Association between race/ethnicity and the risk of amputation of lower extremities among medicare beneficiaries with diabetic foot ulcers and diabetic foot infections

IntroductionThis study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs).Research design and methodsA retrospective study included 2011–2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported.ResultsAmong 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (p<0.05). Multivariable analysis showed that AAs (aHR=1.9, 95% CI 1.7 to 2.2, p<0.0001) and NAs (aHR=1.8, 95% CI 1.3 to 2.6, p=0.001) were associated with an increased risk of major amputation compared with whites. Beneficiaries with DFUs and/or DFIs diagnosed by a podiatrist or primary care physician (aHR=0.7, 95% CI 0.6 to 0.8, p<0.0001, specialists as reference) or at an outpatient visit (aHR=0.3, 95% CI 0.3 to 0.3, p<0.0001, inpatient stay as reference) were associated with a decreased risk of major amputation.ConclusionsRacial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.

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Limb Salvage and Functional Outcomes following Free Tissue Transfer for the Treatment of Recalcitrant Diabetic Foot Ulcers

Journal of Reconstructive Microsurgery ◽

10.1055/s-0038-1667363 ◽

2018 ◽

Vol 35 (02) ◽

pp. 117-123 ◽

Cited By ~ 7

Author(s):

Jocelyn Lu ◽

Michael DeFazio ◽

Chrisovalantis Lakhiani ◽

Michel Abboud ◽

Morgan Penzler ◽

...

Keyword(s):

Lower Extremity ◽

Limb Salvage ◽

Diabetic Foot ◽

Functional Outcomes ◽

Free Tissue Transfer ◽

Major Amputation ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Flap Survival ◽

Foot Reconstruction

Background Recent evidence documenting high success rates following microvascular diabetic foot reconstruction has led to a paradigm shift in favor of more aggressive limb preservation. The primary aim of this study was to examine reconstructive and functional outcomes in patients who underwent free tissue transfer (FTT) for recalcitrant diabetic foot ulcers (DFUs) at our tertiary referral center for advanced limb salvage. Methods Between June 2013 and June 2016, 29 patients underwent lower extremity FTT for diabetic foot reconstruction by the senior author (K.K.E.). In all cases, microsurgical reconstruction was offered as an alternative to major amputation for the management of recalcitrant DFUs. Overall rates of flap survival, limb salvage, and postoperative ambulation were evaluated. The lower extremity functional scale (LEFS) score was used to assess functional outcomes after surgery. Results Overall rates of flap success and lower limb salvage were 93 and 79%, respectively. Flap failure occurred in two patients with delayed microvascular compromise. Seven patients in this series ultimately required below-knee amputation secondary to recalcitrant infection (n = 5), intractable pain (n = 1), and limb ischemia (n = 1). The average interval between FTT and major amputation was 8 months (r, 0.2–15 months). Postoperative ambulation was confirmed in 25 patients (86%) after a mean final follow-up of 25 months (r, 10–48 months). The average LEFS score for all patients was 46 out of 80 points (r, 12–80 points), indicating the ability to ambulate in the community with some limitations. Conclusion FTT for the management of recalcitrant DFUs is associated with high rates of reconstructive success and postoperative ambulation. However, several patients will eventually require major amputation for reasons unrelated to ultimate flap survival. These data should be used to counsel patients regarding the risks, functional implications, and prognosis of microvascular diabetic foot reconstruction.

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The Guyana Diabetes and Foot Care Project: Improved Diabetic Foot Evaluation Reduces Amputation Rates by Two-Thirds in a Lower Middle Income Country

International Journal of Endocrinology ◽

10.1155/2015/920124 ◽

2015 ◽

Vol 2015 ◽

pp. 1-6 ◽

Cited By ~ 4

Author(s):

Julia Lowe ◽

R. Gary Sibbald ◽

Nashwah Y. Taha ◽

Gerald Lebovic ◽

Madan Rambaran ◽

...

