Prevention Of Lower Extremity Amputation Research Articles

Improving Timely Referrals by Implementing Lower Extremity Amputation Prevention Tool in an Suburban Wound Care Clinic

Background: Globally, every 30 seconds there is an amputation due to a non-healing diabetic foot ulcer (DFU). Research shows prevention programs such as utilizing a Lower Extremity Amputation Prevention (LEAP) tool could reduce DFU complications. Local Problem: Impact DuPage (2013) reported that 8.1% of the DuPage population had diabetes, however 12% of the patients with diabetes have had no diabetic foot screening [1]. At a clinic located in DuPage County, the charts audit for the second half of 2017 indicated 55% compliance with documentation of diabetic foot exams. Method: This quality improvement (QI) used four two-weeks Plan-Do-Study-Act cycles. Each cycle included tests of change (TOC) related to patient and team engagement, DFU screening, and referral for treatment. Data were analyzed using run charts and the impact of the interventions were measured. Intervention: Staff was engaged by a kickoff in-service, daily huddles, and weekly team meetings. A modified “Team Effectiveness Diagnostic” survey measured team engagement. Foot Care for a Lifetime was used as shared decision-making tool. Clinicians assessed patients with diabetes with the LEAP checklist and utilized referral log to track appropriate referrals. Results: At the end, patient and team engagement improved to 75% and 92% respectively; also all patients with DFUs were assessed by the LEAP tool (100%) and appropriate referrals (100%) were made. Conclusion: Team engagement was essential in the success of this QI. Patient engagement in the care of their DFU was empowering to patients. The team became better engaged with patients and patients reported more involvement in their own care.

Predicting the amputation risk for patients with diabetic foot ulceration \u2013 a Bayesian decision support tool

BackgroundDiabetes mellitus is a major global health issue with a growing prevalence. In this context, the number of diabetic complications is also on the rise, such as diabetic foot ulcers (DFU), which are closely linked to the risk of lower extremity amputation (LEA). Statistical prediction tools may support clinicians to initiate early tertiary LEA prevention for DFU patients. Thus, we designed Bayesian prediction models, as they produce transparent decision rules, quantify uncertainty intuitively and acknowledge prior available scientific knowledge.MethodA logistic regression using observational collected according to the standardised PEDIS classification was utilised to compute the six-month amputation risk of DFU patients for two types of LEA: 1.) any-amputation and 2.) major-amputation. Being able to incorporate information which is available before the analysis, the Bayesian models were fitted following a twofold strategy. First, the designed prediction models waive the available information and, second, we incorporated the a priori available scientific knowledge into our models. Then, we evaluated each model with respect to the effect of the predictors and validity of the models. Next, we compared the performance of both models with respect to the incorporation of prior knowledge.ResultsThis study included 237 patients. The mean age was 65.9 (SD 12.3), and 83.5% were male. Concerning the outcome, 31.6% underwent any- and 12.2% underwent a major-amputation procedure. The risk factors of perfusion, ulcer extent and depth revealed an impact on the outcomes, whereas the infection status and sensation did not. The major-amputation model using prior information outperformed the uninformed counterpart (AUC 0.765 vs AUC 0.790, Cohen’s d 2.21). In contrast, the models predicting any-amputation performed similarly (0.793 vs 0.790, Cohen’s d 0.22).ConclusionsBoth of the Bayesian amputation risk models showed acceptable prognostic values, and the major-amputation model benefitted from incorporating a priori information from a previous study. Thus, PEDIS serves as a valid foundation for a clinical decision support tool for the prediction of the amputation risk in DFU patients. Furthermore, we demonstrated the use of the available prior scientific information within a Bayesian framework to establish chains of knowledge.

Meta-analysis of risk factors for amputation in diabetic foot infections.

