Prevention Of Amputation Research Articles

The role of hyperbaric oxygen therapy in the treatment of diabetic foot ulcers: a systematic review with meta-analysis of randomized controlled trials on limb amputation and ulcer healing.

Hyperbaric oxygen therapy (HBOT) is increasingly being used in the treatment of as diabetic foot ulcers (DFU). However, definitive evidence regarding its beneficial effects is still scarce. The present systematic review aims to analyze the role of HBOT in the prevention of limb amputation along with improvement of ulcer healing in patients with lower limbs DFU. Three databases were searched: PubMed, Scopus, and ISI Web of Knowledge. The search was enrolled during October 2020. Both titles and abstracts were examined by two independent reviewers. Only randomized controlled trials (RCTs) reporting a comparison between standard DFU treatment and standard treatment associated with HBOT were included. In all studies eligibility was assessed and data regarding studies characteristics, methods and considered outcomes was obtained. Odds ratio (OR) was used to evaluate amputation and complete ulcer healing rates. Percentage of ulcer reduction at two weeks was evaluated using the inverse variance method, and the values were compared using mean difference values. Meta-analysis was done using a fixed-effect model if I2 values were under 50%, and a random-effects model if not. Eleven RCTs were included, with a total of 668 patients studied. Patients undergoing HBOT had lower risk of amputation (OR 0.53 95% CI 0.32-0.90, I2=31%). No difference was found in minor amputations (OR 0.89 95% CI 0.35-2.24, I2=69%). Regarding, healing rates, HBOT patients had greater chances of ulcer healing (OR 4,00 95% CI 1.54-10.44, I2=70%). It has also shown higher percentage of ulcer area reduction after two weeks of treatment in the HBOT group (mean difference 23.19%; 95% CI 14.86-31.52; I2=0%). The present review offers evidence that adjuvant HBOT decreases risk of major amputation while promoting wound healing when combined to standard treatment in the management of DFU. These findings may have clinical relevance in a selected group of patients, yet further larger studies are still needed.

Comparison of bypass versus primary angioplasty for lower extremity chronic limb-threatening peripheral arterial diseases

Aim: Peripheral arterial Diseases (PAD) is seen frequently with increasing age, and have a prevalence of about 20% over 70 years of age. We aimed the results of two different treatment approaches as open surgical procedures and radiological interventions. 
 Methods: We reviewed the data of PAD from the online data system of the hospital. The patients treated by endovascular femoropopliteal revascularization versus open surgical femoropopliteal graft bypass between January 2016 and December 2019 were enrolled in to study. Eighty limbs of 67 patients with the symptomatic severe occlusive disease and results were evaluated in the aspect of reducing ischemia and prevention of amputation in this retrospective study.
 Results: 67 patients were divided into two groups. Group 1(n=29) was the interventional PTA/S group, group 2 (n=38) was the open surgical bypass group. 8 of the patients in Group 2 and 5 of patients in Group 1 had bilateral lesions. Patients were at a mean age of 63.44±8.98 years. The mean time of hospitalization time was significantly longer following a first-time bypass (10 vs. 8 days). The success of results was ending of claudication and ischemia and prevention of amputation of an extremity. In these aspects, there was no difference between procedure types. 
 Conclusion: In the aspect of the length of hospital stay and infection, interventional procedures seem more benefit however in long-term evaluation, freedom from reintervention or redo bypass was significantly higher in the bypass group (92% vs 79 % p

New challenges in vascular biology and medicine: from unravelling the mechanisms of neointima formation to the prevention of amputations and of ischaemic stroke.

New challenges in vascular biology and medicine: from unravelling the mechanisms of neointima formation to the prevention of amputations and of ischaemic stroke.

The prevention of recurrent ulceration and amputation

Patients with recurrent ulceration and amputation can be challenging cases for health-care teams. There are, however, several different approaches that can prevent the recurrence of ulceration and reduce the incidence of amputation. Clinicians treating recalcitrant wounds should consider the patient’s whole health picture, including issues like comorbidities, biomechanics, social supports and barriers to success.

