Limb- and Person-Level Risk Factors for Lower-Limb Amputation in the Prospective Seattle Diabetic Foot Study

Boyko, Edward J.; Seelig, Amber D.; Ahroni, Jessie H.

doi:10.2337/dc17-2210

Cited by 101 publications

(90 citation statements)

References 42 publications

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“…A prediction model developed among 6440 patients with diabetic foot ulcer and based on electronic health record data found that absence of peripheral artery disease (PAD) was associated with higher probability of ulcer healing . Further support for the important role of PAD in amputation risk comes from prospective research in diabetic patients initially without foot ulcer followed prospectively, in whom an ABI ≤ 0.5 and between >0.5 and ≤0.9 were associated with hazard ratios of 3.98 and 1.88 respectively for lower limb amputation compared to an ABI between 0.9 and <1.3 . As treatments exist for PAD that may restore perfusion, the identification of diminished perfusion is highly relevant and potentially remediable .…”

Section: Introductionmentioning

confidence: 99%

“…prospectively, in whom an ABI ≤ 0.5 and between >0.5 and ≤0.9 were associated with hazard ratios of 3.98 and 1.88 respectively for lower limb amputation compared to an ABI between 0.9 and <1.3. 3 As treatments exist for PAD that may restore perfusion, the identification of diminished perfusion is highly relevant and potentially remediable. 4 This article will review clinical signs of diminished arterial perfusion and their value in the assessment of patients with diabetic foot ulcer.…”

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confidence: 99%

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How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer

Boyko

2019

Diabetes Metabolism Res

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Assessment of ischaemia and interventions to improve perfusion are key elements in the management of the diabetic foot ulcer to achieve wound healing. This article will review, analyse and interpret the value of clinical information in determining the likelihood of limb ischaemia and thereby the need for referral to a vascular specialist. I conducted an historical review of the genesis of several currently recommended clinical signs and their diagnostic properties in the assessment of limb ischaemia. Changes in limb ischaemia probability based on such results were calculated using Bayes theorem, and the use of such probabilities is discussed in the context of the threshold approach to clinical decision making. Some clinical signs have negligible value in altering probability of limb ischaemia, possibly because they were advocated by Buerger for the diagnosis of thromboangiitis obliterans, an occlusive vascular disease of a different pathophysiology than atherosclerosis. Pedal pulse palpation, the most widely studied clinical sign, will marginally change a pre‐test probability of ischaemia of 50% to 76% if positive (abnormal pulses) and to 36% if negative (normal pulses). Higher or lower pre‐test probabilities of ischaemia will change the post‐test probabilities such that these are too low or high to rule in or rule out ischaemia, respectively. Individual clinical signs convey little information regarding the presence of limb ischaemia but may have some value in combination or with pre‐test probability near 50% in the assessment of ischaemia and the decision to refer for a vascular consultation.

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Section: Introductionmentioning

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How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer

Boyko

2019

Diabetes Metabolism Res

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“…The short 13-item (RDF-13) scale may help with individualized medical decision-making and may serve as a complement to the current prediction models for lower extremity complications. [52][53][54][55] An automated item-selecting procedure ruled out the items "Tinel left" and "Right" and "MNSI-positive symptoms," meaning that they did not pass the marginal test for fitting the monotone homogeneity model. These items do not hold a robust position in the natural course of the disease, as clinicians will recognize from daily practice-patients who have had an ulcer and patients without aberrant large-fiber function (eg, intact S2PD) may still complain of painful neuropathic symptoms.…”

Section: Discussionmentioning

confidence: 99%

Development of grading scales of pedal sensory loss using Mokken scale analysis on the Rotterdam Diabetic Foot Study Test Battery data

et al. 2019

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IntroductionLoss of sensation due to diabetes‐related neuropathy often leads to diabetic foot ulceration. Several test instruments are used to assess sensation, such as static and moving 2‐point discrimination (S2PD, M2PD), monofilaments, and tuning forks.MethodsMokken scale analysis was applied to the Rotterdam Diabetic Foot Study data to select hierarchies of tests to construct measurement scales.ResultsWe developed 39‐item and 31‐item scales to measure loss of sensation for research purposes and a 13‐item scale for clinical practice. All instruments were strongly scalable and reliable. The 39 items can be classified into 5 hierarchically ordered core clusters: S2PD, M2PD, vibration sense, monofilaments, and prior ulcer or amputation.DiscussionGuided by the presented scales, clinicians may better classify the grade of sensory loss in diabetic patients’ feet. Thus, a more personalized approach concerning individual recommendations, intervention strategies, and patient information may be applied.

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“…Reports of studies of large clinical cohorts were considered to identify factors most important in predicting clinical outcomes of DFU (namely, healing, major amputation, minor amputation, and/or mortality). These variables were then divided into three major groups: person related, which included presence of end‐stage renal disease, increasing age, heart failure, and nonambulatory status; limb related, which included presence of PAD, LOPS, prior minor amputation, and oedema; and ulcer related, which included area, depth, location (forefoot or hind foot), number (single or multiple), and presence of infection.…”

Section: Methodsmentioning

confidence: 99%

Diabetic foot ulcer classifications: A critical review

Monteiro‐Soares

Boyko

Jeffcoate

et al. 2020

Diabetes Metabolism Res

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Classification and scoring systems can help both clinical management and audit outcomes of routine care. The aim of this study was to assess published systems of diabetic foot ulcers (DFUs) to determine which should be recommended for a given clinical purpose. Published classifications had to have been validated in populations of > 75% people with diabetes and a foot ulcer. Each study was assessed for internal and external validity and reliability. Eight key factors associated with failure to heal were identified from large clinical series and each classification was scored on the number of these key factors included. Classifications were then arranged according to their proposed purpose into one or more of four groups: (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) aid clinical management decision making for an individual case, and (d) audit to compare outcome in different populations. Thirty‐seven classification systems were identified of which 18 were excluded for not being validated in a population of >75% DFUs. The included 19 classifications had different purposes and were derived from different populations. Only six were developed in multicentre studies, just 13 were externally validated, and very few had evaluated reliability.Classifications varied in the number (4 ‐ 30), and definition of individual items and the diagnostic tools required. Clinical outcomes were not standardized but included ulcer‐free survival, ulcer healing, hospitalization, limb amputation, mortality, and cost. Despite the limitations, there was sufficient evidence to make recommendations on the use of particular classifications for the indications listed above.

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Limb- and Person-Level Risk Factors for Lower-Limb Amputation in the Prospective Seattle Diabetic Foot Study

Abstract: Arterial disease and neuropathy emerged as the only limb-specific risk factors for amputation, but these and several person-level factors may be amenable to prevention or treatment interventions to potentially reduce diabetic amputation risk.

Cited by 101 publications

References 42 publications

How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer

How to use clinical signs and symptoms to estimate the probability of limb ischaemia in patients with a diabetic foot ulcer

Development of grading scales of pedal sensory loss using Mokken scale analysis on the Rotterdam Diabetic Foot Study Test Battery data

Diabetic foot ulcer classifications: A critical review

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