Risk factors for diabetes amputation

NewsBot · Feb 15, 2008

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Epidemiology of diabetic foot problems and predictive factors for limb loss
Aziz Nather , Chionh Siok Bee, Chan Yiong Huak, Jocelyn L.L. Chew, Clarabelle B. Lin, Shuhui Neo and Eileen Y. Sim
Journal of Diabetes and its Complications
Volume 22, Issue 2, March-April 2008, Pages 77-82

Objectives
The aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major amputations (below- and above-knee).

Methods
This is a prospective study of 202 patients treated in National University Hospital (NUH) during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for limb loss were determined using univariate and stepwise logistic regression analysis.

Results
One hundred ninety-two patients had Type 2 diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays (P=.0015) and Indians (P=.036) and significantly lower in Chinese (P<.05). Of patients, 72.8% had poor endocrine control (GHb level >7%), and 42.1% of patients had sensory neuropathy based on 5.07 Semmes–Weinstein Monofilament test.

Common DFP included gangrene (31.7%), infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcot's osteoarthropathy (2.0%).

Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in 6.9%).

Conclusions
This is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP. Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) <0.8, gangrene, infection, and pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression analysis, only PVD and infection were significant.
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Admin2 · Feb 21, 2008

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NewsBot · Jul 29, 2008

Risks of Nontraumatic Lower-Extremity Amputations in Patients with Type 1 Diabetes
A population-based cohort study in Sweden
Diabetes Care 31:1536-1540, 2008

OBJECTIVE—The purpose of this study was to estimate the risks of nontraumatic lower-extremity amputations (LEAs) in patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS—We identified 31,354 patients with type 1 diabetes (15,001 women and 16,353 men) in the Swedish Inpatient Register between 1975 and 2004. The incidence of nontraumatic LEAs was followed up until 31 December 2004 by cross-linkage in the Inpatient Register and linkage to the Death and Migration registers. Poisson regression modeling was used to compare the risks of nontraumatic LEAs during different calendar periods of follow-up, with adjustment for both sex and attained age at follow-up. Standardized incidence ratios (SIRs) were used to estimate the relative risks (RRs) with the age-, sex-, and calendar period–matched general Swedish population as reference. The cumulative probability of nontraumatic LEAs was calculated by the Kaplan-Meier method.

RESULTS—In total, 465 patients with type 1 diabetes underwent nontraumatic LEAs. The risk was lower during the most recent calendar period (2000–2004) than during the period before 2000 (RR 0.6 [95% CI 0.5–0.8]). However, even in this most recent period, the risk for nontraumatic LEAs among these relatively young patients was 86-fold higher than that in the matched general population (SIR 85.8 [72.9–100.3]). By age 65 years, the cumulative probability of having a nontraumatic LEA was 11.0% for women with type 1 diabetes and 20.7% for men with type 1 diabetes.

CONCLUSIONS—Although the risks appeared to have declined in recent years, patients with type 1 diabetes still have a very high risk for nontraumatic LEAs.
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admin · Feb 7, 2009

PULSE PRESSURE AND PREDICTION OF INCIDENT FOOT ULCERS IN TYPE 2 DIABETES.
Monami M, Vivarelli M, Desideri CM, Colombi C, Marchionni N, Mannucci E.
Diabetes Care. 2009 Feb 5. [Epub ahead of print]

Objectives- To assess the relevance of pulse pressure (PP) as a predictor of foot ulcers in type 2 diabetes.

Research design and methods- A cohort study was performed on a consecutive series of 1,945 type 2 diabetic outpatients without foot ulcer at baseline. Incident foot ulcers were identified through the Regional Hospital Discharge system, which contains ICD codes of current diagnoses.

Results- During a mean follow-up of 4.2+/-2.2 years, 86 ulcers were observed. After adjusting for confounders, the highest quartiles of PP had a 2.39[1.14-5.02]-fold risk of foot ulcers. When ischemic ulcers were considered separately, the highest PP quartile was associated with an increased age- and sex-adjusted risk (2.08[1.02-4.24]), whereas no increase of risk was observed for neuropathic ulcers.

Conclusion- Elevated PP represents an independent predictor of foot ulcers in diabetic patients; this parameter should be considered for the stratification of risk of ischemic or neuroischemic ulcers
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NewsBot · Apr 8, 2009

Incidence and characteristics of lower limb amputations in people with diabetes
S. Fosse, A. Hartemann-Heurtier, S. Jacqueminet, G. Ha Van, A. Grimaldi and A. Fagot-Campagna
Diabetic Medicine Volume 26 Issue 4, Pages 391 - 396

Aims To estimate the incidence, characteristics and potential causes of lower limb amputations in France.

Methods Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002–2003 databases.

Results In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes.

Conclusions We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.
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NewsBot · Apr 26, 2009

Incidence and characteristics of lower limb amputations in people with diabetes.
Fosse S, Hartemann-Heurtier A, Jacqueminet S, Ha Van G, Grimaldi A, Fagot-Campagna A.
Diabet Med. 2009 Apr;26(4):391-6.

AIMS: To estimate the incidence, characteristics and potential causes of lower limb amputations in France.

METHODS: Admissions with lower limb amputations were extracted from the 2003 French national hospital discharge database, which includes major diagnoses and procedures performed during hospital admissions. For each patient, diabetes was defined by its record in at least one admission with or without lower limb amputation in the 2002-2003 databases.

RESULTS: In 2003, 17 551 admissions with lower limb amputation were recorded, involving 15 353 persons, which included 7955 people with diabetes. The crude incidence of lower limb amputation in people with diabetes was 378/100 000 (349/100 000 when excluding traumatic lower limb amputation). The sex and age standardized incidence was 12 times higher in people with than without diabetes (158 vs. 13/100 000). Renal complications and peripheral arterial disease and/or neuropathy were reported in, respectively, 30% and 95% of people with diabetes with lower limb amputation. Traumatic causes (excluding foot contusion) and bone diseases (excluding foot osteomyelitis) were reported in, respectively, 3% and 6% of people with diabetes and lower limb amputation, and were 5 and 13 times more frequent than in people without diabetes.

CONCLUSIONS: We provide a first national estimate of lower limb amputation in France. We highlight its major impact on people with diabetes and its close relationship with peripheral arterial disease/neuropathy and renal complications in the national hospital discharge database. We do not suggest the exclusion of traumatic causes when studying the epidemiology of lower limb amputation related to diabetes, as diabetes may contribute to amputation even when the first cause appears to be traumatic.
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NewsBot · Jan 5, 2010

Predictors of amputation in diabetics with foot ulcer: Single center experience in a large Turkish cohort.
Yesil S, Akinci B, Yener S, Bayraktar F, Karabay O, Havitcioglu H, Yapar N, Atabey A, Kucukyavas Y, Comlekci A, Eraslan S.
Hormones (Athens). 2009 Oct-Dec;8(4):286-95.

OBJECTIVE: Prediction of diabetic foot ulcer outcome may be helpful for clinicians in optimizing and individualizing management strategy. The aim of the present study was to examine the possibility of predicting the outcome of patients with diabetic foot ulcers by using easily assessed clinical and laboratory parameters at baseline.

DESIGN: In this observational study, data were collected prospectively in 670 consecutive diabetic foot ulcer episodes in 510 patients examined between January 1999 and June 2008 and were used to evaluate potential predictors of amputation retrospectively. After exclusion of patients who did not come to the hospital for follow-up for a minimum of six months, data of 574 foot ulcer episodes were evaluated.

RESULTS: Limb ischemia, osteomyelitis and presence of gangrene and ulcer depth, determined by the Wagner classification system, were the major independent predictors of overall and major amputations. Older age, presence of coronary artery disease, smoking and ulcer size were found to be associated with either overall or major amputations. Baseline levels of acute phase reactants (white blood cell count, polymorphonuclear leukocyte count, platelet count, erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP) and albumin) and decreased hemoglobin levels were associated with amputation risk. Multivariate analysis showed that one standard deviation increase in baseline CRP and ESR levels were independent predictors of overall and major amputations, respectively.

CONCLUSIONS: The presence of limb ischemia, osteomyelitis, local and diffuse gangrene and ulcer depth were independent predictors of amputation. Baseline levels of ESR and CRP appeared to be helpful for clinicians in predicting amputation.
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NewsBot · Jun 24, 2010

Predictive model of short-term amputation during hospitalization of patients due to acute diabetic foot infections.
Barberán J, Granizo JJ, Aguilar L, Alguacil R, Sainz F, Menéndez MA, Giménez MJ, Martínez D, Prieto J.
Enferm Infecc Microbiol Clin. 2010 May 28. [Epub ahead of print]

INTRODUCTION: Factors predicting short-term amputation during hospital treatment of patients admitted for acute diabetic foot infections are of interest for clinicians managing the acute episode.