Diabetes, Healthy Feet and You – Train-the-Trainer: A quality improvement inquiry

Diabetic self-management education focused on foot care and footwear, when provided in an organized and structured manner, is a cornerstone of preventing foot problems. Diabetes, Healthy Feet and You (DHFY) is an innovative education program developed to address the learning needs of patients and their families/care partners around self-management, diabetes mellitus, foot care, footwear and prevention of foot ulcers and amputations. This article describes the DHFY program and its associated Train-the-Trainer workshop and workbook.

543 Escharotomy Incisions in the Burn Foot and Toe with Compartment Syndrome

Abstract Introduction Patients with burn injuries are at risk for lower extremity compartment syndrome, especially if the injury is circumferential. The hypothesis was that two dorsal escharotomy incisions to release foot and toe compartment syndrome would be most efficacious in the prevention of lower extremity amputations. Methods This was a retrospective chart review of foot compartment syndrome in burn patients between January 2001 and May 2019. Results The study consisted of 59 feet from 32 patients who had been admitted to the Burn Center for thermal injury. The patient age was a mean±sd of 29±30 years, and 41±29 as the % total body surface area (%TBSA); there were 19 males and 13 females. All patients had received fluid resuscitation on admission. Twenty-one (66%) of the patients did not require amputations after undergoing a median of two incisions (range 1–5); 6 of 59 (11%) required fasciotomies. Compared to medial or dorsal or multiple echarotomies, the majority of patients who underwent two dorsal foot escharotomies did not require amputations, p = .0001. Significantly more patients were alive with no amputation 15 (50%) compared to 4 (13%) (dead with amputations), p = .02. Survivors were significantly younger than the non-survivors (median 20 and range1-69) compared to the non-survivors (48, 12–59), p =.04. The survivors also had significantly less severe %TBSA median 22 (range 2–75) versus 83 (35–95) %TBSA, p < .0002. Dorsal/Lateral incisions had the highest number of amputations. Conclusions Foot dorsal compartment release is the most effective site for escharotomies in the treatment of burn-induced compartment syndrome. It does not require more than two incisions at the skin/fat level and over the second and fourth metatarsal bones on the dorsal part of the foot to decrease the lower extremity amputation rate in the majority of cases.

Surgical strategies for prevention of amputation of the diabetic foot

Prevention of amputation has become a key objective of clinicians providing care to patients with high-risk diabetic foot problems. In this regard, the multidisciplinary diabetic foot team (MDFT) has been embraced as the most effective way to manage patients with foot ulcers, infections, and Charcot feet. Importantly, such specialized teams have also integrated various surgical specialties to enable more expedient management of these often complex conditions. Experienced diabetic foot surgeons over the last three or four decades have contributed much to this discipline, whereby foot-sparing reconstructive procedures or minor amputations have become fundamental strategies for limb preservation teams. Central to limb salvage, of course, is the recognition of underlying vascular insufficiency and the importance of prompt (endo)vascular intervention. Restoration of adequate perfusion is essential to allow the podiatric, orthopaedic, or plastic surgeon to perform indicated functional reconstructive or minor amputation procedures. This evidence-based overview discusses the various indications and surgical principles inherent in modern concepts aimed at preventing amputation in the high-risk diabetic foot.

Forty-eightweeks of statin therapy for type2 diabetes mellitus patients with lower extremity atherosclerotic disease: Comparison of the effects of pitavastatin and atorvastatin on lower femoral total plaque areas.

