Previous Amputation Research Articles

Predictive diabetic foot ulcer risk factors correlated with elevated forefoot peak plantar pressure

Polyneuropathy and foot deformity, such as Claw and hammer-toes (CHT), together with hyperkeratosis, are predictive diabetic foot ulcer (DFU) factors. These factors are correlated with increased forefoot peak plantar pressure (PPP). Increased PPP at metatarsal heads is correlated with forefoot DFU development. The aim of this study was to observe that the presence of CHT, hyperkeratosis and polyneuropathy is correlated with high forefoot PPP (FPPP). An observational transversal survey with 103 diabetic patients, with or without CHT, hyperkeratosis and polyneuropathy, and without peripheral arterial disease, previous or current DFU and lower limb amputation was conducted. Mean age was 74 years old, 41 male and 62 women. Variables were CHT, hyperkeratosis, polyneuropathy and FPPP of each foot. PPP was obtained through the BIOFOOT/IBV baropodometric system. An analysis of difference between means of two samples was performed. “Hyperkeratosis” is correlated with higher FPPP than “CHT and hyperkeratosis”, and both with higher FPPP than those who had none of these features. There is no significant difference between FPPP of the groups without and with polyneuropathy, both without hyperkeratosis. Hyperkeratosis is correlated with higher FPPP, independently of polyneuropathy. The mean FPPP of up to 840 KpPa may be considered as indicative of a lower risk of DFU, in this sample and with this baropodometric system.

Osteomyelitis and Neuropathic Ulcers in Forefoot—Amputation Is the Only Surgical Intervention Resolving?

Background and Aim: The aim of this study is to show a simple therapeutic method in cases of neuropathic ulcer complicated by osteomyelitis in the forefoot to resolve this complication avoiding amputation. Patients-Methods: Our material consists of 28 patients (19 males, 9 females) with “diabetic foot” aged 57,31±10,25 years, mean HbA1c: 8,65±1,7%, of duration of diabetes 13,84±9,2 years and 32% of them are active smokers. NDS, VPT, ABI are measured. All of them had neuropathic ulcers located in the forefoot and 10 of them had previous amputations. The average duration of the ulcer was 1 year complicated with osteomyelitis in admission time. The diagnosis of osteomyelitis was made with MRI, RX, probe-to-bone test and verification of elevated ESR and CRP. We start with the collection of the cultures (bone sample in 6 of 28 patients) and antibiotic treatment according the cultures. After the diagnosis of osteomyelitis we proceeded to prepare a surgical field and through the ulcer we removed the infected bone-phalanx taking a bone sample for microbiological study. After we scraped and cleaned the cavity well, a 48-hour drain was placed and becomes transdermal wound suture if is a necessary. The duration of the antibiotic treatment depends from the lesion area, the results of microbiological culture and varies from 4-6 weeks to 4-6 months. Results: After practicing this technique all cases were healed at an average 40 days with an effective offload and an appropriate topical care to keep the ulcer clean and with an optional moisture. The duration of hospitalization 2-8 days depending on the severity of the infection. Conclusion: It is essential to raise other less invasive and conservative methods than amputation. Specially in those with good distal arterial perfusion that in many cases are young, the avoidance of a amputation has many benefits in their quality of life. Finally, the applied method is rapid inexpensive without disturbing the biomechanical balance of the foot to a large extent. Disclosure D. Skoutas: None. F. Sayegh: None. S. Metallidis: None. S. Sgoutzakos: None. I. Katsanos: None. S. Georga: None. A. Nikolaidis: None. L. Doukas: None. E. Matopoulou: None. S. Tesfaye: Speaker's Bureau; Self; Pfizer Inc.. Other Relationship; Self; Janssen Pharmaceuticals, Inc., Takeda Development Centre Europe Ltd.. Advisory Panel; Self; Wörwag Pharma GmbH & Co. KG. C. Manes: None. G. Tzatzagou: None.

Feasibility of Creating a Diagnosis-Based Diabetic Foot Registry in a Large Health Care Provider