Keyword(s):

Diabetic Foot ◽

Health Care Professionals ◽

Phase 1 ◽

Major Amputation ◽

Foot Ulcers ◽

Quality Improvement Intervention ◽

Foot Care ◽

Middle Income ◽

Increased Risk ◽

Two Phases

Background. Type 2 diabetes is the fourth leading cause of death in Guyana, South America. A complex, interprofessional, quality improvement intervention to improve foot and diabetes care was rolled out in two phases.Methods & Findings. Phase 1: Establishment of an Interprofessional Diabetic Foot Center (DFC) of Excellence to improve foot care and reduce diabetes-related amputations at the national referral hospital. Phase 2: Regionalization to cover 90% of the Guyanese population and expansion to include improved management of diabetes and hypertension. Fourteen key opinion leaders were educated and 340 health care professionals from 97 facilities trained. Eight centers for the evaluation and treatment of foot ulcers were established and 7567 people with diabetes evaluated. 3452 participants had foot screening and 48% were deemed high risk; 10% of these had undocumented foot ulcers. There was a 68% reduction in rate of major amputations (P<0.0001); below knee amputations were decreased by 80%, while above knee amputations were unchanged. An increased association of diabetes with women (F/M = 2.09) and increased risk of major amputation in men [odds ratio 2.16 (95% CI 1.83, 2.56)] were documented.Conclusions. This intervention improved foot care with reduction in major amputations sustained over 5 years.

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Can major amputation rates be decreased in diabetic foot ulcers with hyperbaric oxygen therapy?

International Orthopaedics ◽

10.1007/s00264-008-0623-y ◽

2008 ◽

Vol 33 (2) ◽

pp. 441-446 ◽

Cited By ~ 26

Author(s):

Ahmet Kaya ◽

Figen Aydin ◽

Taskin Altay ◽

Levent Karapinar ◽

Hasan Ozturk ◽

...

Keyword(s):

Hyperbaric Oxygen ◽

Diabetic Foot ◽

Hyperbaric Oxygen Therapy ◽

Oxygen Therapy ◽

Major Amputation ◽

Foot Ulcers ◽

Diabetic Foot Ulcers

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Antibiotic Resistance in Diabetic Foot Soft Tissue Infections: A Series From Greece

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734617737640 ◽

2017 ◽

Vol 16 (4) ◽

pp. 255-259 ◽

Cited By ~ 7

Author(s):

Maria Demetriou ◽

Nikolaos Papanas ◽

Periklis Panagopoulos ◽

Maria Panopoulou ◽

Efstratios Maltezos

Keyword(s):

Antibiotic Resistance ◽

Soft Tissue ◽

Diabetic Foot ◽

Soft Tissues ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Soft Tissue Infections ◽

Diabetic Foot Infections ◽

Initial Choice ◽

Gram Positive Cocci

Diabetic foot infections are a common and serious problem for all health systems worldwide. The aim of this study was to examine the resistance to antibiotics of microorganisms isolated from infected soft tissues of diabetic foot ulcers, using tissue cultures. We included 113 consecutive patients (70 men, 43 women) with a mean age of 66.4 ± 11.2 years and a mean diabetes duration of 14.4 ± 7.6 years presenting with diabetic foot soft tissue infections. Generally, no high antibiotic resistance was observed. Piperacillin-tazobactam exhibited the lowest resistance in Pseudomonas, as well as in the other Gram-negative pathogens. In methicillin-resistant Staphylococcus aureus isolates, there was no resistance to anti-Staphylococcus agents. Of note, clindamycin, erythromycin, and amoxycillin/clavulanic acid exhibited high resistance in Gram-positive cocci. These results suggest that antibiotic resistance in infected diabetic foot ulcers in our area is not high and they are anticipated to prove potentially useful in the initial choice of antibiotic regimen.