Aims/IntroductionType 2 diabetes mellitus is correlated with systemic atherosclerosis. Statin therapies have been proved to reduce low‐density lipoprotein cholesterol (LDL‐C) level, protecting type 2 diabetes mellitus patients from cardiovascular events. Recently, more interest has been focused on the regression of lower extremity atherosclerotic disease (LEAD) for the potential prevention of amputation. However, the effects of pitavastatin and atorvastatin on LEAD in type 2 diabetes mellitus patients have not been directly compared.Materials and MethodsThis study compared the effects of pitavastatin and atorvastatin on femoral total plaque areas (FTPA), and lipids and glucose metabolism in type 2 diabetes mellitus patients with elevated LDL‐C level and LEAD. Type 2 diabetes mellitus patients with LDL‐C level >2.6 mmol/L and LEAD were randomly assigned to receive either pitavastatin 2 mg/day or atorvastatin 10 mg/day for 48 weeks. FTPA were measured at baseline and the end of the study. Levels of glucose and lipids profile were measured periodically. The efficacy was evaluated in 63 patients.ResultsThe percentage change in FTPA measurements was similar between the pitavastatin group and atorvastatin group (−17.79 ± 21.27% vs −14.34 ± 16.33%), as were the changes in LDL‐C (−44.0 ± 18.0% vs −40.3 ± 18.2%) and triglyceride (17.6 ± 20.0% vs 16.2 ± 17.0%). However, the level of high‐density lipoprotein cholesterol was significantly higher in the pitavastatin group compared with the atorvastatin group after 48 weeks of treatment (12.9 ± 10.3% vs 7.2 ± 11.7%, P < 0.05). There were no significant differences between groups for the measurements of glucose metabolism.ConclusionIn type 2 diabetes mellitus patients with elevated LDL‐C level and LEAD, 48 weeks of treatment with either pitavastatin or atorvastatin was associated with significant regression of FTPA. Pitavastatin treatment resulted in a significantly higher high‐density lipoprotein cholesterol level compared with atorvastatin treatment.

Triple assessment for addressing trio-pathy in diabetic foot – Rapid screening tool for amputation prevention in govt. Hospital setting

Introduction: The present study was done to perform foot examination using Amit Jain’s Triple Assessment screening tool on in-patients in surgical wards. Materials and Methods: A descriptive retrospective study was done at Gajra Raja Medical College, Gwalior (M.P.) in department of surgery during a period from April 2018 to June 2018 on patients of diabetic foot admitted in all six units of surgical wards. Results: A total of 72 patients were included in this study as per search in case records. Majority of patients had diabetes of more than ten years duration and males were more commonly affected. All patients had diagnosis of diabetic foot with varied spectrum of associated lesions alone or in combination. Surgical debridement (66.66%) was the commonest procedure done in these patients. The affected foot of all patients was examined, with component assessment of feeling pedal pulses done in 86.11% cases and testing for sensation was done in 25% cases. In contralateral foot 58% patients were examined, in similar percentage pedal pulses were examined and foot sensations were not tested in any of them. Conclusion: Despite foot examination being of paramount importance it is often incomplete and inadequate in diabetic foot subjects as is also evident from observations of present study. Amit Jain’s Triple assessment of diabetic feet is a rapid inexpensive screening tool for obtaining basic foot information in order to segregate at risk feet and offer preventive care against amputation. Keywords: Amit Jain, Assessment, Triple, Diabetic foot, Trio-pathy, Screening, High risk foot.

Prioritisation of diabetes-related footcare amongst primary care healthcare professionals.

To assess primary healthcare professionals' priority for managing diabetic foot disease (DFD) over the progressive course of the condition compared to other aspects of diabetes care. DFD affects up to 60 million people globally. Evidence suggests that comprehensive preventative footcare may reduce serious complications of DFD, such as amputation. A cross-sectional quantitative study reported according to STROBE statement. General Practitioners (GPs) and Credentialled Diabetes Educators (CDEs) working within Australian primary care were invited to complete an online survey, to obtain information about preventative and early intervention footcare priorities and practices. Ten GPs and 84 CDEs completed the survey. On diagnosis of type 2 diabetes, haemoglobin A1c (HbA1c) review was identified to be one of the top three priorities of care by 57 (61%) of participants whilst at 20-year history of diabetes 73 (78%) participants indicated its priority. Foot assessments became a priority for 78% (n=73) of participants and podiatry referrals a priority for 53% (n=50) of participants only when a "foot concern" was raised. Referrals to specialist high-risk foot podiatrists or services were a first priority for 56% (n=53), when the person had significant amputation risk factors. Diabetes-related preventative footcare assessments and management remain a low priority amongst primary healthcare professionals. Preventative care for asymptomatic complications, such as DFD, may be overlooked in favour of monitoring HbA1c or medication management. Limited prioritisation of footcare in primary care is concerning given the risks for amputation associated with DFD. This study reveals the need for primary healthcare decision makers and clinicians to ensure preventative footcare is a focused priority earlier in the diabetes care continuum. Collaborative and widespread promotion of the importance of proactive rather than reactive footcare practices is required to support prevention of foot ulcers and amputation.

Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study.

The care necessary to prevent amputation from diabetes and peripheral artery disease (PAD) remains disjointed in many jurisdictions. To help inform integrated regional care, this study explores the correlation between regional health care services and rates of lower extremity amputation. This ecological study included 14 administrative health regions in Ontario, Canada. All diabetes- or PAD-related major (above ankle) amputations (Apr. 1, 2007, to Mar. 31, 2017) were identified among residents 40 years of age and older. For each region, age-and sex-adjusted amputation rates were calculated as well as per capita counts of key health providers (podiatrists and chiropodists, as well as surgeons) and health care utilization among study patients in the year before the first major amputation (physician visits, publicly funded podiatry visits, emergency department visits, hospital admissions, home care nursing, minor amputation, limb revascularization). A total of 11 658 patients with major amputation were identified (of whom 79.2% had diabetes and 96.5% had PAD). There was wide regional variation in amputation rates: 2.53 to 11.77 per 100 000 person-quarters. At a regional level, the proportion of study patients who received revascularization showed the strongest negative correlation with amputation rates. The regional proportion of study patients who saw a vascular surgeon showed the strongest negative correlation with amputation rates, relative to other health provider visits. Other measures of health care utilization among patients correlated poorly with regional amputation rates, as did the regional provider counts. The results were similar when we restricted the analysis to diabetes-related amputations. Amputation rates related to diabetes and PAD vary widely across Ontario. Access to vascular assessment and revascularization must be integrated into regional amputation prevention efforts.

New public health policy intervention for diabetic foot management in Mexico

Abstract Problem In Mexico, an estimated 12 million people have diabetes, with complications of diabetes contributing to 25-90% of non-traumatic amputations. Description of the Problem We conducted a review through the literature of available studies in English-language databases and libraries, including PubMed and UNAM digital Library to determine the role of teaching first contact health workers and the creation of limb salvage teams in the prevention of amputations. Through this review, we present the basis of our proposal about implementing these strategies to improve a care coordination system for diabetic foot management in Mexico. Results There were 25 publications from different countries, 12 eligible for this review. The review emphasizes that the creation of Specialized Diabetic Foot Teams to treat patients and teach first contact medical workers could help to achieve the following objectives which result in the reduction of amputations and improved patient outcomes: Standardize and simplify the diabetic foot clinical examination. Timely reference of patients with DM with a moderate and high risk of diabetic foot complications. Timely reference of patients with diabetic foot and peripheral arterial disease to third-level hospitals. Periodic first-contact health workers training on risk detection and stratification of diabetic foot. Lessons Implementing the policy of creation of Specialized Diabetic Foot Teams to treat patients and teach first contact medical workers will contribute to reducing major amputations due to diabetes in our country. We aim to implement a successful policy in Mexico to strengthen the health system and improve outcomes and therefore the quality of life of patients with diabetic foot complications. We aim to serve as a legislative voice for all patients in Mexico facing major amputations and other diabetes complications. Key messages New public health policy implementation for diabetic foot management in Mexico. Prevention of major amputations.