We aimed to assess the validity of diagnostic codes relating to diabetic foot ulcer (DFU) in real-world data seeking to create a national DFU registry. Data were obtained from the diabetes registry of Maccabi Healthcare Service (MHS), a 2.1 million member sick fund in Israel, which included 122,500 patients in 2015. We randomly selected and reviewed ∼400 patient files from each of the following categories: 1) had a diagnostic code of DFU in 2015; 2) had a diagnostic code suggestive of DFU in 2015 including: leg ulcer, amputation, DFU in proximate years or abnormality reported by nurse; 3) high risk patients (peripheral arterial disease (PAD), neuropathy, etc.). The patients' charts were reviewed by study physicians and DFU was validated or refuted. Relying upon diagnostic codes entered by physicians, the positive predictive value was 73.1% (95% CI 67.6-78.2) and the sensitivity was 48.2% (95% CI 45.8-50.7%). We therefore conclude that the diagnostic codes alone cannot be reliably used to create a DFU registry, and a prospective registry is considered. The estimated annual prevalence of DFU in the diabetes registry of MHS in 2015 was 1.3% (95% CI 1.0-1.6%). Clinical features and outcomes of patients with validated diagnostic codes of DFU are shown (Table). In multivariate analysis: age, diabetes duration, socioeconomic status, previous amputation and PAD were independently associated with risk of amputation or death. Disclosure A. Cahn: Advisory Panel; Self; AstraZeneca, Novo Nordisk Inc.. Research Support; Self; AstraZeneca. Consultant; Self; GlucoMe. Stock/Shareholder; Self; GlucoMe. Advisory Panel; Self; Eli Lilly and Company. Speaker's Bureau; Self; Novo Nordisk Inc., Eli Lilly and Company, AstraZeneca. Advisory Panel; Self; Sanofi. Speaker's Bureau; Self; Sanofi. Advisory Panel; Self; Boehringer Ingelheim Pharmaceuticals, Inc.. Speaker's Bureau; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Merck Sharp & Dohme Corp.. Consultant; Self; medial early sign. T. Altaras: None. T. Agami: None. O. Liran: None. C.E. Touaty: None. R. Pollack: None. I. Raz: Advisory Panel; Self; AstraZeneca. Consultant; Self; AstraZeneca. Speaker's Bureau; Self; AstraZeneca. Advisory Panel; Self; Boehringer Ingelheim GmbH. Speaker's Bureau; Self; Boehringer Ingelheim GmbH. Advisory Panel; Self; Eli Lilly and Company. Speaker's Bureau; Self; Eli Lilly and Company. Stock/Shareholder; Self; DarioHealth. Advisory Panel; Self; Merck Sharp & Dohme Corp., Novo Nordisk Inc.. Speaker's Bureau; Self; Novo Nordisk Inc.. Advisory Panel; Self; Orgenesis Inc., Pfizer Inc., Sanofi R&D, SmartZyme Biopharma. Consultant; Self; Bristol-Myers Squibb Company. Speaker's Bureau; Self; Bristol-Myers Squibb Company, Johnson & Johnson Diabetes Institute, LLC., Merck Sharp & Dohme Corp., Novartis Pharma K.K., Sanofi-Aventis. Consultant; Self; FuturRx Ltd, Insuline Medical,Camereyes Ltd, Exscopia, Medial EarlySign Ltd. Stock/Shareholder; Self; Glucome Ltd, InsuLine Medical Ltd.. Consultant; Self; Dermal Biomics Inc. Stock/Shareholder; Self; Orgenesis Inc.. Speaker's Bureau; Self; Teva Pharmaceutical Industries Ltd.. Advisory Panel; Self; Concenter BioPharma/Silkim Ltd, Camereyes Ltd. Stock/Shareholder; Self; CameraEyes Ltd. Advisory Panel; Self; Breath of Life PharmaLtd, Panaxia. G. Chodick: None. I. Zucker: None.

Characteristics, prevalence, and outcomes of diabetic foot ulcers in Africa. A systemic review and meta-analysis

BackgroundAmong non-communicable diseases, diabetes represents a growing public health problem in Africa, where diabetes-related needs remain mostly unmet and the disabling features of foot are worsened by hygienic, cultural, and healthcare issues. We aimed to review clinical characteristics, prevalence, and outcomes of patients with diabetic foot ulcer in Africa. MethodsWe searched the literature for cross-sectional and longitudinal studies reporting the characteristics of patients with diabetic foot in African countries, with a particular focus on ulcer prevalence, amputation rate, and mortality. FindingsFifty-five full-text papers and ten abstracts were retrieved, reporting data from 19 African countries on 56,173 diabetic patients. According to the data collected, the overall prevalence of foot ulcers was 13% and increased over time, especially since 2001. Approximately 15% of patients with foot lesions underwent major amputation and 14.2% died during hospitalization. In patients with diabetic ulcers, insulin therapy was uncommon and neuropathy was the most common predisposing factor, but the prevalence of peripheral arterial disease correlated with amputation rates. Amputation and mortality decreased over time, probably as result of the implementation of screening programs in the last ten years. Mortality was directly related to previous amputation. InterpretationThe diabetic foot disease in Africa is a growing problem and is burden by high rate of in-hospital mortality. Educational interventions and screening programs including evaluation of the vascular status may play a crucial role to counter diabetic foot disease in Africa.