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Wound Myiasis in Diabetic Foot Ulcer: Calliphoridae and Sar-cophagidae Family

Iranian Journal of Parasitology ◽

10.18502/ijpa.v16i4.7881 ◽

2021 ◽

Author(s):

Evren Tileklioğlu ◽

İbrahim Yildiz ◽

Fürüzan Bozkurt Kozan ◽

Erdoğan Malatyali ◽

Mustafa Bülent Ertuğrul ◽

...

Keyword(s):

Diabetic Foot ◽

Chronic Wound ◽

Developmental Stages ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Diabetic Foot Infections ◽

Third Stage ◽

Wound Myiasis

Background: Myiasis is a parasitic infestation of tissues or body cavities of mammals with dipterous larvae. The patients with diabetic foot ulcers are more vulnerable to acquiring infestation; however, the infestation may be neglected and mistreated in some cases. Methods: Data were collected of twelve myiasis cases with diabetic foot ulcers in Nazli-Selim Eren Chronic Wound and Infections Care Unit, Aydin, Turkey between 2017 and 2019. Demographic, clinical characteristics of the patients and clinical examination of the wound were recorded. To morphology-based identification method of the agents, the developmental stages of the maggots were examined. Results: The cases aged between 46 and 81 years (10 males, two females). Eight of the larvae collected from wounds had Calliphoridae and four had Sarcophagidae family. The larvae were infested right/left foot sole, thumb, ankle, and mostly left toes. The number of larvae collected from the cases ranged from 2 to 48. Third-stage larvae (L3) were mostly detected. Mixed (L1-L2, L2-L3) larvae were detected in a patient. The infestations were more common in July and August. According to the score of Infectious Diseases Society of America (IDSA), ten (83%) cases had moderate and two (17%) cases were mild diabetic foot infections (DFIs). Conclusion: Diabetic foot ulcers should be evaluated in terms of myiasis. This was the first study in our province indicating that myiasis should not be neglected and different species of flies were responsible for myiasis cases.

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“ ASSESSMENT OF SEVERITY OF DIABETIC FOOT ULCERS USING DIABETIC ULCER SEVERITY SCORE.”

10.36106/gjra/0903090 ◽

2020 ◽

pp. 19-21

Author(s):

Aarushi Mishra ◽

Anilkumar P. Bellad ◽

M.I. Uppin

Keyword(s):

Diabetes Mellitus ◽

Diabetic Foot ◽

Severity Score ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Major Amputation ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Diabetic Ulcer ◽

The Past

INTRODUCTION : Diabetes mellitus is a common metabolic disorder, prevalence steadily increasing over the past few decades. The complications associated with it , hence , has also increased. Diabetic foot ulcer is one of the most serious complications , utilizing resources, significantly contributing to the morbidity of the patient. There is hence, a need to correctly identify the severity of the diabetic foot ulcer so as to plan the appropriate management and to help in counselling of such patients. AIM : To assess severity in diabetic foot ulcer using diabetic ulcer severity score. MATERIAL AND METHODOLOGY : This is a hospital based longitudinal study , conducted on 93 study subjects admitted with diabetic foot ulcers. Diabetic ulcer severity score was calculated for each patient . The score was calculated by adding scores of the respective parameters constituting site of ulcer, number of ulcers, presence/absence of pedal pulsations, presence/ absence of bone involvement. Each patient was followed up for a period of 6 months , or earlier in case of patient undergoing minor/major amputation. After the study was conducted , analysis was done by calculating various percentages of healing /amputation with respect to the score. RESULTS : Out of the total 93 study subjects , 74.2% were males. The mean age was calculated to be 59.6 years with maximum number of subjects being in 55-60 years of age group range. Majority of them had diabetic ulcer severity score of 2 (42%). Out of the total study subjects , 58% had a complete healing , 28% underwent minor amputation whereas 14% underwent major amputation. 100% of the study participants with score 0 had healing of ulcer which decreased to 85% for score 1 , 53.8% for score 2 , 6.25% for score 3 and 0% for score 4. This was suggestive of poorer chances of healing as the diabetic ulcer severity score increases. CONCLUSION : With the increasing incidence of patients diagnosed with diabetes mellitus , the rate of complications of diabetes has also increased over the past few decades including the risk and occurence of diabetic foot ulcers There is an increasing need for diabetic foot ulcer prognostication systems and universal use of the same. Thus ,we recommend the use of diabetic ulcer severity score as a prognostic tool to assess the severity of the diabetic foot which will further enhance communication and counselling of the patient and will help in providing the appropriate treatment to such patients.