METHODS: A retrospective clinical records analysis of 78 consecutive patients hospitalized for acute diabetic foot infections was performed to identify predictive factors for short-term amputation by comparing the data of patients who ultimately required amputation and those who did not. Clinical/epidemiological, laboratory, imaging, and treatment variables were comparatively analyzed. A logistic regression model was performed, with amputation as the dependent variable and factors showing significant differences in the bivariate analysis as independent variables. A prediction score was calculated (and validated by ROC curve analysis) using beta coefficients for significant variables in the regression analysis to predict amputation.

RESULTS: Of the 78 patients (70.5% with peripheral vasculopathy) included, 26 ultimately required amputation. In the bivariate analysis, white blood cell count, previous homolateral lesions, odor, lesion depth, sedimentation rate, Wagner ulcer grade, and arterial obstruction on Doppler study were significantly higher in patients ending in amputation. In the multivariate analysis, the risk of amputation was increased only by Wagner grade 4 or 5 (20-fold higher), obstruction (12.5-fold higher), and elevated sedimentation rate (6% higher per unit). Logistic regression predicted outcome in 76.9% of patients who underwent amputation and 92.3% of those who did not.

CONCLUSION: The score calculated using beta coefficients for significant variables in the regression model (Wagner grades 4 and 5, obstruction on Doppler, and elevated sedimentation rate for the clinical, imaging, and laboratory data, respectively) correctly predicted amputation during hospital management of acute diabetic foot infections
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NewsBot · Sep 22, 2010

Prevalence of diabetic foot syndrome and its risk factors in the UK.
Lauterbach S, Kostev K, Kohlmann T.
J Wound Care. 2010 Aug;19(8):333-7.

Objective: To determine the prevalence of diabetic foot syndrome (DFS) and its risk factors (diabetic neuropathy, peripheral vascular disease, open wounds and mycoses of the feet) at GP practices in the UK in 2008.

Method: We searched the IMS Disease Analyzer database, which stores representative information on approximately 4.2 million patients. All documented diagnoses of diabetes mellitus in 2008, based on either ICD-10 (international classification of diseases) codes or free text comments from doctors, were analysed.

Results: Data from 34,198 patients with type 2 diabetes (47.1% female, mean age 66.1 years [SD 15.1], mean diabetes duration 7.4 years [SD 5.1]) and 2,576 patients with type 1 diabetes (43.2% female, mean age 39.2 years [SD: 18.0], diabetes duration 11.0 years [SD: 6.1]) were analysed. DFS was registered in 7.6% (95% CI: 6.6-8.6) of patients with type 1 diabetes and 8.5% (95% CI: 8.2-8.8) with type 2 diabetes. Many more patients were at high risk of developing DFS, with diabetic neuropathy, diabetic angiopathy, foot mycoses and/or open wounds of the feet.

Conclusion: Results from this analysis of one of the large representative databases show that even though the prevalence of DFS among patients with diabetes mellitus is relatively low, the prevalence of its main risk factors is high. Preventive efforts should target these risk factors
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NewsBot · Oct 22, 2010

Change in amputation predictors in diabetic foot disease: effect of multidisciplinary approach.

Aydin K, Isildak M, Karakaya J, Gürlek A.
Endocrine. 2010 Aug;38(1):87-92.

Diabetic foot disease causes important morbidity in diabetic population, and amputation due to diabetic foot disease occurs more often than in general population. We have been evaluating patients with diabetic foot disease in a multidisciplinary approach since year 2000. In the current study, we sought to investigate the change in amputation rate and its predictors in diabetic foot with a multidisciplinary team approach. Seventy-four patients (52 male, 22 female) hospitalised between January 2002 and December 2007 were retrospectively analysed. Sixteen out of 74 have undergone amputation. We found overall amputation rate as 21.6%, which is lower than previously reported from our institution (36.7 and 39.4%, respectively). Major amputations (syme, below-knee, above-knee) were applied to 11 patients (14.9%). A logistic regression model including osteomyelitis, peripheral neuropathy, peripheral vascular disease, hypertension, gangrene and age revealed that gangrene is now the only significant predictor for amputation. Our observations confirm that amputation rate has declined after implementation of a multidisciplinary team work, and risk factors apart from presence of gangrene are no longer amputation predictors in our centre
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NewsBot · Jan 12, 2011

Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation.
van Battum P, Schaper N, Prompers L, Apelqvist J, Jude E, Piaggesi A, Bakker K, Edmonds M, Holstein P, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, van Acker K, van Baal J, Ferreira I, Huijberts M.
Diabet Med. 2011 Feb;28(2):199-205

Objectives The incidence of minor amputation may vary significantly, and determinants of minor amputation have not been studied systematically. We evaluated minor amputation rate, the determinants of minor amputation and differences in amputation rate between European centres.

Methods In the Eurodiale study, a prospective cohort study of 1232 patients (1088 followed until end-point) with a new diabetic foot ulcer were followed on a monthly basis until healing, death, major amputation or up to a maximum of 1 year. Ulcers were treated according to international guidelines. Baseline characteristics independently associated with minor amputation were examined using multiple logistic regression modelling. Based on the results of the multivariable analysis, a disease severity score was calculated for each patient.

Results One hundred and ninety-four (18%) patients underwent a minor amputation. Predictors of minor amputation were depth of the ulcer (odds ratio 6.08, confidence interval 4.10-9.03), peripheral arterial disease (odds ratio 1.84, confidence interval 1.30-2.60), infection (odds ratio 1.56, confidence interval 1.05-2.30) and male sex (odds ratio 1.42, confidence interval 0.99-2.04). Minor amputation rate varied between 2.4 and 34% in the centres. Minor amputation rate in centres correlated strongly with disease severity score at the moment of presentation to the foot clinic (r = 0.75).

Conclusions Minor amputation is performed frequently in diabetic foot centres throughout Europe and is determined by depth of the ulcer, peripheral arterial disease, infection and male sex. There are important differences in amputation rate between the European centres, which can be explained in part by severity of disease at presentation. This may suggest that early referral to foot clinics can prevent minor amputations.
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NewsBot · Apr 8, 2011

Incidence, risk factors for amputation among patients with diabetic foot ulcer in a Chinese tertiary hospital.
Li X, Xiao T, Wang Y, Gu H, Liu Z, Jiang Y, Liu Y, Lu Z, Yang X, Lan Y, Xu Z.
Diabetes Res Clin Pract. 2011 Apr 3. [Epub ahead of print]

OBJECTIVES: The aim of this study was to evaluate the incidence of amputation among patients with diabetic foot ulcer (DFU) and risk factors for amputations.

METHODS: This is a retrospective study of 450 inpatients treated in a multi-discipline based diabetic centre, 306th Hospital of PLA during the period of January 2000-September 2009. Hospital admission and discharge information including patient profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. The risk factors for amputation were determined using univariate and stepwise logistic regression analysis.

RESULTS: The overall amputation rate among DFU was 21.5%. Significant univariate risk factors for amputation were peripheral vascular disease (PVD), white blood cell (WBC) counts, neutrophil granulocyte percentage, hemoglobin, triglyceride, cholesterol, LDL-C, HDL-C and serum sCRP. Upon stepwise logistic regression analysis, only PVD (odds ratio 4.529, 95% CI 1.500-13.676), WBC (odds ratio 1.146, 95% CI 1.075-1.222), sCRP (odds ratio 1.041, 95% CI 1.002-1.082) and triglyceride (odds ratio -0.488, 95% CI 0.433-0.869) were significant risk factors.

CONCLUSIONS: The risk factors for amputation were presence of PVD, increased WBC, sCRP and decreased triglyceride.
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NewsBot · Jun 3, 2011

Assessing risk of lower extremity amputations using an administrative data-based foot risk index in elderly patients with diabetes.
Helmer D, Tseng CL, Wrobel J, Tiwari A, Rajan M, Pogach L, Sambamoorthi U, Feinglass J.
J Diabetes. 2011 May 7. doi: 10.1111/j.1753-0407.2011.00135.x. [Epub ahead of print]

Objectives: Our objects in this study were to derive a foot risk index using administrative data similar to the International Working Group on the Diabetic Foot clinical risk classification scheme, and to evaluate its association with risk of initial through foot or above amputations.