Clinico-microbiological Profile of Septic Diabetic Foot with Special Reference to Anaerobic Infection.

IntroductionDiabetic foot infections are a major cause of non-traumatic amputations. The role of anaerobes in the prognosis of these infections is particularly unclear. This study was conducted with the aim of correlating microbiological profiles with clinical outcomes in these diabetic foot ulcer patients.MethodologyThis prospective observational study was done in a tertiary care centre in South India. All patients admitted with diabetic foot ulcers for two years were included in the study. Tissue biopsies were collected from the ulcer for aerobic and anaerobic cultures. The patients were grouped as those with aerobic infection alone (anaerobe negative) and those with mixed aerobic and anaerobic infections (anaerobe positive). Anaerobic culture was performed using the Robertson cooked meat (RCM) medium. The ulcer of the foot was described with respect to site, size, duration, history of previous amputation(s), and history of number and class of antibiotic intake prior to hospitalization. Clinical course and Wagner’s grades of the diabetic foot ulcers were compared for aerobic and anaerobic infections.ResultsA total of 104 patients were included in the study. There were no significant differences between the two groups with regards to duration of diabetes, random blood sugar (RBS) at the time of admission, compliance to drugs, and mode of blood sugar control and prior intake of antibiotics. Patients with anaerobic infections were found to have a higher incidence of fever in this study (38.1% vs. 14.5%; p = 0.0057), as compared to patients with aerobic infections. More than half of the patients in the anaerobic infection group presented with Wagner’s grade IV and above, as compared to the aerobic infection group (59.5% vs. 32.2%; p = 0.0059), which was statistically significant. Patients with anaerobic infections also had high numbers of major and minor amputations when compared to patients with aerobic infections.ConclusionSeptic diabetic foot patients with fever at the time of admission and a high Wagner’s grade have a greater chance of harbouring anaerobic infections. Drugs for anaerobic coverage should be considered for wounds beyond Wagner’s grade III. Anaerobic infections resulted in increased risk of morbidity in diabetic foot ulcer patients but did not have any influence on mortality.

Infected diabetic ulcers, when to amputate.

In 2030 diabetes will cause one amputation every 20 seconds. Currently 10 to 20% of all diabetic patients develop infected foot ulcers that recur 40% of the time within one year, even when adequately treated by antibiotics, angioplasty or bypass. Therefore, factors other than infection and peripheral artery disease must be incriminated in wound healing in diabetic patients. The identification of those factors is the subject of our study. A retrospective study done at CHU-NDS (Centre Hospitalier Notre Dame De Secours) included all patients with infected diabetic ulcers between 2012 and 2017. Age was recorded as well as: gender, HbA1c (Hemoglobin A1c), coronary heart disease, antihypertension treatment, creatinine, CRP (C reactive protein), ejection fraction, total cholesterol level and previous amputations. All our patients were followed by an infectious disease specialist, an orthopedist and a vascular surgeon. 139 diabetic ulcers in total were recorded; 83 were infected and 36 underwent amputation (25.9%). Amongst the amputated patients, 25 were males, 22 were > 65YO, 14 had HbA1c > 8,31 had CAD, 23 had previous amputations, 25 had CRP > 80, 14 had an EF < 50% and 17 were treated by dihydropyridine. We concluded that HbA1c > 8%, coronary heart disease, ejection fraction < 50%, CRP above 80 mg/L, as well as history of previous amputations were risk factors for amputation. Moreover, patients treated with dihydropyridine calcium channel blockers showed less ulcer prevalence and less amputation procedures.

FACTORS RELATED TO AMPUTATION LEVEL AND WOUND HEALING IN DIABETIC PATIENTS.

ABSTRACTObjectiveThere are no specific criteria that define the level of amputation in diabetic patients. The objective of this study was to assess the influence of clinical and laboratory parameters in determining the level of amputation and the wound healing time.MethodsOne hundred and thirty-nine diabetic patients were retrospectively assessed. They underwent surgical procedures due to infection and/or ischemic necrosis. Type of surgery, antibiotic use, laboratory parameters and length of hospital stay were evaluated in this study.ResultsThe most common amputation level was transmetatarsal, occurring in 26 patients (28.9%). The wound healing time increased with statistical significance in individuals undergoing debridement, who did not receive preoperative antibiotics and did not undergo vascular intervention. Higher levels of amputation were statistically related to limb ischemia, previous amputation and non-use of preoperative antibiotics.ConclusionPatients with minor amputations undergo stump revision surgery more often, but the act of always targeting the most distal stump possible decreases energy expenditure while walking, allowing patients to achieve better quality of life. Risk factors for major amputations were ischemia and previous amputations. A protective factor was preoperative antibiotic therapy. Level of Evidence III, Retrospective Study.