Management of diabetic foot, an interventional study

The diabetic foot is a group of diseases in which neuropathy, ischemia, and infection lead to tissue breakdown resulting in morbidity, possible amputation and mortality. The aim of the study to identify the risk factors for amputation in diabetic patients hospitalized for foot infection. Seventy patients with diabetic foot infection were studied. The frequency for foot amputation in diabetic foot patients was significantly affected by many factors. Smoking was significantly associated with increased frequency of amputations by 10 times. Those with coronary heart disease are predisposed to amputations 5 times those who are healthy. The less the Wagner grade of foot ulcer, the less possibility for foot amputations. 74.1% of those with ulcers of Wagner grade of 4 were exposed to foot amputation, while only 25% of those of grades 2 or 3 had their foot been amputated. Similarly, Control of blood glucose level is associated with less possibility for diabetic foot amputation. Foot was amputated in 70.5% of those with blood glucose level of ≥ 7.77 mmol/l, while only 11.1% of those with blood glucose level of < 7.77 mmol/l exposed to foot amputation. Diabetic foot amputation is a preventable disabling complication of diabetes mellitus and diabetic foot care must aim to prevent and manage risk factors for amputation in order to improve the squeals of diabetes mellitus. Stopping smoking is the important way to decrease the likelihood for amputation. Controlling coronary heart disease is must be for diabetic foot lesions to get better. Local wound care is an important step in the process of diabetic foot care. Control of blood sugar is the cornerstone in the project of diabetic foot amputation prevention. Management of diabetic foot needs a multidisciplinary approach in order to target all predictors and risk factors for foot amputation aiming at decrease community disabilities and health costs.

Impact of Diabetes Foot Care Education on Amputation Rate in the University of Abuja Teaching Hospital, Nigeria.

Ulceration of the foot is a major problem for people with diabetes. In a developing country like Nigeria, huge challenge is caused by diabetes foot problems. The aim of this study was to determine the impact of diabetic foot care education of patients and health care staff on the outcome of diabetic foot complications in our hospital. This was a pre and post design carried out from April 2013 to March 2014 on 155 diabetes patients. Patient education was carried out by diabetes nurses and doctors, at diagnosis and re-enforced at follow-up clinics. At the end of 1 year, the impact of education was assessed. Descriptive statistics were generated as appropriate. A total of 155 patients, 64 (41%) males and 91 (59%) females, were studied with mean age of 49 ± 3 years and mean duration of diabetes 6 ± 2.6 years. At the onset of the program, 70% of the patients had no knowledge of foot care education. Only 13.5% knew that diabetes mellitus foot ulcer could be related to long duration of diabetes, nerve damage, blood vessel blockage, foot deformity, and uncontrolled blood glucose. Ninety-two percent of the patients preferred home remedies, herbal treatment, or chemist in the event of an ulcer. After the program, 77% would seek hospital care as first option, and amputation rate decreased from 50% in 2009 to 10% by 2017. Our experience has shown that education is the cheaper option for the prevention of lower limb amputation in a resource-poor setting like ours.

Results of a Qualitative Study to Understand Risk Factors for Amputation in Patients With Diabetes and/or Peripheral Arterial Disease in a Highly Rural State

