Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study.

AIM: The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available. METHODS: Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival. RESULTS: Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period. CONCLUSIONS: In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.

Between visit variability of thermal imaging of feet in people attending podiatric clinics with diabetic neuropathy at high risk of developing foot ulcers.

OBJECTIVE: People with diabetic neuropathy who have previously ulcerated are at high risk of re-ulceration. They should regularly attend podiatry clinics for surveillance and routine protective podiatric treatment. It has been suggested that inflammation prior to skin breakdown shows up as a hotspot on a thermal image even in the absence of clinical signs. The aim of this study is to quantify inter-patient and intra-patient thermal variations presented by diabetic feet at high risk of ulceration. APPROACH: Whole foot and spot temperatures were recorded for 96 patients who attended two successive podiatry appointments without ulceration 28 [28, 31] days apart, median [interquartile range]. This was a part of a longer study into whether thermal imaging in clinic can reduce the rate of re-ulceration. MAIN RESULTS: The variation in spot temperature right/left differences for single patients between visits was comparable to the variation observed between patients (0.8 [0.3, 1.5] °C compared with 0.9 [0.4, 1.7] °C). Similarly, whole foot temperature variation for a single patient between visits was comparable to the variation observed between patients (0.6 [0.2, 1.1] °C compared with 0.8 [0.2, 1.3] °C). SIGNIFICANCE: Thresholds which depend on thermal differences from visit to visit are unlikely to have sufficient specificity to effectively target treatment designed to prevent the development of foot ulcers.

Delayed referral of patients with diabetic foot ulcers across Europe: patterns between primary care and specialised units.

OBJECTIVE: Diabetic foot ulceration (DFU) has the potential to deteriorate rapidly without prompt assessment and treatment. The aim of this study was to assess the referral patterns for DFU, from primary care to specialised diabetes foot care units. METHOD: A two-part, quantitative, online questionnaire was administered to GPs across four countries in Europe: France, the UK, Germany and Spain. The first part entailed a survey of GPs' perceptions of referrals for DFU. The second part of the questionnaire collected data on recently managed DFU cases. RESULTS: There were 600 questionnaires collected in the first part of the study (150 per country), and 1188 patient cases of DFU management were included in the second part. Up to 95% of patients had type 2 diabetes. Patients' complaints led to diagnosis, on average, 60% of the time, and the diagnosis was an incidental finding during a consultation 13-28% of the time. On average, only 40% of GPs completely agreed that they have clearly identified DFU clinical practitioners working in a hospital facility. In 55-66% of cases, the duration of DFU was unknown or DFU diagnosis was delayed more than three weeks from the onset of the wound. On average, 48% of patients were referred after an unknown duration or more than one month from the onset of DFU. CONCLUSION: Despite differences in health-care structures across Europe, delays in referral to specialist foot care teams seems to be a common theme. There is an ongoing need to educate GPs, nurses and patients to be more aware of the risk of DFU, and the need for prompt referral to specialist diabetic foot teams.

Thermal symmetry of healthy feet: a precursor to a thermal study of diabetic feet prior to skin breakdown.

Early identification of areas of inflammation may aid prevention of diabetic foot ulcers. A new bespoke thermal camera system has been developed to thermally image feet at risk. Hotspots (areas at least 2.2 °C hotter than the contralateral site) may indicate areas of inflammation prior to any apparent visual signs. This article describes the thermal pattern and symmetry of 103 healthy pairs of feet. 68% of participants were thermally symmetric at the 33 foot sites measured. 32% of participants had at least one hotspot, but hotspots overall only accounted for 5% of the measurements made. Refinements to the definition of hotspots are proposed when considering feet at risk of ulceration.

Effectiveness of combined therapy with angiotensin-converting enzyme inhibitors and statins in reducing mortality in diabetic patients with critical limb ischemia: an observational study.

AIMS: To investigate the effect of combined treatment with angiotensin-converting enzyme inhibitors (ACE) and statins on mortality in diabetic patients with critical limb ischemia (CLI). METHODS: Prospective observational study of 553 consecutive diabetic patients admitted because of CLI followed for a mean of 2.2 years. All patients underwent peripheral revascularization and antithrombotic therapy was prescribed or continued and therapy with statin and ACE was recorded. Mortality from any cause was assessed and Kaplan-Meier analyses were performed to compare the relationship between survival and recorded variables. RESULTS: One hundred thirty-nine patients did not have therapy with statin or an ACE, 78 had therapy with statin without ACE, 164 had therapy with ACE without statin and 172 patients had therapy with both statin and ACE. One hundred thirty-six patients died, 45/139 with neither statin nor ACE, 40/164 with ACE only, 26/78 with statin only, and 25/172 with both statin and ACE. Multivariate analysis confirmed the independent role of age, history of stroke, renal insufficiency and dialysis. Combined treatment with ACE and statin appeared to have a protective role. CONCLUSIONS: In patients with diabetes and CLI mortality after two years is high. Life expectancy was better in patients receiving combined therapy with ACE and statin but not with therapy with only a statin or an ACE.

Revascularization by angioplasty of type D femoropopliteal and long infrapopliteal lesion in diabetic patients with critical limb ischemia: are TASC II recommendations suitable? A population-based cohort study.