Immediate and late outcomes of endovascular therapy for lower extremity arteries in Buerger disease

ObjectiveBuerger disease is a rare inflammatory vasculopathy presenting with severe claudication or critical limb ischemia. In this study, we sought to evaluate the feasibility and clinical outcomes of endovascular therapy for Buerger disease involving arteries in the lower extremities. MethodsBetween January 2006 and May 2016, there were 44 Buerger disease patients (43 men; mean age, 40.4 ± 9.6 years) with 50 target limbs treated by endovascular therapy at the Severance Cardiovascular Hospital. Baseline characteristics as well as both immediate and late clinical outcomes were retrospectively analyzed. ResultsThe majority (86.4%) of patients presented with critical limb ischemia. A total of 88 target lesions in 50 limbs were treated with endovascular procedures. All limbs showed infrapopliteal artery occlusions, and multilevel diseases involving the iliac or femoropopliteal artery were found in 31 patients (62%). Technical success was achieved in 80% of subjects. We found that a lower serum level of C-reactive protein, specifically the log C-reactive protein value (odds ratio, 0.03; 95% confidence interval [CI], 0.00-0.71; P = .030), was an independent predictor of technical failure. The median follow-up duration was 29 months. Major adverse limb event-free survival and reintervention- and amputation-free survival were 83.3% and 67.9% at 3 years, respectively. In a multivariate Cox proportional hazards analysis, previous endovascular treatment (hazard ratio, 3.70; 95% CI, 1.20-11.31; P = .022) and previous amputation (hazard ratio, 4.68; 95% CI, 1.37-15.96; P = .014) were identified as independent risk factors for reintervention- and amputation-free survival. ConclusionsIn patients with Buerger disease, endovascular treatment achieved technical success in the majority of the cases and was associated with favorable immediate and late clinical outcomes. These findings indicate that endovascular therapy may be considered a first-line treatment option for severe symptomatic patients with Buerger disease.

Risk of lower limb amputation in a national prevalent cohort of patients with diabetes.

Lower limb amputation is a serious complication of diabetes mellitus. Understanding how amputation risk differs by population subgroups is crucial in terms of directing preventive strategies. In this study, we describe those factors that impact amputation risk in the entire prevalent diabetic population of New Zealand. A national prevalent cohort of 217,207 individuals with diabetes in 2010 were followed up until the end of 2013 for lower limb amputations, and 2014 for mortality. Inpatient hospitalisation data were used to define lower limb amputation using ICD-10 codes. Cox proportional hazards models were used to describe relative hazard of amputation over the follow-up period. A total of 784 individuals (3.6 cases/1000 individuals) underwent a major (above-ankle) lower limb amputation during follow-up, while 1217 (5.6/1000) underwent a minor (below ankle) amputation. The risk of major and minor amputation was 39% and 77% greater for men than women, respectively (adjusted HR: major amputation 1.39, 95% CI 1.20, 1.61; minor amputation 1.77, 95% CI 1.56, 2.00). Indigenous Māori were at 65% greater risk of above-knee amputation compared with the European/Other diabetic population (HR 1.65, 95% CI 1.37, 1.97). Amputation risk increased with increasing comorbidity burden, and peripheral vascular disease conferred the greatest independent risk of all comorbid conditions. Prior minor amputation increased the risk of subsequent major amputation by tenfold (HR 10.04, 95% CI 7.83, 12.87), and increased the risk of another minor amputation by 20-fold (HR 21.39, 95% CI 17.89, 25.57). Death was common among the total cohort, but particularly among those who underwent amputation, with more than half of those who underwent a major amputation dying within 3years of their procedure (57%). Using a large, well-defined, national prevalent cohort of people with diabetes, we found that being male, indigenous Māori, living in deprivation, having a high comorbidity burden and/or having a previous amputation were strongly associated with subsequent risk of lower limb amputation. The use of this prevalent cohort strengthens the value of our estimates in terms of applicability to the general population, and highlights the subgroups at greatest risk of lower limb amputation.

Risk Factors for Infection with Pseudomonas aeruginosa in Diabetic Foot Infections.