Amputation is a devastating but preventable complication of diabetes and peripheral arterial disease (PAD). It serves as a marker for severe disease as well as for disparities in quality of care. The majority of studies on this issue use quantitative methods, which are useful for identifying prevalence rates and patterns of disease, but have difficulty providing deeper explanations about why certain groups have higher risks for amputation than others. Qualitative methods are ideal for providing rich, meaningful answers for such questions. The purpose of this study was to use a qualitative approach to understand barriers to limb preservation in patients with diabetes and/or PAD in the highly rural state of West Virginia. Participant recruitment was directed by preliminary research identifying high-risk areas for amputation across the state. Focus groups and interviews were conducted by a moderator using a semistructured interview guide focused on barriers to limb preservation. Four groups were interviewed: diabetic and/or PAD patients who have undergone amputation (and their caretakers), vascular providers and surgeons, wound care providers, and primary care providers. Audio recordings of each session were transcribed verbatim and data were analyzed by two coders using NVivo software. Conventional content analysis was carried out to develop a codebook and analyze data for themes related to patient and provider barriers. Eight focus groups, three phone interviews, and three in-person interviews (n = 64) were conducted. Lack of education was the most frequently cited barrier by both patients and providers across all sessions. Geographic isolation, lack of transportation, and cultural norms also emerged as barriers to limb preservation. There was also consensus that health care costs, access to care, and care coordination were major obstacles patients faced when attempting to manage their conditions. Providers emphasized that patient adherence to care plans was a significant barrier to limb preservation. In addition to these barriers, three main risk factors related to patient care emerged: depression, diabetes, and tobacco use. This qualitative study identified important themes contributing to the risk of amputation in West Virginia from the perspective of patients and providers. These include (1) lack of education, (2) geographic and cultural barriers, (3) difficulty with care coordination, (4) poor patient adherence and (5) depression, diabetes and tobacco use. Based on these themes, amputation prevention efforts in West Virginia should be directed toward improving patient education, improving access to care, improving social and mental health support systems, and providing culturally sensitive approaches to patient care.

Maggot Debridement Therapy in Malaysia.

Maggot therapy, also known as maggot debridement therapy, larval therapy, biodebridement, or biosurgery, is a type of biotherapy involving the intentional application of live, disinfected fly larvae or maggots into the nonhealing wound of a human or animal to debride the necrotic wound, reduce bacterial contamination of the wound as well as enhance the formation of healthy granulation tissue and stimulate healing in nonhealing wounds. In addition, van der Plas et al reported that the use of the medicinal larvae as natural remover of necrotic and infected tissue had prevented amputation in 11 selected patients. In Malaysia, Aaron et al had demonstrated prevention of amputation in 25 patients.

The impact of organized multidisciplinary care on limb salvage in patients with mild to moderate WIfI ischemia grades

The impact of organized multidisciplinary care on limb salvage in patients with mild to moderate WIfI ischemia grades

725 Escharotomy Incisions in the Burn Foot and Toe with Compartment Syndrome

Abstract Introduction Patients with burn injuries are at risk for lower extremity compartment syndrome, especially if the injury is circumferential. The hypothesis was that two dorsal escharotomy incisions to release foot and toe compartment syndrome would be most efficacious in the prevention of lower extremity amputations. Methods This was a retrospective chart review of foot compartment syndrome in burn patients between January 2001 and May 2019. Results The study consisted of 59 feet from 32 patients who had been admitted to the Burn Center for thermal injury. The patient age was a mean±sd of 29±30 years, and 41±29 as the % total body surface area (%TBSA); there were 19 males and 13 females. All patients had received fluid resuscitation on admission. Twenty-one (66%) of the patients did not require amputations after undergoing a median of two incisions (range 1–5); 6 of 59 (11%) required fasciotomies. Compared to medial or dorsal or multiple echarotomies, the majority of patients who underwent two dorsal foot escharotomies did not require amputations, p = .0001. Significantly more patients were alive with no amputation 15 (50%) compared to 4 (13%) (dead with amputations), p = .02. Survivors were significantly younger than the non-survivors (median 20 and range1-69) compared to the non-survivors (48, 12–59), p =.04. The survivors also had significantly less severe %TBSA median 22 (range 2–75) versus 83 (35–95) %TBSA, p &amp;lt; .0002. Dorsal/Lateral incisions had the highest number of amputations. Conclusions Foot dorsal compartment release is the most effective site for escharotomies in the treatment of burn-induced compartment syndrome. It does not require more than two incisions at the skin/fat level and over the second and fourth metatarsal bones on the dorsal part of the foot to decrease the lower extremity amputation rate in the majority of cases. Applicability of Research to Practice This research was a critical appraisal of the safest escharotomy foot incisions for compartment syndrome to avoid possible amputations in burn injury.