Methods: This is an analysis of merged Veterans Health Administration administrative and Medicare inpatient and outpatient claims data for a historical cohort of Veterans Health Administration users with diabetes. We classified individuals with diabetes, aged 67 and over in 1999, into seven foot risk categories (0-no foot risk conditions to 6-severe foot conditions) of different severity. The outcome variable was incidence of an initial lower extremity-through foot or above- amputation (ILEA) in a five-year period, 2000-2004. Foot risk was derived from 1998 and 1999, and other independent variables, from 1999. We evaluated the associations between foot risk category and risk of ILEAs using Cox proportional hazards regression models.

Results: Of 255,534 individuals with diabetes, 54.8% had a documented foot condition in 1999; 6,869 (26.9 per 1,000) had an ILEA in years 2000-2004. We found increased rates of ILEAs as foot risk increased. Based on a Cox regression model containing all independent variables, the hazard ratios for risk of amputation progressively increased from 1.13 (1.00-1.28) for the lowest foot risk category to 6.75 (6.31-7.23) for the highest foot risk category, when compared to individuals without defined foot conditions.

Conclusions: An administrative data-derived foot risk category was associated with risk of ILEAs in a risk level-dependent pattern.
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NewsBot · Jul 25, 2011

Developing and Validating a Risk Score for Lower-Extremity Amputation in Patients Hospitalized for a Diabetic Foot Infection
Benjamin A. Lipsky et al
Diabetes Care August 2011 vol. 34 no. 8 1695-1700

OBJECTIVE Diabetic foot infection is the predominant predisposing factor to nontraumatic lower-extremity amputation (LEA), but few studies have investigated which specific risk factors are most associated with LEA. We sought to develop and validate a risk score to aid in the early identification of patients hospitalized for diabetic foot infection who are at highest risk of LEA.

RESEARCH DESIGN AND METHODS Using a large, clinical research database (CareFusion), we identified patients hospitalized at 97 hospitals in the U.S. between 2003 and 2007 for culture-documented diabetic foot infection. Candidate risk factors for LEA included demographic data, clinical presentation, chronic diseases, and recent previous hospitalization. We fit a logistic regression model using 75% of the population and converted the model coefficients to a numeric risk score. We then validated the score using the remaining 25% of patients.

RESULTS Among 3,018 eligible patients, 21.4% underwent an LEA. The risk factors most highly associated with LEA (P < 0.0001) were surgical site infection, vasculopathy, previous LEA, and a white blood cell count >11,000 per mm3. The model showed good discrimination (c-statistic 0.76) and excellent calibration (Hosmer-Lemeshow, P = 0.63). The risk score stratified patients into five groups, demonstrating a graded relation to LEA risk (P < 0.0001). The LEA rates (derivation and validation cohorts) were 0% for patients with a score of 0 and ~50% for those with a score of ≥21.

CONCLUSIONS Using a large, hospitalized population, we developed and validated a risk score that seems to accurately stratify the risk of LEA among patients hospitalized for a diabetic foot infection. This score may help to identify high-risk patients upon admission.
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NewsBot · Sep 20, 2011

Predictive factors for lower extremity amputations in diabetic foot infections
Zameer Aziz, Wong Keng Lin, Aziz Nather, Chan Yiong Huak
Diabetic Foot & Ankle 2011, 2: 7463 - DOI: 10.3402/dfa.v2i0.7463

The objective of this study was to evaluate the epidemiology of diabetic foot infections (DFIs) and its predictive factors for lower extremity amputations. A prospective study of 100 patients with DFIs treated at the National University Hospital of Singapore were recruited in the study during the period of January 2005- June 2005. A protocol was designed to document patient’s demographics, type of DFI, presence of neuropathy and/or vasculopathy and its final outcome. Predictive factors for limb loss were determined using univariate and stepwise logistic regression analysis. The mean age of the study population was 59.8 years with a male to female ratio of about 1:1 and with a mean follow-up duration of about 24 months. All patients had type 2 diabetes mellitus. Common DFIs included abscess (32%), wet gangrene (29%), infected ulcers (19%), osteomyelitis (13%), necrotizing fasciitis (4%) and cellulitis (3%). Thirteen patients were treated conservatively, while surgical debridement or distal amputation was performed in 59 patients. Twenty-eight patients had major amputations (below or above knee) performed. Forty-eight percent had monomicrobial infections compared with 52% with polymicrobial infections. The most common pathogens found in all infections (both monomicrobial and polymicrobial) were Staphylococcus aureus (39.7%), Bacteroides fragilis (30.3%), Pseudomonas aeruginosa (26.0%) and Streptococcus agalactiae (21.0%). Significant univariate predictive factors for limb loss included age above 60 years, gangrene, ankle-brachial index (ABI)<0.8, monomicrobial infections, white blood cell (WBC) count ?15.0x109/L, erythrocyte sedimentation rate ?100 mm/hr, C-reactive protein 15.0 mg/dL, hemoglobin (Hb) ?10.0g/dL and creatinine ?150 mmol/L. Upon stepwise logistic regression, only gangrene, ABI <0.8, WBC ?15.0x109/L and Hb ?10.0g/dL were significant.
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NewsBot · Oct 12, 2011

Risk factors for lower extremity amputation among patients with diabetes in Singapore.
Yang Y, Ostbye T, Tan SB, Abdul Salam ZH, Ong BC, Yang KS.
J Diabetes Complications. 2011 Oct 7. [Epub ahead of print]

BACKGROUND:
Among other risk factors, renal disease and ethnicity have been associated with diabetic lower extremity amputation (LEA) in Western populations. However, little is known about risk factors for LEA among Asian patients.

OBJECTIVE:
The objective was to assess the proportion of hospitalized patients with diabetes who have a LEA among all hospital patients with diabetes mellitus (DM) and to investigate risk factors for diabetic LEA (especially renal disease and ethnicity) using hospital discharge database.

METHOD:
A retrospective study of hospital discharge database (2004-2009) was performed to identify patients with DM, LEA and renal disease using the International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Australian Modification codes.

RESULTS:
Of 44 917 hospitalized patients with DM during the 6 years, 7312 (16.3%) patients had renal disease, and 1457 (3.2%) patients had LEA. DM patients with renal disease had significant higher rates of LEA (7.1%) compared to DM patients without renal disease (2.5%, P<.001). The differences were present for foot (2.7% vs. 1.2%), ankle or leg (2.8% vs. 0.9%), and knee or above amputation (1.6% vs. 0.4%, all P<.001). Malays had the highest rate of diabetic LEA (5.1%), followed by Indians (3.0%), Chinese (3.0%), and others (2.3%, P<.001). In logistic regression analyses, renal disease and ethnicity were significant predictors of diabetic LEA (renal disease: odds ratio 3.2, 95% confidence interval 2.8-3.6; ethnicity: odds ratio, 1.6, Malays vs. Chinese, P<.001; 1.0, Indians vs. Chinese, P=.784) after adjustment for age, gender, and year of discharge.

CONCLUSION:
DM patients with renal disease and Malay ethnicity had higher rates of LEA in this Asian patient population. Malay patients with DM and diabetic patients with renal disease should be considered as high-risk groups for LEA and therefore screened and monitored systematically.
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NewsBot · Nov 15, 2011

Incidence, risk factors for amputation among patients with diabetic foot ulcer in a North Indian tertiary care hospital.
Zubair M, Malik A, Ahmad J.
Foot (Edinb). 2011 Nov 11.

OBJECTIVE:
Aim of this study was to evaluate the incidence and risk factors for amputation among patients with diabetic foot ulcer (DFU).

RESEARCH DESIGN AND METHODS:
We performed a prospective study of 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology centre of Jawaharlal Nehru Medical College of Aligarh Muslim University, Aligarh, India during the period of December 2008-March 2011. Detailed history and physical examination was carried out for every subject. Risk factors for amputation were determined by univariate analysis with 95% of CI.

RESULTS:
The overall amputation rate was 28.4%. On univariate analysis, male sex [OR 2.8, RR 1.28], hypertension [OR 2.83, RR 1.31], neuropathy [OR 3.01, RR 1.35], nephropathy [OR 2.24, RR 1.26], LDL-C (>100mg/dl) [OR 2.53, RR 1.28], total cholesterol (>150mg/dl) [OR 3.74, RR 1.52],HDLC(<40mg/dl) [OR 1.19, RR 1.18], triglycerides (>200mg/dl) [OR 5.44, RR1.76], previous antibiotic use [OR 9.12, RR 1.92], osteomyelitis [OR 6.97, RR 2.43] and biofilm infection [OR 4.52, RR 1.41] were significant risk factors.