Selecting empirical therapy for a diabetic foot infection (DFI) requires knowing how likely infection with Pseudomonas aeruginosa is in a particular patient. We designed this study to define the risk factors associated with P aeruginosa in DFI. We performed a preplanned microbiological subanalysis of data from a study assessing the effects of treatment with intralesional epidermal growth factor for diabetic foot wounds in patients in Turkey between January 1, 2012, and December 31, 2013. Patients were screened for risk factors, and the data of enrolled individuals were recorded in custom-designed patient data forms. Factors affecting P aeruginosa isolation were evaluated by univariate and multivariate logistic regression analyses, with statistical significance set at P < .05. There were 174 patients enrolled in the main study. Statistical analysis was performed in 90 evaluable patients for whom we had microbiological assessments. Cultures were sterile in 19 patients, and 89 bacterial isolates were found in the other 71. The most frequently isolated bacteria were P aeruginosa (n = 23, 25.8%) and Staphylococcus aureus (n = 12, 13.5%). Previous lower-extremity amputation and a history of using active wound dressings were the only statistically significant independent risk factors for the isolation of P aeruginosa in these DFIs. This retrospective study provides some information on risk factors for infection with this difficult pathogen in patients with DFI. We need prospective studies in various parts of the world to better define this issue.

Factors associated with foot ulceration and amputation in adults on dialysis: a cross-sectional observational study

BackgroundAdults on dialysis are at increased risk of foot ulceration, which commonly precedes more serious lower limb complications, including amputation. Limited data exist regarding the prevalence and factors associated with foot disease in this population. Hence, this study set out to investigate factors associated with foot ulceration and amputation in a dialysis cohort.MethodsThis study presents a cross-sectional analysis of baseline data from a multi-center prospective cohort study. We recruited 450 adults with end-stage renal disease on dialysis from multiple satellite and home-therapy dialysis units in Melbourne, Australia from January to December 2014. Data collection consisted of a participant interview, medical record review, health-status questionnaire and non-invasive foot examination. Logistic regression analyses were conducted to evaluate associations between screened variables and study outcomes.ResultsMean age was 67.5 (SD, 13.2) years, 64.7% were male, 94% were on hemodialysis, median dialysis duration was 36.9 (IQR, 16.6 to 70.1) months, and 50.2% had diabetes. There was a high prevalence of previous ulceration (21.6%) and amputation (10.2%), 10% had current foot ulceration, and 50% had neuropathy and/or peripheral arterial disease. Factors associated with foot ulceration were previous amputation (OR, 10.19), peripheral arterial disease (OR, 6.16) and serum albumin (OR, 0.87); whereas previous and/or current ulceration (OR, 167.24 and 7.49, respectively) and foot deformity (OR, 15.28) were associated with amputation.ConclusionsDialysis patients have a high burden of lower limb complications. There are markedly higher risks of foot ulceration and/or amputation in those with previous and/or current ulceration, previous amputation, peripheral arterial disease, lower serum albumin, and foot deformity. Although not a major risk factor, diabetes in men was an important effect modifier for risk of ulceration.

The CANVAS trial programme raises more questions than answers

The CANVAS trial programme raises more questions than answers

Factors affecting lifespan following below-knee amputation in diabetic patients

IntroductionUntreatable foot problems in diabetics may require lower extremity amputation, which has a high level of patient mortality. This high mortality rate is worse than most malignancies. The present study aimed to identify parameters that can be used to estimate survival in DM patients undergoing below-knee amputations for diabetic foot problems. Materials and methodsA total of 470 patients (299 males, 171 females) with a mean age of 64.32 years who underwent below-knee amputation for diabetic foot problems between 2004 and 2014 were enrolled in the study. The length of time from the operation to time of death was recorded in days. Patient details were obtained, including age during surgery, BMI, oral antidiabetic and insulin usage, dialysis therapy history, lower extremity endovascular intervention, previous amputation at the same extremity, the need for stump revision surgery during follow-up, and above-knee amputation at the same site. Biochemical test results of pre-operative HbA1c, ESR, and levels of CRP, BUN, and creatinine were also obtained. ResultsA total of 333 patients (70.9%) died and 137 (29.1%) survived post-surgery. Survival rates were 90% in the first 7 days, 84% in the first 30 days, and 64% after the first year. Patient median life expectancy post-surgery was 930 ± 106 days. Hemodialysis treatment (p = 0.001), endovascular intervention (p = 0.04), sex (p = 0.004), age (p = 0.001), BUN level (p = 0.001), and duration of insulin use (p = 0.003) were shown to be effective predictors of mortality. ConclusionsLife expectancy is low (<3 years) in DM patients requiring below-knee amputations for untreatable foot problems. Survival could be predicted by duration of insulin use, age, sex, and renal insufficiency. Level of evidenceLevel IV, Therapeutic study.