Knowledge of risk factors is crucial to develop management and treatment protocols for the prevention of lower extremity amputation for patients with diabetic foot infections (DFIs). We searched the research literature for studies reporting risk factors for lower extremity amputation in patients with DFI. The main outcome variables included both minor and major amputations. This study was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, and the protocol was registered in PROSPERO (CRD42018118543). A total of 2471 potential articles from the database search met the inclusion criteria. After reviewing the titles, abstracts, and full texts, remaining 25 articles were included in the final analysis. We identified 6132 patients with DFI in the 25 included articles. Of these, 1873 patients who underwent amputation were investigated. Male gender (odds ratio [OR]: 1.31), smoking (OR: 1.38), history of amputation (OR: 1.47), history of osteomyelitis (OR: 1.94), peripheral arterial disease (OR: 2.35), retinopathy (OR: 1.32), International Working Group on the Diabetic Foot (IWGDF) grades 3 and 4 (OR: 1.7 and 2.5), Wagner grades 4 and 5 (OR: 4.3 and 6.4), gangrene/necrosis (OR: 9.9), osteomyelitis (OR: 4.5), neuroischaemic DFI (OR: 3.06), severe infection (OR: 3.12), length of hospitalization (standardized mean difference [SMD]: 0.7), leukocytosis (OR: 1.76), mean erythrocyte sedimentation rate (ESR) (SMD: 0.5), mean C-reactive protein (CRP) (SMD: 0.8), tissue culture positivity (OR: 1.61), and isolation of Gram-negative bacteria from tissue culture (OR: 1.5) were found as predictors of amputation in DFI. The present study highlighted some differences in diabetic foot ulcers and DFIs in terms of risk factors for lower extremity amputation. These data provide detailed information about risk factors for amputations among patients with DFI, thus contributing to the creation of new classification systems for assessment of high-risk patients.

A Study on The Prevalence And Risk Factors Associated with Peripheral Vascular Disease In Type2 Diabetes Mellitus

A Study on The Prevalence And Risk Factors Associated with Peripheral Vascular Disease In Type2 Diabetes Mellitus

The relationship between self-efficacy and diabetic foot self-care

AimsResearch has shown that the ongoing rate of diabetes-related amputations remains significant despite the existence of prevention methods and that amputation in most cases can be prevented. The purpose of the study was to assess the relationship between the level of self-efficacy and performance of foot self-care in those with diabetes as they relate to the prevention of lower extremity amputation (LEA). MethodsA descriptive correlational study was conducted using the theoretical framework of Bandura's social cognitive theory. The Foot Care Confidence Scale (FCCS) and the Nottingham Assessment of Functional Footcare (NAFF) survey instruments were distributed to individuals over 18 years old with diabetes Type 1 and 2 in the lower peninsula of Michigan (N = 223). ResultsNo significant correlation was identified between the level of self-efficacy and performance of foot self-care behaviors. Statistical significance was found between foot self-care behaviors and gender with males scoring higher than females. ConclusionsThis study adds to the body of knowledge regarding self-efficacy and diabetic foot self-care behaviors. Further research is needed to explore the relationship of gender, diabetes education attendance, and foot self-care behaviors as influencing factors in LEA prevention.

Lack of Effectiveness of Hyperbaric Oxygen Therapy for the Treatment of Diabetic Foot Ulcer and the Prevention of Amputation

OBJECTIVEHyperbaric oxygen (HBO) is a device that is used to treat foot ulcers. The study goal was to compare the effectiveness of HBO with other conventional therapies administered in a wound care network for the treatment of a diabetic foot ulcer and prevention of lower-extremity amputation.RESEARCH DESIGN AND METHODSThis was a longitudinal observational cohort study. To address treatment selection bias, we used propensity scores to determine the “propensity” that an individual was selected to receive HBO.RESULTSWe studied 6,259 individuals with diabetes, adequate lower limb arterial perfusion, and foot ulcer extending through the dermis, representing 767,060 person-days of wound care. In the propensity score–adjusted models, individuals receiving HBO were less likely to have healing of their foot ulcer (hazard ratio 0.68 [95% CI 0.63–0.73]) and more likely to have an amputation (2.37 [1.84–3.04]). Additional analyses, including the use of an instrumental variable, were conducted to assess the robustness of our results to unmeasured confounding. HBO was not found to improve the likelihood that a wound might heal or to decrease the likelihood of amputation in any of these analyses.CONCLUSIONSUse of HBO neither improved the likelihood that a wound would heal nor prevented amputation in a cohort of patients defined by Centers for Medicare and Medicaid Services eligibility criteria. The usefulness of HBO in the treatment of diabetic foot ulcers needs to be reevaluated.