CONCLUSION:
The risk factors for amputation were presence of PVD, leukocytosis, neuropathy, nephropathy, hypertension, dyslipidemia, over use of antibiotics, osteomyelitis, biofilm production and higher grade of ulcer.
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NewsBot · Nov 27, 2011

Risk factors for lower extremity amputation in diabetic foot disease categorized by Wagner classification.
Sun JH, Tsai JS, Huang CH, Lin CH, Yang HM, Chan YS, Hsieh SH, Hsu BR, Huang YY.
Diabetes Res Clin Pract. 2011 Nov 22.

AIMS:
To elucidate the risk factors for lower extremity amputation (LEA) in patients of diabetic foot disease with different Wagner gradings.

METHODS:
This study was conducted in a multidisciplinary diabetic foot care center. Demographic characteristics, laboratory data, disease history, ankle brachial pressure index (ABI) and Wagner classification were considered as independent variables to predict the therapeutic outcome (major LEA, minor LEA, and non-amputation). Risk factors for LEA in different Wagner grades were further analyzed. Multivariate stepwise ordinal logistic regression was performed.

RESULTS:
Of 789 study subjects, 19.9% received major LEA and 22.9% received minor LEA. Higher Wagner grade, lower ABI, serum albumin and hemoglobin, and elevated white blood cell (WBC) count were significantly associated with an increased risk of LEA. When stratified by Wagner classification, most of the above predictors and estimated glomerular filtration (eGFR) were detected only in grade 3. While in grades 2 and 4, WBC count was identified as primary predictor positively associated with an increased risk of LEA.

CONCLUSIONS:
Wagner classification remarkably influenced the potential risk factors for LEA, showing different predictors in different grades. The traditionally recognized predictors for diabetic foot amputation such as lower ABI, albumin or eGFR were almost exclusively found in patients with Wagner grade 3.
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NewsBot · Feb 22, 2012

Risk factors for lower extremity amputation in diabetic foot disease categorized by Wagner classification
Jui-Hung Sun et al
Diabetes Research and Clinical Practice; Volume 95, Issue 3, March 2012, Pages 358–363

Aims
To elucidate the risk factors for lower extremity amputation (LEA) in patients of diabetic foot disease with different Wagner gradings.

Methods
This study was conducted in a multidisciplinary diabetic foot care center. Demographic characteristics, laboratory data, disease history, ankle brachial pressure index (ABI) and Wagner classification were considered as independent variables to predict the therapeutic outcome (major LEA, minor LEA, and non-amputation). Risk factors for LEA in different Wagner grades were further analyzed. Multivariate stepwise ordinal logistic regression was performed.

Results
Of 789 study subjects, 19.9% received major LEA and 22.9% received minor LEA. Higher Wagner grade, lower ABI, serum albumin and hemoglobin, and elevated white blood cell (WBC) count were significantly associated with an increased risk of LEA. When stratified by Wagner classification, most of the above predictors and estimated glomerular filtration (eGFR) were detected only in grade 3. While in grades 2 and 4, WBC count was identified as primary predictor positively associated with an increased risk of LEA.

Conclusions
Wagner classification remarkably influenced the potential risk factors for LEA, showing different predictors in different grades. The traditionally recognized predictors for diabetic foot amputation such as lower ABI, albumin or eGFR were almost exclusively found in patients with Wagner grade 3.
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NewsBot · Jul 31, 2012

Identifying the Incidence of and Risk Factors for Reamputation Among Patients Who Underwent Foot Amputation.
Kono Y, Muder RR.
Ann Vasc Surg. 2012 Jul 25.

BACKGROUND:
Many patients who have lower-extremity amputations secondary to peripheral vascular disease or diabetes require reamputation eventually. This study was designed to identify the incidence of and risk factors for ipsilateral reamputation after forefoot amputation, to evaluate whether postoperative infection increases the risk of reamputation, and to evaluate whether the risk of reamputation was reduced by the duration of antimicrobial therapy after amputation.

METHODS:
A retrospective analysis of patients who underwent foot amputation for nontraumatic reason from January 2002 to December 2004 at the Veterans Affairs Pittsburgh Healthcare System was performed.

RESULTS:
Among 116 patients, 57 (49.1%) had ipsilateral reamputation within 3 years after their first surgeries; 78.9% received reamputation in the first 6 months; 53 (45.7%) died within 3 years; and 16 (13.8%) developed postoperative infections. Upper level of amputation, long duration of hospitalization, insulin-dependent diabetes, and gangrene on physical examination on admission were risk factors for reamputation in univariate analysis. Gangrene (odds ratio: 3.81, 95% confidence interval: 1.60-9.12, P = 0.003) and insulin-dependent diabetes (odds ratio: 2.93, 95% confidence interval: 1.26-6.78, P = 0.012) were risk factors in multivariate analysis. Postoperative infection did not increase the risk of reamputation. Longer than 2-week course of antibiotic use after amputation did not prevent reamputation.

CONCLUSIONS:
Approximately one-half of patients required ipsilateral reamputation and died in 3 years. Gangrene on admission and history of insulin-dependent diabetes were significant risk factors (P = 0.003, P = 0.028). Long duration of antibiotic use after amputation and postoperative infection did not change the risk of reamputation.
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NewsBot · Aug 4, 2012

Press Release:
Contralateral Amputation Predicts Worse Outcomes for Lower Extremity Bypasses
Intact limbs with critical limb ischemia studied; bypasses show more adverse events and complications

Researchers from the Vascular Study Group of New England (VSGNE) report that prior contralateral amputation predicts worse outcomes for lower extremity bypasses (LEB's) performed in the intact limb.“This is the first study conducted that suggests contralateral amputation as a predictor of outcomes after LEB for critical limb ischemia (CLI),” said co-author Donald T. Baril, MD, assistant professor in the division of vascular and endovascular surgery at the University of Massachusetts Medical School in Worchester.

A retrospective analysis of all patients undergoing infrainguinal LEB for CLI between 2003 and 2010 within hospitals comprising the Vascular Study Group of New England was performed. Patients were stratified according to whether or not they had previously undergone a contralateral major or minor amputation before LEB. Primary end points included major amputation and graft occlusion at one year postoperatively. Secondary end points included in-hospital major adverse events, discharge status and mortality at one year.

Of 2,636 LEB procedures, 228 (8.6 percent) were performed in the setting of a prior contralateral amputation. Patients with a prior amputation compared to those without were more likely to have congestive heart failure (CHF) (25 percent vs. 16 percent), hypertension (94 percent vs. 85 percent), renal insufficiency (26 percent vs. 14 percent), and hemodialysis-dependent renal failure (14 percent vs. 6 percent). These patients were younger (66.5 vs. 68.7 percent), more likely to be nursing home residents (8 percent vs. 3.6 percent), less likely to ambulate without assistance (41 percent vs. 80 percent) and more likely to have had a prior ipsilateral bypass (20 percent vs. 12 percent).

Patients with prior amputation experienced increased in-hospital major adverse events, including myocardial infarction (8.9 percent vs. 4.2 percent), CHF (6.1 percent vs. 3.4 percent), deterioration in renal function (9.0 percent vs. 4.7 percent), and respiratory complications (4.2 percent vs. 2.3 percent). They were less likely to be discharged home (52 percent vs. 72 percent) or to be ambulatory on discharge (25 percent vs. 55 percent). Although patients with a prior contralateral amputation experienced increased rates of graft occlusion (38 percent vs.17 percent) and major amputation (16 percent vs. 7 percent) at one year, there was not a significant difference in mortality (16 percent vs. 10 percent).

On multivariable analysis, prior contralateral amputation was an independent predictor of both major amputation (odds ratio, 1.73; confidence interval, 1.06-2.83) and graft occlusion (odds ratio, 1.93; confidence interval, 1.39-2.68) at one year.

“Our study shows that patients with prior contralateral amputations who present with CLI in the intact limb represent a high-risk population with increased comorbidity rates compared to those without, even among patients with advanced peripheral arterial disease," said Dr. Baril. “Physicians and patients should expect increased rates of perioperative adverse events, increased rates of one-year graft occlusion and increased rates of limb loss when compared with patients who have not had a prior contralateral amputation. The presence of a prior contralateral amputation, along with other known predictors of LEB failure should be factored into the decision when selecting a treatment for lower extremity occlusive disease.”
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NewsBot · Sep 5, 2012

Incidence and risk factors of amputation among inpatients with diabetic foot
Fei YF, Wang C, Chen DW, Li YH, Lin S, Liu GJ, Ran XW.
Zhonghua Yi Xue Za Zhi. 2012 Jun 26;92(24):1686-9.

