputation in People with Diabetes with Foot Ulcers: A Pilot Study.

Objective: The aim of this pilot study was to determine clinical and laboratory factors that predict amputation surgery and to evaluate the predictive value of soluble CD14 (sCD14), interleukin-6 (IL-6), and procalcitonin (PCT) in patients with diabetic foot ulcers (DFUs). Methods: Twenty-seven (20 males, 7 females) Diabetic Foot Ulcers (DFU) patients admitted to our department were consecutively enrolled. The patients’ demographics and wound characteristics were noted. IL-6, PCT, and sCD14 were measured at admission. Results: Six of the 27 patients (22%) eventually underwent lower extremity amputation. Compared to the non-amputation group, a previous history of amputation (p=0.017), the presence of gangrene (p=0.044), the Wagner grade (p=0.011), the IL-6 concentration (p=0.018), the white blood cell count (WBC) (p=0.036), and the erythrocyte sedimentation rate (ESR) (p=0.042) were significantly high in the amputation group. However, the sCD14 and PCT concentration were not significantly different. Conclusion: We have shown for the first time that IL-6 may have predictive value for lower extremity amputation in patients with DFU. Further studies are needed to confirm its predictive value in this patient group.