Prevention of amputation by diabetic education

doi:10.1016/0002-9610(89)90183-9

The American Journal of Surgery

Volume 158, Issue 6, December 1989, Pages 520-524

https://doi.org/10.1016/0002-9610(89)90183-9 Get rights and content

Abstract

This prospective randomized study evaluated the influence of a simple education program on the incidence of lower extremity amputation in diabetic patients. Two hundred three patients were randomized into two groups: Group 1, education (103 patients, 203 limbs) and Group 2, no education (100 patients, 193 limbs). There were no significant differences in medical management or clinical risk factors between the two groups. The amputation rate was three times higher in Group 2 (21 of 177 limbs versus 7 of 177 limbs; p ≤ 0.025), the ulceration rate was three times higher in Group 2 (26 of 177 limbs versus 8 of 177 limbs; p ≤ 0.005), and there was no difference in the overall incidence of infection (2 of 177 limbs). Overall success in Group 1 was highly significantly different from Group 2 (160 of 177 limbs versus 128 of 177 limbs; p ≤ 0.0005). This study demonstrated that a simple education program significantly reduced the incidence of ulcer or foot and limb amputation in diabetic patients.

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Factors Associated With Amputation Following Ankle Fracture Surgery
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Patients with diabetes mellitus (DM) are at increased risk of complications following ankle fracture surgery. Previous research suggests that patients of low socioeconomic status are at increased risk of amputation following orthopedic complications. The purpose of this research was to determine if low socioeconomic status increases risk of below-knee amputation (BKA) following ankle fractures among patients with DM. The National Inpatient Sample (NIS) was queried from 2010 to 2014 to identify 125 diabetic patients who underwent ankle fracture surgical fixation followed by BKA. Two cohorts (BKA vs no BKA) and a multivariate logistic regression model were created to compare the effects of independent variables, including age, sex, race, primary payer, median household income by ZIP code, hospital location/teaching status, and comorbidities. The most predictive variables for BKA were concomitant peripheral vascular disease (odds ratio [OR] 5.35, 95% confidence interval [CI] 3.51-8.15), history of chronic diabetes-related medical complications (OR 3.29, CI 2.16-5.01), age in the youngest quartile (OR 2.54, CI 1.38-4.67), and male sex (OR 2.28, CI 1.54-3.36). Patient race and median household income were not significantly associated with BKA; however, risk of BKA was greater among patients with Medicaid (OR 2.23, CI 1.09-4.53) or Medicare (OR 1.85, CI 1.03-3.32) compared to privately insured patients. Diabetic inpatients with Medicaid insurance are at over twice the odds of BKA compared to privately insured patients following ankle fracture. Furthermore, peripheral vascular diseases, uncontrolled diabetes, younger age, and male sex each independently increase risk of BKA.
Improved Self-Reported Comfort, Stability, and Limb Temperature Regulation With an Immediate Fit, Adjustable Transtibial Prosthesis
2020, Archives of Rehabilitation Research and Clinical Translation
The purpose of this investigation was to assess participants’ self-reported satisfaction with an adjustable, immediate fit transtibial prosthetic system as compared to their conventionally fabricated prosthetic device.
A prospective study involving a 2-week single-group pre-post intervention design.
Physical medicine and rehabilitation clinic of a university hospital.
Adults (N=27) with transtibial limb loss.
Participants were fit with the iFIT prosthetic system and instructed to wear it for a 2-week evaluation period.
A modified Prosthetic Evaluation Questionnaire (PEQ) scale was completed on the participant’s conventional prosthetic during the initial visit and the iFIT system after 2 weeks.
Twenty-seven persons with lower limb loss were enrolled. Three were lost to follow-up leaving 24 participants with completed data. Three participants had recent amputations with no conventional device for comparison. The modified PEQ scores were significantly higher for the iFIT prosthetic in comparison to their conventional device (29.18±4.63 vs 23.82±6.38, P<.01). Participants were also found to perceive significantly better temperature control with the iFIT prosthetic system (4.19±0.68 vs 2.97±1.02, P<.001). Participants did not report any skin breakdown, prosthetic issues, or falls.
This immediate fit, adjustable transtibial prosthesis demonstrated significantly better patient satisfaction and temperature perception compared to conventional devices. These results are consistent with previous findings and further support the efficacy of an immediate fit adjustable transtibial prosthetic system. Longer-term studies in the United States and internationally are underway to assess the durability and efficacy of this new prosthesis in different populations and settings.