OBJECTIVE:
To evaluate the incidence and risk factors of lower extremity amputation among inpatients with diabetic foot.

METHODS:
For this retrospective study, a total of 685 inpatients with diabetic foot (Wagner grade 1-5) admitted at a multi-disciplinary Diabetic Foot Care Center, West China Hospital, Sichuan University during January 1, 2005 and June 30, 2011. The data of each patient including clinical information, laboratory results and final outcome were collected and analyzed. They were divided into non-amputated and amputated groups. And the latter included minor and major amputation groups according to amputation site.

RESULTS:
The overall amputation rate was 11.4% in diabetic foot inpatients. The incidences of minor amputation and major amputation were 5.4% and 6.0% respectively. 17.9% of amputated patients experienced a second amputation. The amputated patients had a longer hospitalized stay, higher counts of white blood cells and neutrophils, greater HbA1c and lower serum levels of hemoglobin and albumin than the non-amputation patients (P < 0.05). The prevalence of diabetic peripheral neuropathy was significantly higher in the amputation group than that in the non-amputation group (P < 0.05). However, no difference existed between the minor and major amputation groups (P > 0.05). Ankle brachial index (ABI) in the amputation group was significantly lower than that in the non-amputation group (0.41 ± 0.25 vs 0.91 ± 0.36, P < 0.01). Minor and major amputation inpatients had similar ABI (0.43 ± 0.24 vs 0.39 ± 0.26, P = 0.087). Ordinal regression showed that HbA1c (P = 0.015), ABI (P = 0.016), history of amputation (P < 0.01) and Wagner grade of diabetic foot (P < 0.01) were the independent risk factors of amputation.

CONCLUSIONS:
Diabetic foot inpatients have a higher rate of lower extremity amputation. The risk factors of amputation include HbA1c, ABI, history of amputation and Wagner grade of diabetic foot. And diabetic peripheral neuropathy, ischemia of lower limbs (especially peripheral arterial diseases below knees), infection and nutritional state are closely associated with amputation of diabetic foot inpatients.
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NewsBot · Nov 6, 2012

Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients.
Moura Neto A, Zantut-Wittmann DE, Fernandes TD, Nery M, Parisi MC.
Endocrine. 2012 Nov 3.

Treatment strategies for foot at risk and diabetic foot are mainly preventive. Studies describing demographic data, clinical and impacting factors continue to be, however, scarce. Our objective was to determine the epidemiological presentation of diabetic foot and understand whether there were easily assessable variables capable of predicting the development of diabetic foot. This was a retrospective study of 496 patients with established foot at risk or diabetic foot, who were evaluated based on age, gender, type and duration of diabetes, foot at risk classification, and the presence of deformities, ulceration, and amputation. The presence of deformities, ulceration, and amputation was recorded in 45.9, 25.3, and 12.9 % of patients, respectively. As for diabetic foot classification, the great majority of our cohort had diabetic neuropathy (92.9 %). Approximately 30 % had neuro-ischemic disease and only 7.1 % had ischemic disease alone. Sixty-two percent of patients presented neuropathy with no signs of arteriopathy. Foot classification was as a significant predictor for the presence of ulcer (p = 0.009; OR = 3.2; 95 % CI = 1.18-7.3). Only male gender was a significant predictor for ulceration (p < 0.001). Predictors of amputation were male gender (p < 0.001; OR = 3.44 95 % CI = 1.81-6.56) and neuro-ischemic diabetic foot (p < 0.049; OR = 4.6; 95 % CI = 1.01-20.9). The predictors for diabetic foot were male gender and the presence of neuropathy. The combination of neuropathy and peripheral vascular disease adds significantly to the risk for amputation among patients with the diabetic foot syndrome. Men, presenting combined risk factors, should be a group receiving special attention and in the foot clinic, due to their potentially worse evolution
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NewsBot · Nov 9, 2012

Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients
Arnaldo Moura Neto, Denise Engelbrecht Zantut-Wittmann, Tulio Diniz Fernandes, Marcia Nery and Maria Candida Ribeiro Parisi
Endocrine: International Journal of Basic and Clinical Endocrinology Published online: 3 November 2012

Treatment strategies for foot at risk and diabetic foot are mainly preventive. Studies describing demographic data, clinical and impacting factors continue to be, however, scarce. Our objective was to determine the epidemiological presentation of diabetic foot and understand whether there were easily assessable variables capable of predicting the development of diabetic foot. This was a retrospective study of 496 patients with established foot at risk or diabetic foot, who were evaluated based on age, gender, type and duration of diabetes, foot at risk classification, and the presence of deformities, ulceration, and amputation. The presence of deformities, ulceration, and amputation was recorded in 45.9, 25.3, and 12.9 % of patients, respectively. As for diabetic foot classification, the great majority of our cohort had diabetic neuropathy (92.9 %). Approximately 30 % had neuro-ischemic disease and only 7.1 % had ischemic disease alone. Sixty-two percent of patients presented neuropathy with no signs of arteriopathy. Foot classification was as a significant predictor for the presence of ulcer (p = 0.009; OR = 3.2; 95 % CI = 1.18–7.3). Only male gender was a significant predictor for ulceration (p < 0.001). Predictors of amputation were male gender (p < 0.001; OR = 3.44 95 % CI = 1.81–6.56) and neuro-ischemic diabetic foot (p < 0.049; OR = 4.6; 95 % CI = 1.01–20.9). The predictors for diabetic foot were male gender and the presence of neuropathy. The combination of neuropathy and peripheral vascular disease adds significantly to the risk for amputation among patients with the diabetic foot syndrome. Men, presenting combined risk factors, should be a group receiving special attention and in the foot clinic, due to their potentially worse evolution.
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NewsBot · Nov 9, 2012

NewsBot said: ↑

Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients
Arnaldo Moura Neto, Denise Engelbrecht Zantut-Wittmann, Tulio Diniz Fernandes, Marcia Nery and Maria Candida Ribeiro Parisi
Endocrine: International Journal of Basic and Clinical Endocrinology Published online: 3 November 2012
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Press Release:
Diabetic foot complication risk highlighted in men

Men should be considered for aggressive treatment for foot complications associated with diabetes, such as ulceration and amputation, say researchers.

The study, published in Endocrine, indicates that male gender may be a significant predictor for diabetic foot outcomes, alongside the well-characterized risk factors for diabetic neuropathy and peripheral vascular disease.

"This difference in gender is attributable to better wound care in women, as men are more commonly involved in heavy physical work activities and deal with more social pressure to keep providing the family income," suggest Maria Candida Ribeiro Parisi (University of Campinias, Brazil) and co-workers.

"Also important, absenteeism is higher among men. These issues cause ulcerations to take longer to recover, being more likely to present at a consult at any given moment, and also more likely to terminate in amputation," they emphasize.

The team reviewed medical records for 496 patients with a diagnosis or risk factors for diabetic foot. The majority of patients had Type 2 diabetes (94%), 48.6% of patients were male, and the average diabetes duration was 16.8 years. Most of the patients were treated with insulin (80.8%), and 67.3% also received oral drugs.

At the last foot clinic visit, 45.9% of patients had diabetic foot deformity, 25.3% had foot ulceration, and 12.9% had undergone amputation. Two-thirds (67.2%) of patients had no present or past history of ulceration or amputation.

Of note, 92.9% of the patients had diabetic neuropathy, 30% had neuro-ischemic disease, and 7.1% had only ischemic disease. Neuropathy with no evidence of arteriopathy was reported in 62% of patients.

Patients with neuro-ischemic symptoms or neuropathy alone were significantly more likely than patients with only ischemic symptoms to have foot deformity (46 and 48 vs 22%), regardless of age, gender, and diabetes duration or type.

Ulceration was significantly more common in men than women (33.0 vs 18.0%), and male gender was the only significant risk factor for ulceration in multivariate analysis (odds ratio [OR]=2.15).

Amputation was also significantly more common in men than women (20 vs 7%), and in patients with neuro-ischemic disease than neuropathy or ischemic disease alone (21 vs 9 and 6%, respectively), with multivariate analysis ORs of 3.44 and 4.6, respectively, for these risk factors.

"We thus believe that older men, presenting combined risk factors should be a group receiving more special attention and aggressive treatment in the foot clinic, due to their potentially worse evolution," Parisi et al conclude.
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NewsBot · Feb 5, 2013

Prognostic Factors of Wound Healing after Diabetic Foot Amputation; ABI, TBI, and Toe Pressure.
Park SJ, Jeong HJ, Kim E, Lee JW.
J Korean Foot Ankle Soc. 2012 Dec;16(4):217-222.