A conservative approach to select patients with ischemic wounds is safe and effective in the setting of deferred revascularization

ObjectiveThe Wound, Ischemia, and foot Infection classification system has been validated to predict benefit from inmediate revascularization and major amputation risk among patients with peripheral arterial disease. Our primary goal was to evaluate wound healing, limb salvage, and survival among patients with ischemic wounds undergoing revascularization when intervention was deferred by a trial of conservative wound therapy. MethodsAll patients with peripheral arterial disease and tissue loss are prospectively enrolled into our Prevention of Amputation in Veterans Everywhere limb preservation program. Limbs are stratified into a validated pathway of care based on predetermined criteria (immediate revascularization, conservative treatment, primary amputation, and palliative care). Limbs allocated to the conservative strategy that failed to demonstrate adequate wound healing and were candidates, underwent deferred revascularization. Rates of wound healing, freedom from major amputation, and survival were compared between patients who underwent deferred revascularization with those who received immediate revascularization by univariate and multivariate analysis. ResultsBetween January 2008 and December 2017, 855 limbs were prospectively enrolled into the Prevention of Amputation in Veterans Everywhere program. A total of 203 limbs underwent immediate revascularization. Of 236 limbs stratified to a conservative approach, 185 (78.4%) healed and 33 (14.0%) underwent deferred revascularization (mean, 2.7 ± 2.6 months). The mean long-term follow-up was 51.7 ± 37.0 months. Deferred compared with immediate revascularization demonstrated similar rates of wound healing (66.7% vs 57.6%; P = .33), freedom from major amputation (81.8% vs 74.9%; P = .39), and survival (54.5% vs 50.7%; P = .69). After adjustment for overall Wound, Ischemia, and foot Infection stratification stages, deferred revascularization remained similar to immediate revascularization for wound healing (hazard ratio [HR], 1.5; 95% confidence interval [CI], 0.7-3.2), freedom from major amputation (HR, 0.7; 95% CI, 0.3-1.7) and survival (HR, 1.2; 95% CI, 0.6-2.4). ConclusionsLimbs with mild to moderate ischemia that fail a trial of conservative wound therapy and undergo deferred revascularization achieve similar rates of wound healing, limb salvage, and survival compared with limbs undergoing immediate revascularization. A stratified approach to critical limb ischemia is safe and can avoid unnecessary procedures in selected patients.

Patients' and Clinicians' Preferences on Outcomes and Medication Attributes for Type 2 Diabetes: a Mixed-Methods Study.

Patients' views on the relative importance of treatment outcomes and medication attributes for type 2 diabetes may differ from clinicians' perceptions. To assess which treatment outcomes and medication attributes are considered important by patients and clinicians for therapeutic decisions in type 2 diabetes. Exploratory, sequential, mixed-methods design comprising a qualitative (focus groups) and a quantitative (survey) phase. Patients in the focus groups (n = 33) and the survey study (n = 656) were recruited from 4 and 9 diabetes clinics across Greece, respectively. Clinicians in the survey study (n = 363) were identified from Greek registries for healthcare professionals. We conducted 6 focus groups to obtain patients' views regarding the impact of type 2 diabetes on their lives. Identified themes informed the development of a survey, which aimed to assess which outcomes and medication attributes are considered most important by patients and clinicians. We calculated odds ratios to compare patients' and clinicians' responses. The focus groups identified 6 main themes and 15 subthemes. In the survey study, patients were more likely than clinicians to rate prevention of amputation (odds ratio, 9.32; 95% CI, 6.51 to 13.35), diabetic eye disease (6.16; 4.63 to 8.21), sexual dysfunction, and stroke as important, while clinicians were more likely than patients to choose risk for hypoglycemia, and reduction of all-cause mortality, HbA1c, and body weight. Compared with clinicians, patients were less concerned about drug cost (0.16; 0.11 to 0.23), but more concerned about route of administration and need for less frequent glucose self-monitoring. Patients and clinicians differ in the perception of the relative importance of treatment outcomes and drug characteristics. Individual patient preferences should be explored and implemented in the therapeutic decision-making for type 2 diabetes.