Guideline for the Management of Wounds in Patients With Lower-Extremity Neuropathic Disease

This article summarizes the WOCN Evidence-Based Clinical Practice Guideline for Management of Wounds in Patients with Lower Extremity Neuropathic Disease. It is intended for use by physicians, nurses, therapists, and other health care professionals who work with adults who have or are at risk for, lower-extremity neuropathic disease (LEND), and includes updated scientific literature available from January 2003 through February 2012. The full guideline contains definitions of lower extremity neuropathic disorders and disease, prevalence of the problem, relevance and significance of the disorders, as well as comprehensive information about etiology, the nervous system, pathogenesis, and the overall management goals for patients at risk for developing neuropathic foot ulcers. A detailed assessment section describes how to conduct a full clinical history and physical examination. The guideline also provides two approaches to interventions. The first focuses on prevention strategies to reduce the risk of developing LEND wounds or recurrence, including life-long foot offloading, routine dermal temperature surveillance, use of adjunctive therapies, medication management, and implementing lower extremity amputation prevention measures and patient self-care education. The second approach summarized LEND wound management strategies including wound cleansing, debridement, infection management, maintenance of intact peri-wound skin, nutrition considerations, pain and paresthesia management, edema management, offloading and management of gait and foot deformity, medication management, surgical options, adjunctive therapies, patient education, and health care provider follow-up. A comprehensive reference list, glossary of terms, and several appendices regarding an algorithm to determine wound etiology, pharmacology, Lower Extremity Amputation (LEAP) Program, diabetes foot screening and other information is available at the end of the guideline.

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...

The Role of Certified Foot and Nail Care Nurses in the Prevention of Lower Extremity Amputation

The primary purpose of this article is to outline the role, opportunities, and benefits of the certified foot and nail care nurse (CFCN). Current demographic trends toward an aging population and associated health issues such as diabetes mellitus, arthritis, peripheral arterial disease, dementia, and loss of visual acuity hinder self-care of the feet and nails. The resulting foot and nail care needs create opportunities for CFCN to promote health and prevent adverse outcomes such as infection and limb loss. Routine foot and nail assessment, clinically appropriate care, and individualized patient education are essential for achieving positive outcomes. Until recently, individuals had limited options for obtaining needed care and have relied on nonclinicians or podiatry appointments that may not be covered by insurance and, thus, may not be affordable. Through the CFCN certification process, nurses gain knowledge and skills to provide the care that can improve foot health for an aging population.

The Role of Certified Foot and Nail Care Nurses in the Prevention of Lower Extremity Amputation

The Role of Certified Foot and Nail Care Nurses in the Prevention of Lower Extremity Amputation

Critical limb ischaemia in a diabetic population from an Asian Centre: angiographic pattern of disease and 3-year limb salvage rate with percutaneous angioplasty as first line of treatment

Purpose:Lower extremity amputation prevention (LEAP) is an ongoing program in our institution aimed at salvaging limbs in patients with critical limb ischemia (CLI). Patients in the LEAP program with reconstructible anatomy on initial Doppler imaging received either bypass surgery or percutaneous transluminal balloon angioplasty (PTA). We present the 3 year limb salvage rate and angiographic disease patterns in 42 consecutive diabetic patients with CLI who received PTA in 2005.Methods and Material:26 women and 16 men with diabetes between the ages of 45 and 91 years old (mean age, 70.8 years) received PTA in 2005. Presenting symptoms were rest pain (n = 22), pre-existing gangrene (n = 17), non-healing ulcer (n = 16) and cellulitis (n = 2). The aim of the PTA was to achieve straight-line flow from the abdominal aorta down to the patent dorsalis pedis or plantar arch, with limb salvage as the ultimate outcome. Failure of treatment was defined as any amputation above the level of a Syme’s amputation or the need for further surgical bypass. Technical success was achieved in 90% (38 out of 42 patients).Results:Limb salvage rates were 93% at 1 month, 87% at 3 months, 82% at 6 months, 78% at 1 year, 69% at 2 years and 66% at 3 years. Mortality was 17% (n = 7) at 3 years. Of the 13 patients with failed therapy, 3 underwent bypass, 9 had amputations and 1 had bypass followed by amputation. Four of the cases required further intervention due to worsening gangrene and infection, while the remaining was due to persistent rest pain. The rest of the 32 patients had no lower limb related issues at the end of 3 years, with improvement of the presenting symptoms. Patterns of treated segments were aortoiliac occlusions (n = 3), pure infrapopliteal disease (n = 3), femoropopliteal with at least 1 good infrapopliteal run-off vessel (n = 14) and combined femoropopliteal and infrapopliteal disease (n = 25).Conclusion:Involvement of infrapopliteal vessels that needs to be treated is common in Asian diabetics. While early limb salvage rates up to 1 year are similar, the 3 year limb salvage rates in Asian diabetics are lower than the western population.