PURPOSE: The purpose of this study is to establish guidelines for ankle-brachial index (ABI), toe-brachial index (TBI) and toe pressure with regard to healing of diabetic foot amputation wound.

MATERIAL AND METHODS: We designed a retrospective study that included patients with diabetic foot ulcer. From 2008 to 2011, 46 patients who had suffered from amputation of a foot due to diabetic foot ulcer were included in this study. We divided them into amputation-success group and amputation-revision group, and compared their ankle-brachial index (ABI), toe-brachial index (TBI) and toe pressure between two groups. Amputation-revision group is that first forefoot amputation is failed to heal successfully and need to have another proximal amputation.

RESULTS: Toe pressure was 78 mmHg (54~107) in the amputation success group, 0 mmHg (0~43) in the amputation revision group (p=0.000). Ankle-brachial index was 1.1650(1.0475~1.1975) in the amputation success group, 0.92(0.5275~1.0750) in the amputation revision group (p=0.05), and toe-brachial index was 0.6100(0.4050~0.7575) in the amputation success group, 0.00(0.00~0.4150) in the amputation revision group (p=0.04), respectively.

CONCLUSION: ABI, TBI, toe pressure of amputation success group were significantly higher than those of amputation revision group.
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NewsBot · Feb 5, 2013

Comprehensive Analysis for Risk Factors of Lower Extremity Amputation as a Treatment of Complicated Diabetic Foot.
Chung HJ, Bae SY, Min BK, Park JG, Kam MC, Choi JW.
J Korean Foot Ankle Soc. 2012 Dec;16(4):257-264.

PURPOSE: The diabetic foot lesions are intractable, and aggravation often leads to amputation. None or minor amputation group was treated debridement or toe amputation and major amputation group was treated Ray, Lisfranc, Chopart, Below Knee and Above Knee amputation. We investigate the risk factors for major limb amputations among patients with diabetic foot lesion.

MATERIALS AND METHODS: The subjects were 73 diabetic foot lesion patients (83 diabetic foot lesions) treated at our department from January 2006 to December 2010. Non or Minor amputation group of 44 cases were treated with debridement or toe amputation. Major amputation group of 39 cases were treated with Ray, Lisfranc, Chopart, below or above Knee amputation. We investigated socioeconomic factors, diabetes mellitus related factors and wound related factors and laboratory factors. Statistical analysis was done by Students t-test, Chi-square test, Mann-Whitney's U test.

RESULTS: In our analysis, wound size, wound classification (Wagner classification, Brodsky classification), white blood cell counts, polymorphoneuclear neutrophil percentage, hemoglobin, C-reactive protein and albumin were risk factors for major amputation (p<0.05).

CONCLUSION: Low education level, nutritional condition, premorbid activity level and progressed wound condition were observed in major amputation group compared with non or minor amputation group. In the major amputation group, higher white blood cell count, C-reactive protein level and lower albumin level were observed. Together with maintenance of adequate nutritional condition, early detection of lesions and foot care for early treatment is important. Therefore, active investigation with full risk evaluation of vascular complication is also important.
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NewsBot · Feb 20, 2013

Reamputation after Minor Foot Amputation in Diabetic Patients: Risk Factors Leading to Limb Loss.
Nerone VS, Springer KD, Woodruff DM, Atway SA.
J Foot Ankle Surg. 2013 Mar;52(2):184-187.

The prevalence of lower extremity reamputation in diabetic patients has been well-documented. We sought to determine the risk factors for major lower extremity amputation (LEA) after minor foot amputation in diabetic patients. We studied 163 diabetic patients who had undergone an initial minor foot amputation and then had undergone at least 1 subsequent major or minor LEA. The patients were separated into a minor LEA group (initial minor LEA followed by at least 1 subsequent minor LEA) and a major LEA group (initial minor LEA followed by at least 1 subsequent major LEA). We then studied the possible risk factors for both groups. The possible risk factors analyzed were age, glycemic control, kidney function, previous kidney or kidney-pancreas transplantation, smoking history, and presence and severity of peripheral arterial disease (PAD). No statistical significance was found between the 2 groups for hemoglobin A1c, smoking status, chronic kidney disease, end-stage renal disease requiring dialysis, kidney or kidney-pancreas transplantation, or vascular intervention (peripheral arterial bypass). In the minor group, 22.23% had severe PAD. In the major group, 71.15% had severe PAD. This was statistically significant (p < .001). The average interval to major amputation in those without PAD, mild to moderate PAD, and severe PAD was 1,180.9, 591.0, and 559.6 days, respectively. This demonstrates the importance of assessing the peripheral vascular status in all diabetic patients with minor LEA. Early referral to a vascular surgeon might delay (or prevent) major LEA.
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NewsBot · Feb 26, 2013

Risk factors for ulceration and amputation in diabetic foot: study in a cohort of 496 patients.
Moura Neto A, Zantut-Wittmann DE, Fernandes TD, Nery M, Parisi MC
Endocrine

Treatment strategies for foot at risk and diabetic foot are mainly preventive. Studies describing demographic data, clinical and impacting factors continue to be, however, scarce. Our objective was to determine the epidemiological presentation of diabetic foot and understand whether there were easily assessable variables capable of predicting the development of diabetic foot. This was a retrospective study of 496 patients with established foot at risk or diabetic foot, who were evaluated based on age, gender, type and duration of diabetes, foot at risk classification, and the presence of deformities, ulceration, and amputation. The presence of deformities, ulceration, and amputation was recorded in 45.9, 25.3, and 12.9 % of patients, respectively. As for diabetic foot classification, the great majority of our cohort had diabetic neuropathy (92.9 %). Approximately 30 % had neuro-ischemic disease and only 7.1 % had ischemic disease alone. Sixty-two percent of patients presented neuropathy with no signs of arteriopathy. Foot classification was as a significant predictor for the presence of ulcer (p = 0.009; OR = 3.2; 95 % CI = 1.18-7.3). Only male gender was a significant predictor for ulceration (p < 0.001). Predictors of amputation were male gender (p < 0.001; OR = 3.44 95 % CI = 1.81-6.56) and neuro-ischemic diabetic foot (p < 0.049; OR = 4.6; 95 % CI = 1.01-20.9). The predictors for diabetic foot were male gender and the presence of neuropathy. The combination of neuropathy and peripheral vascular disease adds significantly to the risk for amputation among patients with the diabetic foot syndrome. Men, presenting combined risk factors, should be a group receiving special attention and in the foot clinic, due to their potentially worse evolution.
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NewsBot · Mar 26, 2013

Amputations and foot ulcers in patients newly diagnosed with Type 2 diabetes mellitus and observed for 19 years. The role of age, gender and co-morbidity
C. Bruun, V. Siersma, A. D. Guassora, P. Holstein, N. de Fine Olivarius
Diabetic Medicine (in press)

Aims
To determine the prevalence of foot ulcers and the incidence of amputations in patients with Type 2 diabetes observed for 19 years after diagnosis. We investigated the role of gender, age and co-morbidities.

Methods
From the Diabetes Care in General Practice study, 1381 patients were included and examined at diabetes diagnosis, at 6 years and at 14 years after diagnosis. Register-based follow-up was for 19 years. Foot ulcers and amputations were related to gender, age and co-morbidities by odds and hazard ratios from logistic and Cox regression models, respectively.

Results
The incidence of any amputation and major amputation was 400 (95% CI 307–512) and 279 (95% CI 203–375) per 100 000 patient-years, respectively. At the three observation points, the foot ulcer prevalences were 2.76% (95% CI 1.89–3.63), 2.93% (95% CI 1.86–4.00) and 4.96% (95% CI 3.10–6.82). Multivariate analyses showed associations between foot ulcers and peripheral neuropathy, peripheral arterial disease, male gender, retinopathy and myocardial infarction. After multivariate adjustment, significant predictors (hazard ratio; 95% CI) of any amputation were peripheral neuropathy (hazard ratio 2.09; 95% CI 1.19–3.69), peripheral arterial disease (hazard ratio 3.43; 95% CI 1.65–7.12), microalbuminuria (hazard ratio 2.11; 95% CI 1.21–3.67), retinopathy (hazard ratio 6.42; 95% CI 2.59–15.90), impaired vision (hazard ratio 6.92; 95% CI 2.35–20.38) and male gender (hazard ratio 2.40; 95% CI 1.31–4.41). For women, the risk of amputation increased with age, but for men the risk was higher when diagnosed with diabetes at a younger age.

