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J Diabetes Res. 2016; 2016: 5941957.
Published online 2016 Jun 29. doi:Β 10.1155/2016/5941957
PMCID: PMC4942664
PMID: 27446962

Beverly T. Rodrigues

Department of Diabetes and Endocrinology, The Townsville Hospital and College of Medicine and Dentistry, James Cook University, 100 Angus Smith Drive, Douglas, QLD 4814, Australia

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services marketing 3rd mary bitner pdf 79bf65013 logbook (πŸ”₯ headache) | services marketing 3rd mary bitner pdf 79bf65013 sugar levelhow to services marketing 3rd mary bitner pdf 79bf65013 for Venkat N. Vangaveti

Department of Diabetes and Endocrinology, The Townsville Hospital and College of Medicine and Dentistry, James Cook University, 100 Angus Smith Drive, Douglas, QLD 4814, Australia

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Usman H. Malabu

Department of Diabetes and Endocrinology, The Townsville Hospital and College of Medicine and Dentistry, James Cook University, 100 Angus Smith Drive, Douglas, QLD 4814, Australia

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Department of Diabetes and Endocrinology, The Townsville Hospital and College of Medicine and Dentistry, James Cook University, 100 Angus Smith Drive, Douglas, QLD 4814, Australia
*Usman H. Malabu: [email protected]
Academic Editor: Nikolaos Papanas
Received 2016 Mar 23; Accepted 2016 May 3.
Copyright © 2016 Beverly T. Rodrigues et al.
This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
See letter ""/pmc/articles/PMC5664343/"" in volume 2017, 6015326.
This article has been cited by other articles in PMC.

Abstract

services marketing 3rd mary bitner pdf 79bf65013 gene (β˜‘ ricotta) | services marketing 3rd mary bitner pdf 79bf65013 treatment nicehow to services marketing 3rd mary bitner pdf 79bf65013 for Objective. The aim of the study was to evaluate the prevalence of and risk factors for lower limb amputation in a specialist foot clinic-based setting. Methods. A retrospective quantitative study was conducted, using clinical and biochemical profiles of diabetic foot patients attending the High Risk Foot Clinic at The Townsville Hospital, Australia, between January 1, 2011, and December 31, 2013. Results. The total study sample included 129 subjects, comprising 81 males and 48 females with M : F ratio of 1.7 : 1. Twenty-three subjects were Indigenous Australians, representing 17.8% of the study population. The average age of the cohort was 63.4 years ± 14.1 years [CI 90.98–65.89]. Lower limb amputation was identified as a common and significant outcome (n = 44), occurring in 34.1%, more commonly amongst the Indigenous Australians (56.5% versus 29.2%; p = 0.94, OR 0.94). Risk factors most closely associated with amputation included diabetic retinopathy (p = 0.00, OR 4.4), coronary artery bypass graft (CABG) surgery (p = 0.01, OR 4.1), Charcot''s Townsville Hospital between January 1, 2011, and December 31, 2013, were included in the study. Patients 18 years of age and over with a confirmed diagnosis of either type 1 or type 2 diabetes and coexisting DFU were included. Subjects under the age of 18 and those with nondiabetic foot ulcers (e.g., trauma-related, vasculitic, and neoplastic ulcers) were excluded from the study. Subjects who attended the clinic for other management purposes (e.g., podiatry reviews, nail pathology, and education about prevention) were also excluded.