Diabetic foot care: prevention of lower extremity amputation

Diabetic foot care: prevention of lower extremity amputation

Diabetes is the strongest risk factor for lower-extremity amputation in new hemodialysis patients.

End-stage renal disease (ESRD) patients, especially those with diabetes, have an increased risk of nontraumatic lower-extremity amputation (LEA). The present study aims to examine the association of demographic and clinical variables with the risk of hospitalization for LEA among incident hemodialysis patients. The study population consisted of incident hemodialysis patients from the study years 1996-1999 of the ESRD Core Indicator/Clinical Performance Measures (CPM) Project. Cox proportional hazard modeling was used to identify factors associated with LEA. Four percent (116 of 3,272) of noncensored incident patients had an LEA during the 12-month follow-up period. Factors associated with LEA included diabetes as the cause of ESRD or preexisting comorbidity (hazard ratio 6.4, 95% CI 3.4-12.0), cardiovascular comorbidity (1.8, 1.2-2.8), hemodialysis inadequacy (urea reduction ratio [URR] <58.5% (1.9, 1.1-3.3), and lower serum albumin level (1.6, 1.1-2.3). Among patients with diabetes, hemodialysis inadequacy and cardiovascular comorbidity were risk factors for LEA (2.6, 1.4-4.8, and 1.7, 1.1-2.6, respectively). These data suggest that diabetes is a potent risk factor for LEA in new hemodialysis patients. In ESRD patients with diabetes, a multipronged approach may reduce the rate of LEA. Potentially beneficial strategies include adherence to hemodialysis adequacy guidelines, aggressive treatment of cardiovascular comorbidities, and the utilization of LEA prevention strategies recommended for the general population of patients with diabetes.

Team approach toward lower extremity amputation prevention in diabetes.

Through a discussion of the etiology and pathology of diabetic foot lesions with particular emphasis on ulceration and osteoarthropathy, the author will develop a plan for treatment and prevention using a multidisciplinary approach to such problems. Underlying risk factors including neuropathy, ischemia, infection, and, especially high pressures must be evaluated and appropriately ameliorated in order to promote resolution and avoidance of recidivism. Accordingly, conservative management with pressure-relieving devices, topical therapies, and prophylactic surgery on structural deformities plays an integral part in the overall podiatric management of the high-risk foot in diabetes mellitus.

Lower Extremity Amputation Prevention Program

Lower Extremity Amputation Prevention Program

Why bother educating the multi-disciplinary team and the patient--the example of prevention of lower extremity amputation in diabetes.

Amongst all the long-term complications of diabetes it is believed that foot ulceration and amputation are the most preventable: small studies have suggested that more than 50% of amputations should be avoidable by screening and appropriate education. There is ample evidence that simple non-invasive screening tests are not being carried out in many diabetic clinics--one study confirmed that poor patient care was responsible for 50% of heel ulcers in a hospital setting. There is a similar lack of awareness of potential problems in many 'at risk' diabetic patients. Thus, simple screening of diabetic patients should be routine clinical practice: those identified as being at 'high risk' of foot, problems should receive appropriate education in protective foot care. The rewards are potentially great, and include the realization of the St. Vincent target, a 50% reduction in amputation.

Pivotal events: Important markers for planning tertiary prevention of lower extremity amputation

Pivotal events: Important markers for planning tertiary prevention of lower extremity amputation