Conclusions
Despite improved treatment regimens, the incidence of amputations is still high in this population-based patient sample. Men diagnosed with diabetes before age 65 years and patients with diabetes-related co-morbidities are at particularly high risk of foot ulcers and amputations.
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NewsBot · Mar 26, 2013

Diabetes related amputations in Pacific Islands countries: A root cause analysis of precipitating events.
Win Tin ST, Gadabu E, Iro G, Tasserei J, Colagiuri R.
Diabetes Res Clin Pract. 2013 Mar 21.

AIM:
To identify precipitating events and factors preceding diabetes related amputations in Pacific Islands countries (PICs).

METHODS:
Using a root cause analysis approach, a questionnaire seeking information on events leading up to amputation was administered to a convenience sample of 85 people with diabetes in three PICs (Solomon Islands, Nauru and Vanuatu) who had a lower limb amputation in the previous five years.

RESULTS:
There were 85 participants (36% females) with a mean age of 54.1 years and a mean diabetes duration of 10.5years prior to amputation. The first event was trauma and an infected wound in 55% and a blister in another 41%. Half (51%) did take any action soon after the initial trigger event. The major reasons leading to the amputation included delaying treatment (42%), use of traditional treatments (18%) and insufficient knowledge about foot care (11%). 36% of participants had not received foot care information prior to the amputation and 19% did not attend anywhere for regular treatment.

CONCLUSIONS:
This study identified key precipitating events and underlying factors which contribute to diabetes related amputations and which, if addressed successfully, have the potential to reduce amputations rates.
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NewsBot · Jul 5, 2013

Determinants of lower extremity amputations: an institutional experience.
Soomro N, Khan M, Ahmed SI, Minhas MA.
J Coll Physicians Surg Pak. 2013 Jul;23(7):491-4.

Objective: To determine the determinants of lower extremity amputations in diabetics and non-diabetics in a tertiary care institute.

Study Design: Cross-sectional, analytical study.

Place and Duration of Study: Outpatients Department of the Institute of Physical Medicine and Rehabilitation, Dow University of Health Sciences, Karachi, from January 2007 to December 2010.

Methodology: All patients with amputations reporting at the study centre for prosthesis fitting were included in the study. Patient`s age, level of amputation, stump complications and associated risk factors of amputation were recorded on a structured proforma. Prosthesis and orthotic assessment were carried out. The frequency and determinants were collected to compare diabetic and non-diabetic amputees. The data was analyzed in SPSS windows version 16.

Results: A total of 1091 subjects were provided prosthesis, including 847 males (77.6%). Mean age in diabetic and nondiabetics being 49.6 ± 15.2 and 26.6 ± 17.9 years respectively which is significant at (p < 0.001). Socioeconomic status and educational levels were significantly associated with diabetic status (p < 0.001). Amputation was more common in non-diabetic 858 (78.6%) compared to diabetics 233 (21.4%).

Conclusion: This study has identified that most common and significant predictors were gender, low social status and educational levels. Other significant predictors of amputation identified were type of lesion, (infections and ischaemia), initial diagnosis acute/chronic arterial insufficiency and diabetic foot.
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NewsBot · Aug 8, 2013

Fate of the contralateral limb after lower extremity amputation
Julia D. Glaser, et al
Journal of Vascular Surgery; Article in Press

Objective
Lower extremity amputation is often performed in patients where both lower extremities are at risk due to peripheral arterial disease or diabetes, yet the proportion of patients who progress to amputation of their contralateral limb is not well defined. We sought to determine the rate of subsequent amputation on both the ipsilateral and contralateral lower extremities following initial amputation.

Methods
We conducted a retrospective review of all patients undergoing lower extremity amputation (exclusive of trauma or tumor) at our institution from 1998 to 2010. We used International Classification of Diseases-Ninth Revision codes to identify patients and procedures as well as comorbidities. Outcomes included the proportion of patients at 1 and 5 years undergoing contralateral and ipsilateral major and minor amputation stratified by initial major vs minor amputation. Cox proportional hazards regression analysis was performed to determine predictors of major contralateral amputation.

Results
We identified 1715 patients. Mean age was 67.2 years, 63% were male, 77% were diabetic, and 34% underwent an initial major amputation. After major amputation, 5.7% and 11.5% have a contralateral major amputation at 1 and 5 years, respectively. After minor amputation, 3.2% and 8.4% have a contralateral major amputation at 1 and 5 years while 10.5% and 14.2% have an ipsilateral major amputation at 1 and 5 years, respectively. Cox proportional hazards regression analysis revealed end-stage renal disease (hazard ratio [HR], 3.9; 95% confidence interval [CI], 2.3-6.5), chronic renal insufficiency (HR, 2.2; 95% CI, 1.5-3.3), atherosclerosis without diabetic neuropathy (HR, 2.9; 95% CI, 1.5-5.7), atherosclerosis with diabetic neuropathy (HR, 9.1; 95% CI, 3.7-22.5), and initial major amputation (HR, 1.8; 95% CI, 1.3-2.6) were independently predictive of subsequent contralateral major amputation.

Conclusions
Rates of contralateral limb amputation are high and predicted by renal disease, atherosclerosis, and atherosclerosis with diabetic neuropathy. Physicians and patients should be alert to the high risk of subsequent amputation in the contralateral leg. All patients, but particularly those at increased risk, should undergo close surveillance and counseling to help prevent subsequent amputations in their contralateral lower extremity.
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NewsBot · Sep 17, 2013

Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)
Laura N. McEwen, Kelly R. Ylitalo, William H. Herman, James S. Wrobel
Journal of Diabetes and its Complications; Available online 10 September 2013

Aims
The objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors.

Methods
We assessed the period prevalence of foot complications on 6992 patients using ICD-9 diagnosis codes from health plan administrative data. Demographic and biological variables were ascertained from surveys and medical record reviews. We defined four mutually exclusive groups: any Charcot foot, DFU with debridement, amputation ± DFU and debridement, and no foot conditions.

Results
Overall, 55 (0.8%) patients had Charcot foot, 205 (2.9%) had DFU with debridement, and 101 (1.4%) had a lower-extremity amputation. There were 6631 patients with no prevalent foot conditions. Racial/ethnic minorities were less likely to have Charcot foot (OR = 0.21; 95% CI: 0.10, 0.46) or DFU (OR = 0.61; 95% CI: 0.44, 0.84) compared to non-Hispanic Whites, but there were no racial/ethnic differences in amputation. Histories of micro- or macrovascular disease were associated with a two- to four-fold increase in the odds of foot complications.

Conclusion
In managed care patients with uniform access to health care, we found a relatively high prevalence of foot complications, but attenuation of the racial/ethnic differences of rates reported in the literature.
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NewsBot · May 21, 2014

Distance as a risk factor for amputation in patients with diabetes: a case-control study.
Gallagher D, Jordan V, Gillespie P, Cullinan J, Dinneen S.
Ir Med J. 2014 Apr;107(4):107-9.

We studied the association between amputation and distance of patients' residences to a diabetes care centre. We performed a case-control study matching each case (amputation) with 5 controls (no amputation) by age and sex. We compared the distance of residence to the diabetes centre, duration and type of diabetes, haemoglobin-A1c levels and foot examination findings for cases and controls. We analysed the association between distance and the strongest predictors of amputation. Sixty-six cases of amputation and 313 controls were identified. Distance of residence was 12.1km greater for cases (p = 0.028). In multivariate analysis, only diabetes duration (OR/year 1.07, 1.03 to 1.11) and neuropathy (OR 10.73, 4.55 to 25.74) were significantly associated with amputation. Patients with neuropathy resided 97 km further than those without neuropathy (p = 0.01). Patients requiring amputation reside at greater distances from the diabetes centre, possibly due to higher rates of neuropathy.
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NewsBot · Jun 17, 2014

A Prospective Study of Risk Factors for Lower Limb Amputation
EDWARD J. BOYKO, JESSIE H. AHRONI, AMBER SEELIG, Seattle, WA
Presented at the 74th American Diabetes Association Mtg; San Francisco; June 14-17 2014