Management of diabetic foot ulcers in a teaching hospital

Background: Diabetic foot ulcers (DFUs) are major public health problem, especially in developing countries. Still now management of diabetic foot ulcer is the major challenge for surgeons.Methods: A prospective study was done at Kamineni Institute of Medical Sciences, Narketpally; from February 2014 to January 2017. All the collected data was analyzed by the SPSS 20.0 software.Results: A total of 350 DFUs patients was included in this study. Among all of them 77.14% were male and 22.86% were female. Most common age group with DFUs was 40-60 years. All the patients had type 2 diabetes mellitus. The majority of patients were presented foot ulcers between 4 weeks to 32 weeks. 18% patients had previous history of DFUs and 11.14% had previous amputation. The forefoot was commonly affected in 48.3% of cases. Neuropathic ulcers were the most common type of DFUs in 50.6% of cases. Wagner's stage 3, 4 and 5 ulcers were the most common at 20.86%, 28% and 22% respectively. 52.86% patients were treated surgically. Lower limb amputation was the most common surgical procedure performed in 60% of cases. The complication rate was (49.7%) and surgical site infection was the most common complication (34.8%). 60% of cultures had polymicrobial growth and Staphylococcus aureus (53.3%) was the most common microorganism isolated. Most of the microorganisms isolated showed multi drug resistance to commonly used antibiotics except for Carbapenems group drugs (sensitivity 100%). The hospital stay was ranged between 15-116 days. Mortality rate was 9.4%.Conclusions: Diabetic foot ulcer is the major cause of morbidity and mortality among patients with diabetes mellitus. A proper education on foot care and appropriate foot ware, good sugar level control and early surgical intervention is needed to decrease the morbidity and mortality among diabetic foot ulcer patients.

Predictors of first ischemic lower limb ulcer in dialysis patients: an observational cohort study.

Lower limb ischemia affects the quality of life, physical activity and life expectancy of dialysis patients. The aim of this study was to investigate the risk factors associated with ischemic foot ulcers considering clinical, laboratory and therapeutic domains. This observational cohort study was based on data from the Nephrology and Dialysis Department database of Alessandro Manzoni Hospital, Lecco (Italy). All of the incident patients who started dialysis between 1 January 1999 and 29 February 2012 were enrolled, excluding temporary guests, patients with acute renal failure and patients with previous limb ischemia or amputation. Multivariate Cox regression analysis identified the predictors in each domain, which were matched in the final model. A time-dependent approach was used to take into account the evolution of some of the prognostic covariates. Of the 526 incident dialysis patients, 120 developed a lower limb ischemic lesion after a median of 13months. The incidence of new ulcers was constant during the study period (6 per 100 person-years), but higher in the diabetics with a relative rate of 4.5. The variables significantly related to an increased risk of lower limb ulcers were age, male gender, diabetes, ischemic heart disease, treatment with proton pump inhibitors, iron, anticoagulants and calcium-based binders, and blood levels of phosphorus, triglycerides and C-reactive protein. The incidence of lower limb ulcers was highest during the early dialysis follow-up and was associated with, in addition to diabetes, modifiable laboratory and therapeutic predictors such as anticoagulants, proton pump inhibitors, calcium-containing binders, calcimimetics and iron.

A study to find the causes of diabetic foot infections in a selected community

Background: Ulcerations associated with diabetes are the most common cause of foot infections. Most of these ulcers are a direct result of loss of sensation secondary to peripheral neuropathy. The prevalence of leg ulceration is approximately 1% to 2%, and is slightly higher in the older adult population. Venous ulcers are the most common form of leg ulcers, accounting for almost 80% of all lower extremity ulcerations. Peak prevalence is between 60 and 80 years. Approximately one third of patients with chronic venous insufficiency will develop venous ulceration before the age of 40 years. In addition, venous ulcers may have a prolonged duration and are associated with a high rate of recurrence, which contributes to their prevalence. Approximately 15% of persons with diabetes will develop foot ulceration during their lifetime. Most lower extremity amputations in India are preceded by a foot ulcer. This study is done to find the commonest causes of foot infection in the background of neuropathy among the selected population.Methods: Total of 153 patients were included in this study. Detailed history was taken and all the wounds were classified according to Wagner’s grades. Foot infections in the grade 3,4, 5 (which required debridement/amputations) were included in the study. Foot ulcerations without infections were excluded from the study.Results: 142 (92%) of the patients with infection had diabetic neuropathy. All patients with diabetic neuropathy presented with sensory neuropathy. 33 (21%) patients presented with infection due to previous callus. 52 (33%) patients presented with infection due to previous non-healing ulcer. 20 (13%) patients with deformities developed callus at bony pressure areas due to neuropathy or post-surgery sequel. One patient had hot water burns injury. Five (0.03%) patients had Ingrown nails. 14 (0.09%) patients related to barefoot walking/thorn prick injuries. 6 (0.03%) patients had fungal infection. Two (0.01%) patients had itching and scratching over legs. 15 (0.09%) patients had history of previous amputation. Vigorous massage was the cause in 1 patient (0.006%). Shoe bite injury resulted in foot ulcer in 2 (0.02%) patients. Two (0.02%) patients presented with infection due to deep cracks in heels.Conclusions: Neuropathic changes is the most common cause of diabetic foot infections among which callus, non-healing trophic ulcer and previous amputee are the predominant causes. Patient education has a crucial role in prevention of diabetic foot infections by foot care precautions.