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A clinicopathogical study on diabetic foot ulcer with special reference to the causative factors and its management

International Surgery Journal ◽

10.18203/2349-2902.isj20191469 ◽

2019 ◽

Vol 6 (5) ◽

pp. 1540

Author(s):

Sailendranath Paul ◽

Dilip Kumar Das

Keyword(s):

Diabetic Foot ◽

Age Of Onset ◽

Management Strategies ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Major Amputation ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

E Coli ◽

Related Risk

Background: Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. The present study was done to identify the incidence and related risk factors of diabetic foot ulcers in study participants.Methods: This was a prospective done on 50 patients with diabetic foot ulcers. All the patients were examined thoroughly and related laboratory investigations were done. Wound culture and sensitivity was done in all cases.Results: Mean age of onset with foot ulcers was 53.5 yrs in male and 55 yrs in females. Nephropathy was present in 12 (24%) patients. Sensorimotor neuropathy was present in 29 (58%) cases and autonomic neuropathy was present in 06 (12%) cases. Most common infection identified in diabetic foot ulcers was due to gram-negative bacteria (E. coli in 45 cases). Major amputation was done in 2 (4%) patients.Conclusions: Implementation of management strategies at early stages prevents the development of complications related to diabetic foot ulcers in patients.

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Prospective observational study evaluating the predictive value of ankle branchial pressure index on the outcomes of diabetic foot ulcers

International Surgery Journal ◽

10.18203/2349-2902.isj20202527 ◽

2020 ◽

Vol 7 (7) ◽

pp. 2352

Author(s):

Vishnu S. Ravidas ◽

Samadarsi P. ◽

Ajayan G.

Keyword(s):

Wound Healing ◽

Observational Study ◽

Diagnostic Accuracy ◽

Diabetic Foot ◽

Prospective Observational Study ◽

Major Amputation ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Pressure Index ◽

Study Participants

Background: The study was conducted to determine the diagnostic accuracy of ankle branchial pressure index (ABPI) in predicting major amputation and duration of wound healing in diabetic foot ulcers.Methods: 105 participants (30-85 years) admitted in general surgery inpatient with diabetic foot ulcers during 18 months were enrolled in the present prospective observational study. Institutional ethics committee approved the study and written informed consent was obtained from all study participants. Data was analyzed using R and the tests of significance were chi square test and ANOVA. Area under curve (AUC) of receiver operator characteristic (ROC) was used to describe the diagnostic accuracy of ABPI. P<0.05 was considered statistically significant.Results: The mean ABPI of study participants was 0.7 with 23.8% participants having normal ABPI. Lower ABPI was associated with longer duration of ulcer healing (p=0.003). All participants with ABPI <0.3 required more than 120 days for wound healing (p<0.001) and required above knee amputation (p<0.001). AUC ROC of ABPI and major amputation is 0.987 with 92.9% sensitivity and 98.9% specificity. Significantly higher proportion of participants with ABPI ≤0.48 underwent major amputation. The AUC of ROC of ABPI on duration of wound healing was 0.953 with 84.9% sensitivity and 98.1% specificity. Conclusions: ABPI can be used as a routine tool in all patients with diabetic foot ulcers for screening peripheral arterial disease so that the decision for amputation can be made early during diabetic foot ulcers.

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