Feasibility of revascularization of type D femoropopliteal and long infrapopliteal lesions by angioplasty (peripheral translumenal angioplasty [PTA]) in diabetic patients with critical limb ischemia (CLI) according to the TransAtlantic Inter-Society Consensus (TASC) II recommendations was studied. A total of 292 diabetic patients were admitted for CLI; 308 limbs underwent a PTA. Out of 211 femoropopliteal lesions treated with PTA, 44 were TASC II type A, 45 type B, 48 type C, and 76 type D lesions. In 44 of the 76 patients with type D lesions revascularized by PTA, no artery was patent down to the foot before the PTA. In 172 limbs with all infrapopliteal arteries occluded, revascularization was carried out down to the foot in 167 limbs. Follow-up was 3.1 ± 0.3 years. A first episode of restenosis occurred in 66/308 limbs with an incidence/year of 7.9. PTA procedures were successfully repeated in 57/66 restenosis episodes: secondary patency was 97.1%. The incidence/year of type D femoropopliteal lesions was 5.4, the incidence/year in others was 5.0, without statistically significant differences: P = .417. The only variable found significantly associated with restenosis occurrence on logistic analysis was the presence of lesions in both femoropopliteal and infrapopliteal axes. A total of 26/308 above-the-ankle amputations were performed, with an incidence/year of 2.5. Multivariate analysis showed the independent role of only crural artery occlusion after PTA. These data show that the choice to refer to angioplasty diabetic patients with type D and/or long infrapopliteal lesions without good run-off at the foot and/or high surgical risk allowed high revascularization feasibility, with an optimal amputation outcome.

The safety and efficacy of dressings with silver - addressing clinical concerns.

With the increasing use of silver as a topical application in wound care, concerns focussing on its role are bound to arise. These concerns, which centre on issues such as resistance and toxicity, clinical efficacy and cost-effectiveness, need to be addressed and openly discussed so that they are viewed from a rational perspective. While clinical efficacy and safety, along with cost-benefit, are of obvious interest, the origin of some of these concerns is a matter of debate. The silver-containing dressing segment of the medical device market is of huge commercial importance, and, consequently, marketing and promotional issues occasionally obscure the evidence that clinicians need to have in order that they may provide appropriate treatment for their patients. The impact of silver application on the wound bioburden needs to be examined carefully to heighten our awareness of any deleterious effects on the healing process, without inducing any unfounded anxieties.

The use of antibiotics in the diabetic foot.

Lower limb infections are the most common indication for hospital admission in patients with diabetes. However, diagnosis of infection can be delayed because the normal clinical signs are often absent in patients with diabetes. The proper use of antibiotics in the treatment of the diabetic foot remains contested: one view is to administer antibiotics only in the presence of clinical infection; the other one is to give antibiotics freely to all patients with ulcers. This review of literature includes 2 controlled studies of antibiotics in diabetic foot ulcers. The first study showed no advantage from amoxicillin plus clavulanate as a supplement to standard therapy in uncomplicated ulcers. Patients (N = 44) with neuropathic ulcers (some of whom had cellulitis) were randomized to oral amoxicillin plus clavulanate or matched placebo. At 20 days' follow-up, there was no significant difference in outcome between the 2 groups. A further investigation (N = 64) compared ulcer patients who received oral antibiotics with those who did not. In the group with no antibiotics, 15 patients developed clinical infection, whereas none did in the antibiotic group (P <0.001). Seven patients in the nonantibiotic group needed hospital admission and 3 patients came to amputation. In the nonantibiotic group, 11 of 15 with infection had a positive swab compared with 1 of 17 without infection (P <0.01). In the nonantibiotic group, 17 patients healed, compared with 27 in the antibiotic group (P <0.02), with significantly more ischemic patients healing in the antibiotic group (P <0.01). Patients with diabetes who have clean ulcers associated with peripheral vascular disease and positive ulcer swabs should be considered for early antibiotic treatment. The diabetic foot is highly susceptible to repeat ulceration, and diabetic ulcers are more prone to infection than other ulcers. Furthermore, untreated infection can lead to amputation. This cycle can be broken only with aggressive treatment.

Ethnicity and risk of diabetes-related lower extremity amputation: a population-based, case-control study of African Caribbeans and Europeans in the United kingdom.

BACKGROUND: In the United States, people of black African descent with diabetes have 2 to 3 times the amputation risk of whites. This may be due to differences in care or pathophysiological characteristics. We therefore determined diabetes-related amputation rates in African Caribbeans vs Europeans in the United Kingdom, where care delivery is more equitable. METHODS: We conducted an incidence and case-control study, based in London, England. All diabetes-related amputations performed between 1992 and 1997 were identified. Controls, those with diabetes but no amputation, were sampled from family practitioners. Risk factor data were abstracted from medical records. RESULTS: Incident diabetes-related amputation occurred in 67 Europeans and 19 African Caribbeans. Amputation rates, age standardized to the diabetic population, were 147 per 100 000 and 219 per 100 000 in African Caribbeans and Europeans, respectively (relative risk, 0.67; 95% confidence interval [CI], 0.32-1.40; P =.2). Case-control analyses were performed on 178 cases and 350 controls. The ethnic difference in amputation risk differed significantly by sex (P =.009 for interaction). The unadjusted odds ratio comparing African Caribbeans with Europeans in men was 0.31 (95% CI, 0.17-0.57; P<.001), and in women was 0.97 (95% CI, 0.49-1.85; P =.9). Adjustment for smoking attenuated the odds ratio in men to 0.45 (95% CI, 0.23-0.89, P =.02); adding neuropathy, peripheral vascular disease, and age attenuated the odds ratio further to 0.97 (95% CI, 0.34-2.73; P =.9). CONCLUSIONS: In contrast to the United States, we find no ethnic difference in diabetes-related amputation in women in the United Kingdom, but in men, amputation risk in African Caribbeans is one third that of Europeans. This was wholly accounted for by low smoking, neuropathy, and peripheral vascular disease rates.