Prospective evaluation of toceranib phosphate in metastatic canine osteosarcoma.

Efficacious therapies for measurable metastatic canine osteosarcoma (OSA) are generally lacking. Preliminary retrospective studies suggested that approximately 50% of dogs with measurable metastatic OSA experienced clinical benefit (objective response or clinically meaningful disease stabilisation) following toceranib (TOC) treatment. The purpose of this clinical trial was to prospectively evaluate the clinical outcome following TOC treatment in dogs with measurable pulmonary metastatic OSA. A secondary goal was to identify potential biomarkers of clinical benefit by measuring changes in plasma vascular endothelial growth factor (VEGF) and circulating regulatory T-cell (Treg) percentage. Twenty-two dogs with pulmonary metastasis from appendicular OSA having undergone previous amputation were treated prospectively with TOC. Adverse events (AEs) were common but predominantly low grade. Nine patients were withdrawn from the study prior to the week 8 assessment of response either due to progressive disease (PD), decreased quality of life or owner perceived unacceptable AEs. Of the patients evaluable for disease progression at week 8 (or earlier), 3/17 (17.6 %) had stable disease with the remainder having PD. The median progression-free survival time for all patients was 57 days (range 7-176 days) with a median overall survival time of 89 days (range 7-574 days). Plasma VEGF concentrations were significantly elevated in patients after 4 weeks of TOC treatment, but no changes were observed in percentage of Treg in peripheral blood. Overall, the results of this clinical trial do not support the use of TOC as single agent therapy for canine metastatic OSA.

Happy Feet in a Rural Clinic: A Diabetic Foot Education Intervention

The prevalence of Type 2 Diabetes is higher in rural areas than in urban areas and this population have more barriers to health care (Rural Healthy People, 2010). Many diabetic patients in disparate population in rural communities do not receive the established diabetes standards of care such as foot screenings and diabetic foot prevention education which contribute to incidence in foot ulcer formation and amputations (Agency for Healthcare Research and Quality, 2008). The complexity of Diabetes requires a multidisciplinary approach which in most cases may not be available in many rural health care settings (Abu Qamar, 2012). Fragmented diabetic patient education leads to non-compliance, diabetic foot ulcer development and subsequent rise in lower limb amputations. Under usage of the diabetes standards of care among disparate population can be addressed by implementation of an evidenced based diabetic foot education intervention. Purpose: The purpose of this study was to determine the effectiveness of a patient-centered diabetes foot education intervention in a rural clinic, designed to improve patients’ knowledge, as evidenced by an increase in the Patient Interpretation of Neuropathy (PIN) scores from pre-intervention to post-intervention. Methods: The participants were clinically diagnosed with type 2 diabetes for at least six months and were less than 70 years of age. Patients were excluded if they were more than 70 years of age, had active foot ulcers, with previous minor or major amputations, or Charcot's joints. The Patient Interpretation of Neuropathy (PIN) questionnaire was used. It is a 73item reliable and valid measurement tool that evaluated type 2 diabetic patients’ level of understanding of the link between foot ulceration, self-care deficit, cognitive and emotional understanding of peripheral neuropathy. A single group pretestposttest quasi-experimental design was used with paired samples t-test which compared mean scores for the same group of participants in two different occasions. To estimate the sample size, a priori, G*Power was used to determine the appropriate number of participants needed to detect a difference between pre and posttest PIN total scores with 95% confidence that the difference was real. Estimated sample size needed for power was N=34. A total of 25 participants completed the education intervention with (n=25) pre-test and (n=25) post-test. Results: There was a significant increase on T2DM patient’s knowledge scores from Pre-educational intervention (M = 261.64, SD = 30.0) to Post educational intervention (M = 327.96, SD = 22.0), t value = 7.952, p = .000 (two-tailed). The Mean difference of the two scores was -66.32, with a 95 percent confidence interval stretching from a lower bound of -83.53334 to an upper bound of -49.10666. The eta squared statistic (.7) indicated an extremely large effect size. Majority of the participants were women which may have increased the probability of female to male ratio. The hypothesis and question posed in this study were both answered YES. The use of the HPM theoretical framework and the selected educational material demonstrated significant changes in knowledge and behavior as evidenced by the statistically significant improvement in diabetic patients’ PIN scores from pre to post implementation of diabetic foot care education intervention. Conclusion: The use of a scientific approach, such as evidence-based practice, plays a crucial role in the provision of appropriate care to patients. The move towards evidenced based practice paves the way for healthcare professionals to move away from long-established style of care delivery to the new paradigm where decisions are driven according to the best evidence available. The hypothesis and question posed in this study were both answered yes. The use of Pender’s health promotion model as theoretical framework and the selected standardized educational materials demonstrated significant changes in the knowledge and behavior of the participants in this study as evidenced by improvement in diabetic patients’ PIN scores from pre to post implementation of a diabetic foot care prevention education. The findings indicated increased knowledge, willingness and motivation, which are important elements that contribute to behavior change in this patient population. Diabetic foot education and prevention among diabetic patients in this rural clinic is essential because the knowledge and skills acquired as a result of the education intervention will have a significant impact in therapeutic outcomes among this patient population.