Little prospective research has been conducted on the risk of diabetic lower limb amputation with limb-specific neurovascular measurements. We prospectively followed 1,641 diabetic veteran primary care patients without foot ulcer for the occurrence of an lower limb amputation. Each lower limb underwent the following tests: ankle-arm index (AAI), 5.07 monofilament insensitivity (MI), and transcutaneous oximetry of the dorsal foot at 44o C (TcPO2). Multiple other characteristics were assessed including diabetes features, body size, past history of ulcer and amputation on either foot, and serum creatinine concentration. Cox regression was used to estimate hazard ratios (HR) for amputation in one limb from each patient by exposures of interest. Baseline characteristics were 98% male and mean age 64 yrs, weight 97 kg, and diabetes duration 17 yrs. Mean follow-up duration was 4 yrs, during which time 50 amputations occurred. In univariate Cox models, significant predictors of amputation were history of foot ulcer (HR 3.63, 95% CI 1.98-6.66) or amputation (4.61, 2.34-9.09), insulin use (2.36, 1.16-4.80), MI (3.57, 1.81-7.04), AAI (0.26, 0.01-0.67), TcPO2 (0.98, 0.96-1.00), and HbA1c (1.09, 1.00-1.18), but no associations were seen with age, weight, sex, creatinine, or diabetes duration. Using a forward selection algorithm among males only, the following covariates significantly predicted amputation in a multivariable model: history of foot ulcer (2.78, 1.51-5.12) and amputation (3.87, 1.88-7.96), MI 2.41 (1.13-5.11), AAI (0.32, 0.11-0.92), TcPO2 (0.98, 0.96-1.00), HbA1c (1.10, 1.01-1.21), and creatinine (1.07, 1.00-1.14). Harrell’s C concordance statistic for this model (equivalent to area under the ROC curve) was 0.902, indicating excellent discrimination. We conclude that multiple factors contribute to the causation of diabetic foot ulcer, including arterial disease, tissue oxygenation, neuropathy, diabetes control, and renal disease, and that these factors permit highly accurate amputation prediction.
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NewsBot · Aug 9, 2014

Gender Differences of Lower Extremity Amputation Risk in Patients With Diabetic Foot
A Meta-Analysis
Zhu-Qi Tang, Hong-Lin Chen, Fang-Fang Zhao
International Journal of Lower Extremity Wounds August 8, 2014

In this meta-analysis, we aim to evaluate gender differences of lower extremity amputation risk in patients with diabetic foot. Systematic computerized searches of PubMed and Web of Knowledge were performed. The pooled odds ratio (OR) and 95% confidence interval (CI) for amputation risk were calculated. Twenty studies with 15 385 case (present amputation) and 438 760 control (absent amputation) patients were included in the meta-analysis. The pooled crude OR was 1.676 (95% CI 1.307-2.149; Z = 4.07, P = .000). In the retrospective study subgroup, the pooled OR was 1.708 (95% CI = 1.235-2.363; Z = 3.24, P = .001); in the prospective study subgroup, the pooled OR was 1.478 (95% CI = 1.189-1.838; Z = 3.51, P = .000). The pooled adjusted OR was 1.439 (95% CI = 1.238-1.671; Z = 4.76, P = .000). In retrospective study subgroup, the pooled OR was 1.440 (95% CI = 1.208-1.717; Z = 4.07, P = .000); in prospective study subgroup, the pooled OR was 1.478 (95% CI = 1.080-2.024; Z = 2.44, P = .015). No significant publication bias was found. Sensitivity analyses by omitting a heterogeneity study showed the results were robust. In conclusion, our meta-analysis indicates that men with diabetic foot have about one half increased amputation risk than women with diabetic foot. Men with diabetes should receive more complete follow-up and more adequate health education.
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NewsBot · Nov 17, 2014

The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration.
Tabur S, Eren MA, Celik Y, Dağ OF, Sabuncu T, Sayiner ZA, Savas E.
Wien Klin Wochenschr. 2014 Nov 15

BACKGROUND:
Diabetic foot infections are associated with substantial morbidity and mortality. Prediction of diabetic foot ulcer outcome may be helpful for optimizing management strategy. This study aimed to determine the major predictors of amputation and length of stay in diabetic patients with acute foot ulceration.
METHODS:
A total of 55 type 2 diabetic patients with diabetic foot infection were enrolled. The patients were evaluated according to the Infectious Diseases Society of America and International Working Group on the Diabetic Foot criteria and also the Wagner's classification. Blood samples were taken at the start of hospitalization for the measurement of glucose, hemoglobin A1C (HbA1C), white blood cells (WBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR). Length of stay in hospital was recorded.
RESULTS:
WBC and CRP were significantly higher in lower-extremity amputation (LEA) group (p = 0.001 and p = 0.008, respectively); also, ESR was higher in this group, but there was no statistical significance. Wagner grade and infection severity were significantly higher in the LEA group as compared with the non-LEA group (both p values < 0.001). Glycemic control parameters (i.e., HbA1C, plasma glucose) were not different in LEA and non-LEA groups. In correlation analyses, amputation rate was negatively correlated (r = - 0.512, p < 0.001) with length of stay. WBC, ESR, CRP, Wagner grade, and severity of infection showed positive correlation with length of stay (r = 0.493, p < 0.001; r = 0.271, p = 0.045; r = 0.299, p = 0.027; r = 0.434, p = 0.001; and r = 0.464, p < 0.001, respectively).
CONCLUSIONS:
Baseline levels of acute-phase reactants, especially CRP, WBC, ESR, and increased Wagner grade, appeared to be helpful in predicting amputation and length of stay in diabetic patients with acute foot ulceration. However, duration of diabetes and glucose control seems to have no effect.
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NewsBot · Nov 27, 2014

Great Toe Necrosis Predicts an Unfavorable Limb Salvage Prognosis.
Sano H, Ichioka S.
Plast Reconstr Surg Glob Open. 2014 Oct 7;2(9):e216. eCollection 2014.

The initial location of necrosis may affect the limb salvage rate. This study of 130 patients with chronic toe ulcers or gangrene was performed to assess whether the location of initial necrosis in the toes affected limb salvage prognosis. The patients were divided into 2 groups according to whether the initial necrosis was in the great toe or in other toes. Limb salvage prognosis was determined retrospectively. In the great toe group, the rates of total toe loss and major amputation were 50.0% and 24.4%, respectively. When the initial necrosis was in other toes, these rates were 27.3% and 9.3%, respectively. Great toe necrosis is associated with significantly higher rates of total toe loss (odds ratio = 3.10; P = 0.003; 95% confidence interval, 1.43-6.68) and major amputation (odds ratio = 3.66; P = 0.007; 95% confidence interval, 1.37-9.79). The great toe is supplied by 3 source arteries, whereas the lesser toes are fed by 1 or 2 arteries. Therefore, necrosis initiating from the great toe may reflect the presence of severe vascular disorders. The great toe is also anatomically connected to much of the foot via the tendons. Infection is more likely to spread along these tendons, which may reduce limb prognosis. Thus, the initial location of necrosis may be predictive of limb prognosis.
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NewsBot · Jan 9, 2015

Epidemiology of Type 2 Diabetic Foot Problems and Predictive Factors for Amputation in China
Yufeng Jiang et al
International Journal of Lower Extremity Wounds January 8, 2015

To determine incidence and clinically relevant risk factors for diabetic amputation in a large cohort study of diabetic foot ulceration patients in China, we investigated a total of 669 diabetic foot ulceration patients, who were assessed at baseline for demographic information, medical and social history, peripheral neuropathy screening, periphery artery disease screening, assessment of nutritional status and diabetic control, physical examination including foot deformity in 15 Grade III-A hospitals. Of the 669 patients, 435 were male and 201 were female, with the mean age being 64.0 years. Of all patients, 110 had neuropathic ulcers, 122 had ischemic ulcers, 276 had neuroischemic ulcers, and 12 cases were unclassified. Wagner classification showed 61 cases were grade I, 216 cases grade II, 159 cases grade III, 137 cases grade IV, and 7 cases grade V. The overall amputation rate among diabetic foot patients was 19.03%, and major and minor amputation rates were 2.14% and 16.88%, respectively. By univariate analysis, statistically significant differences were found in smoking, rest pain, ulcer history, revascularization history, amputation history, gangrene, infection, Wagner grades, duration of diabetes, and postprandial blood glucose, aldehyde, total protein, globulin, albumin, white blood cell (WBC), hemoglobin, HbA1c, ulcer property, body mass index, as well as creatinine. Binary logistic regression model showed that increased WBC (odds ratio 1.25) and ulcer history (odds ratio 6.8) were associated with increased risks from diabetic foot ulcer to major amputation; increased duration of diabetes (odds ratio 1.004), WBC (odds ratio 1.102), infection (odds ratio 2.323), foot deformity (odds ratio 1.973), revascularization history (odds ratio 2.662), and decreased postprandial blood sugar (odds ratio 0.94) were associated with increased risks from diabetic foot ulcer to minor amputation. It is of great importance to give better management to diabetic patients at early stages. Following a diagnosis of DFU more intensive surveillance and aggressive care may improve outcome.
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