2.2. Data Extraction

There were two main processes involved in data extraction, including gathering of clinical and biochemical data from patient profile. A retrospective chart audit was initially performed, focusing on the correspondence and outpatient attendance sections. The HRFC pro forma sheet was then used to collect information regarding the onset, duration, outcome, and type of ulcer defined as ischaemic or nonischaemic based on University of Texas Wound Classification System [21]. Furthermore, clinical information on the diagnosis and management of diabetes, coexisting macrovascular and microvascular complications, and medication lists of the subjects was recorded. We also obtained biochemical data using the hospital''s arthropathy (p = 0.01, OR 2.9 [1.38–9.29]), longer diabetes duration, defined as 15 years or longer (p = 0.03, 2.2 [1.00–4.86]), dyslipidaemia (p = 0.04, 3.4 [0.94–12.38]), neuropathy (p = 0.03, 3.3 [1.05–10.26]), PVD (p = 0.04, 2.6 [1.03–6.55]), and CABG surgery (p = 0.01, OR 4.1 [1.81–30.76]) to be significantly associated with increased risk of amputation, amongst others (refer to Table 3). Binary logistic regression analyses identified retinopathy, CABG surgery, Charcot''s arthropathy p = 0.01, 2.9 [1.29–6.70]Chronic kidney disease p = 0.27, 1.5 [0.72–3.16]Coronary artery bypass graft surgery p = 0.01, 4.1 [1.29–13.17]Depression p = 0.05, 2.2 [0.98–5.10]Dialysis p = 0.62, 1.5 [0.32–6.94]Dyslipidaemia p = 0.04, 3.4 [0.94–12.38]eGFR < 45 mL/min p = 0.08, 2.1 [0.91–4.73]Foot antibiotics p = 0.04, 2.3 [1.03–4.98]Gastrooesophageal reflux disease (GORD) p = 0.34, 1.5 [0.67–3.15]Haemoglobin < 8 g/dL p = 0.46, 1.7 [0.42–6.64]Hba1c > 7.5% p = 0.92, 1.1 [0.40–2.73]Hypertension p = 0.41, 1.6 [0.50–5.43]Hypoalbuminaemia p = 0.73, 0.9 [0.37–1.99]Indigenous ethnicity p = 0.01, 3.1 [1.25–7.92]Infection severity (mod-severe) p = 0.02, 0.4 [0.18–0.89]Insulin treatment p = 0.12, 1.9 [0.85–4.28]Ischaemic heart disease p = 0.24, 1.6 [0.75–3.24]Ischaemic ulcer type p = 0.84, 1.1 [0.52–2.25]Longer duration of diabetes p = 0.03, 2.2 [1.00–4.86]Male sex p = 0.53, 0.8 [0.37–1.66]Multiple ulcers p = 0.15, 0.6 [0.25–1.25]Nephropathy p = 0.15, 1.7 [0.82–3.56]Neuropathy p = 0.03, 3.3 [1.05–10.26]Obesity p = 0.09, 0.5 [0.23–1.13]Osteomyelitis p = 0.00, 3.9 [1.54–10.07]Peripheral vascular disease p = 0.04, 2.6 [1.03–6.55]Previous history of ulcers p = 0.06, 2.1 [0.98–4.41]Retinopathy p = 0.00, 4.4 [1.99–9.59]Smoking history p = 0.49, 0.8 [0.37–1.60]Statin therapy p = 0.06, 2.7 [0.95–7.78]Type of diabetes p = 0.46, 1.4 [0.56–3.65]Wound classification p = 0.93, 1.1 [0.30–3.78]

denotes being statistically significant.

Table 4

Risk factors associated with lower limb amputation in the study population [logistic regression analysis].

Risk factor p value, OR [CI]
Coronary artery bypass graft surgery p = 0.01, 7.5 [1.81–30.76]
Indigenous ethnicity p = 0.02, 3.3 [1.17–9.16]
Charcot'' findings of 15.4% to 21.4% [22, 23]. On the other hand our report conforms to Miner and Kirsner and Amogne et al. report of higher rate of LLA in their respective diabetic foot clinic populations [13, 24]. The high prevalence might be related to inclusion of the population at the highest risk of the disease and its complications [25]. In this study, Indigenous Australians were found to be at greater risk of diabetic LLA, which is in keeping with others''s foot, and Indigenous ethnicity. Whilst Ndip et al. provide data linking diabetic retinopathy to increased risk of DFU development [27], ours is the first study to identify retinopathy not only as a contributing factor, but also as the most significant factor leading to amputation amongst DF patients, accentuating the importance of early detection and management of diabetic complications. McEwen et al. found no association with retinopathy but reported a 2-3-fold amputation risk amongst patients with diabetic neuropathy [28], results that are consistent with ours, which isolate neuropathy and dyslipidaemia as significant risk factors for amputation. We identified PVD with increased risk of adverse outcome, also supported by current literature, which labels it as a causal factor for amputation and mortality amongst diabetics [2932]. We have additionally extended existing knowledge by highlighting CABG surgery as a novel risk factor for amputation, which supports the role of both microvascular and macrovascular disease as significant risk factors for LLA in subjects with diabetic foot ulcer.