Clinical characteristics and mortality in patients treated in a Multidisciplinary Diabetic Foot Unit

Background and objectiveThis study reviews the clinical characteristics of patients with diabetic foot ulcer treated in a Multidisciplinary Diabetic Foot Unit (MDFU) and analyzes the mortality and factors associated with its survival. Material and methodsData from all patients who attended the MDFU for the first time for a diabetic foot ulcer during the 2008–2014 period were analized. The patients were followed until their death or until June 30, 2016, for up to 8 years. ResultsA total of 345 patients were included, with a median age (P25–P75) of 71 (61.5–80) years, and 321 (93%) had type 2 diabetes. They were characterized as patients with inadequate glycemic control, 48% had HbA1c≥8% and high prevalence of chronic complications: 60.2% retinopathy, 43.8% nephropathy and 47.2% ischemic heart disease and/or cerebrovascular disease. A total of 126 (36.5%) patients died and 69 (54.8%) were due to cardiovascular disease. Survival measured by Kaplan–Meier declined over time to 69, 60 and 45% at 3, 5 and 7 years respectively. Cox's multivariate regression analysis showed the following variables associated with mortality, HR (95% CI): age 1.08 (1.05–1.11); previous amputation 2.24 (1.34–3.73); active smoking 2.10 (1.12–3.97); cerebrovascular disease 1.75 (1.05–2.92); renal dysfunction 1.65 (1.04–2.61) and ischemic heart disease 1.60 (1.01–2.51). ConclusionsPatients with diabetic foot ulcer are characterized by high morbidity and mortality, with cardiovascular disease being the most frequent cause of death. It is necessary to pay more attention to this risk group, tailoring objectives and treatments to their situation and life expectancy.

Características clínicas y mortalidad de los pacientes atendidos en una Unidad Multidisciplinar de Pie Diabético

Background and objectiveThis study reviews the clinical characteristics of patients with diabetic foot ulcer treated in a Multidisciplinary Diabetic Foot Unit (MDFU) and analyzes the mortality and factors associated with its survival. Material and methodsData from all patients who attended the MDFU for the first time for a diabetic foot ulcer during the 2008-2014 period were analized. The patients were followed until their death or until June 30, 2016, for up to 8 years. ResultsA total of 345 patients were included, with a median age (P25-P75) of 71 (61.5-80) years, and 321 (93%) had type 2 diabetes. They were characterized as patients with inadequate glycemic control, 48% had HbA1c ≥ 8% and high prevalence of chronic complications: 60.2% retinopathy, 43.8% nephropathy and 47.2% ischemic heart disease and/or cerebrovascular disease. A total of 126 (36.5%) patients died and 69 (54.8%) were due to cardiovascular disease. Survival measured by Kaplan-Meier declined over time to 69, 60 and 45% at 3, 5 and 7 years respectively. Cox's multivariate regression analysis showed the following variables associated with mortality, HR (95% CI): age 1.08 (1.05-1.11); previous amputation 2.24 (1.34-3.73); active smoking 2.10 (1.12-3.97); cerebrovascular disease 1.75 (1.05-2.92); renal dysfunction 1.65 (1.04-2.61) and ischemic heart disease 1.60 (1.01-2.51). ConclusionsPatients with diabetic foot ulcer are characterized by high morbidity and mortality, with cardiovascular disease being the most frequent cause of death. It is necessary to pay more attention to this risk group, tailoring objectives and treatments to their situation and life expectancy.