Foot Ulcer and Risk of Lower Limb Amputation or Death in People With Diabetes: A National Population-Based Retrospective Cohort Study

Abstract

Objective <p>To describe incidence of foot ulceration and amputation free survival associated with foot ulceration status in a national population-based cohort study of people with diabetes.</p> <p>Research Design and Methods</p> <p>The study population included 233,459 people with diabetes who were alive in Scotland on 1<sup>st</sup> January 2012 identified from the national population-based register (national prevalence 4.9%). Characteristics of patients identified from linked hospital and mortality records during follow-up to the end of November 2017 were compared by outcome. Cox regression was used to assess the association between history of foot ulcer and amputation free survival. </p> <p>Results</p> <p>The population included 23,395 people with type-1 diabetes and 210,064 people with type-2 diabetes. In total there were 13,093 (5.6%) people with a previous foot ulceration, 9,023 people developed a first ulcer, 48,995 died and 2,866 underwent minor or major amputation during follow-up. Overall incidence of first time foot ulcers was 7.8 per 1000 person years (95% CI: 7.6-7.9) and 11.2 (11.0-11.4) for any ulcer. Risk factors for reduced amputation-free survival included social deprivation, mental illness and being underweight in addition to conventional cardiovascular risk factors. Adjusted hazards ratios (95% CI) were 2.09 (1.89-2.31) for type-1 diabetes and 1.65 (1.60-1.70) for type-2 diabetes. </p> <p>Conclusion</p> <p>The overall incidence of foot ulceration in a population-based study of people with diabetes was 11.2 per 1000<b> </b>person years. Foot ulceration is associated with lower amputation-free survival, a potential measure of effectiveness of care among people with diabetes. Mental illness and social deprivation are also highlighted as risk factors.</p>

Nutritional Interventions May Improve Outcomes of Patients Operated on for Diabetic Foot Infections: A Single-Center Case-Control Study

“…This is the main difference to our study, in which we included only infected cases and also accepted DFI episodes without DFU. Nevertheless, all our findings and those of the literature suggest the same: a positive role of enhanced nutrition in DFU healing[8][9][10][11][12][13] and, consequently, cure of infection (with or without underlying ulcers).…”

“…The multivariable Cox regression revealed that a low GNRI (hazard ratio (HR) 2.0, 95% confidence interval 1.4-3.0), a low PNI (HR 2.0, 95% CI 1.3-3.2), and a high CONUT score (HR 1.5, 95% CI 1.1-2.2) were all independently associated with high all-cause mortality [10]. In Scotland, Chamberlain et al [12] found a relation between a low BMI and the risk of amputation and/or all-cause mortality among diabetic patients. Most likely, the low BMI (<18.5 kg/m 2 ) reflected current malnutrition of their patients.…”

“…To cite concrete and recent examples, Hong et al evaluated 771 geriatric Chinese patients with type 2 diabetes and DFU and associated three different geriatric scores 12 (geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), and controlling nutritional status (CONUT)) to all-cause mortalities [10]. All scores were heavily influenced by the current insufficient nutritional status.…”

“…Most likely, the low BMI (<18.5 kg/m 2 ) reflected current malnutrition of their patients. Similarly, they also suspected that a low serum glycated hemoglobin level could be associated with poor nutrition, malignancy, and frailty [11,12]. Gazzaruso et al investigated predictors of healing, DFU recurrence or persistence, amputation, and general mortality in 583 Italian diabetic patients [13].…”

Research priorities to prevent and treat diabetic foot ulcers—A digital James Lind Alliance Priority Setting Partnership

“…The list of uncertainties was at the planning stage aimed mainly for primary prevention of DFU but during the partnership process a few issues about treatment uncertainties remained highly important. In a nation‐wide study on people with type 1 and type 2 diabetes, 94.4% had no history of DFU at baseline, 6 justifying our focus on primary prevention, and not prevention of recurrence of DFU. The rankings of research uncertainties might have been different if this JLA priority setting partnership exclusively were about people with a history of DFU with, above all, increased risk of death 31 .…”