Interestingly, there has been conflicting data on the role of ethnicity in the outcome of DFUs. Whilst multiple studies found unremarkable figures in amputation rates amongst a multiracial cohort [27, 28], Lavery et al. found a significant difference in both prevalence and ulcer severity contributing to amputation amongst African American cohorts in other parts of the world [33]. Correspondingly, we have found Indigenous ethnicity to be amongst the strongest contributing factors in our cohort, who were almost twice as likely to undergo an amputation. The higher prevalence of amputations in the group of Indigenous Australians could be attributed to a genetic predisposition or to a socioeconomic status that drives the patients to present late for clinical care. This result is supported by previous Australian data stating that Indigenous Australians are known to develop diabetes and its associated metabolic complications at a younger age [24, 34]. As the first study to be conducted in Northeastern Australia which hosts some of the largest Indigenous peoples nationwide, our results hold considerable significance for the local population, given that longer diabetes duration was flagged as a contributor for adverse outcome and highlights the need for earlier detection and management amongst Indigenous Australians [32, 35, 36].

Our results identified other risk factors of LLA in subjects with DFU including Charcot''s arthropathy, placing DFU patients at a 12 times higher lifetime risk of amputation [37, 38]. Similarly, in keeping with our findings, Wukich et al. have linked history of cellulitis and moderate-to-severe foot infection to amputation [39]. There is notably no current evidence suggesting use of antibiotics to prevent infections in subjects with DFU at risk of LLA in spite of our findings of antibiotics use preceding amputation. The tropical climate of Northeastern Australia is a likely contributor to this association, resulting in increased rates of bacterial skin and soft tissue infections requiring ongoing antimicrobial treatment. Moreover, a new association was also found with depression, suggesting that psychological health can be an indicator of healing and recovery in physical illness. Given that the DFU is known to have a biopsychosocial impact on its patients, this information accents the importance of a multidisciplinary team approach in treating the individual as a whole and calls for additional research in the area.

In contrast to others''s study, whose dialysis cohort mainly focused on a non-Hispanic Caucasian population, yet whilst they identified more limb amputations amongst their renal disease subgroup, we found no significant association between the two [41]. This could be explained by the nature of our study cohort, which focused on DFU patients with concurrent renal disease rather than a specific CKD or dialysis population, thereby missing a number of diabetic LLA patients that either did not meet the criteria or failed to attend the HRFC. Intensive glycaemic control has been established as an important prognostic healing factor and found to reduce diabetes-related mortality [42, 43]. However when discussed in linkage with lower extremity complications, some studies report a 20% higher risk of amputation amongst subjects with Hba1c levels above 7.5% similar to our findings but in contrast to Winkley et al. who reported Hba1c levels below 7.5% as having higher mortality and increased risk of amputation [31, 32, 44]. In light of this conflicting report further research is required to characterise the findings.

The period prevalence of IHD and AMI amongst the study cohort was similar to others''s arthropathy, and CABG surgery. Whilst there were no significant differences in amputation prevalence between the ischaemic and nonischaemic groups in the overall cohort, Indigenous subjects with ischaemic ulcers were amputated much more frequently. Extended research in the local area is encouraged to study factors leading to selectively higher amputation rate in the Indigenous population. We have made a huge development in identifying predisposing characteristics amongst DF patients, but our knowledge is not yet comprehensive to enable us to prevent limb amputation in the high risk diabetic population.

Competing Interests

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