Barriers to diabetic foot care in a disadvantaged population: A qualitative assessment
2020, Journal of Diabetes and its Complications
We explored barriers to proper foot care in this population using a qualitative approach with focus group discussions (FGD).
Participants were recruited from clinics at a safety-net hospital in Atlanta, Georgia and stratified into two groups: diabetic foot ulcer (DFU) and minor amputation (below ankle). The FGDs addressed patient experience in receiving care with a goal of understanding: foot care knowledge, barriers to care, and preferred educational methods. Surveys were performed to supplement FGDs.
Forty participants (90% Black) were enrolled. Dominant themes emerging from FGDs were: 1-Patients reported adequate understanding of recommended foot care practices; 2-Personal barriers to self-care included lack of motivation, high cost, poor insurance coverage of supplies, and difficulty limiting activity for proper offloading; 3-Hospital system barriers included difficulty making timely appointments and reaching a provider to arrange care; 4-Access to footcare-related information and services improved with greater disease severity. Participants stressed that improved access often came too late to alter their course. They expressed interest in developing peer support groups to facilitate learning and sharing information relating to DFU.
We found that patients with DFU or minor amputations have adequate footcare-related knowledge, but personal and systemic barriers limited appropriate foot care.
Evaluation of antimicrobial therapy and patient adherence in diabetic foot infections
2019, Clinical Epidemiology and Global Health
Diabetic foot infections (DFI) are common complications among diabetics. These wounds can cause discomfort and often become infected. In India, currently there is a paucity of data on patient adherence towards antibiotic use in DFIs. Therefore, this study was aimed to evaluate antimicrobial susceptibility pattern, antimicrobial therapy and its adherence in DFI patients.
A prospective observation study (N = 150, newly diagnosed DFI patients) was conducted in Kasturba hospital, Manipal over a period of 6 months. Culture and Sensitivity pattern of the microbes of the patients were obtained from hospital data management system to develop cumulative antimicrobial susceptibility pattern. Medication adherence was measured by using Culig adherence scale at the first follow-up visit.
The most common microbes were Methicillin-sensitive Staphylococcus aureus (23.9%), Klebsiella pneumonia (13.3%) and Escherichia coli (13.3%). Inj. Amoxicillin-Clavulanic acid 1.2 gm (28.6%) was highest prescribed empirical therapy in DFI's followed by Inj. Cefuroxime-Sulbactam 2.25 gm (14.6%), Ceftriaxone (0.7%) and Trimethoprim- Sulfamethoxazole (2%) was the most sensitive antibiotic. Cumulative antimicrobial susceptibility pattern shows Chloramphenicol, Colistin, Levofloxacin, Rifampicin has developed resistance towards most of the common organisms in DFI. Statistically significant association was observed between empirical therapy with T.Cefuroxime 625 mg and improved clinical outcomes (p < 0.001). Adherence shows that only 14% of patients have high adherence rates during first follow-up visit.
Ceftriaxone and Trimethoprim-Sulfamethoxazole are most sensitive antibiotics towards most common organisms in DFIs. T. cefuroxime 625 mg showed statistically significant improvement in clinical outcomes while adherence is very low in most of the DFI patients.
A systematic review and meta-analysis of patient education in preventing and reducing the incidence or recurrence of adult diabetes foot ulcers (DFU)
2018, Heliyon
Citation Excerpt :
The outcomes (incidence of ulcer and amputation, callus, nail problems, infections due to fungi and behaviour assessment score) were not specified in the method section of the study (Bloomgarden et al., 1987). In four of the six included RCTs, participants were at high risk of diabetic foot ulceration (Monami et al., 2015; Gershater et al., 2011; Lincoln et al., 2008; Malone et al., 1989) while in two RCTs participants were at low or medium risk of diabetic foot ulceration (Rönnemaa et al., 1997; Bloomgarden et al., 1987). Two RCTs focused solely on patient education in diabetic foot care (Monami et al., 2015; Gershater et al., 2011).
The World Health Organization (WHO) states that diabetic foot ulcers (DFU) are associated with disability, death among patients with diabetes and substantial costs, if not prevented or managed effectively. The aim here is to examine the effectiveness of patient education in preventing and reducing the incidence or recurrence of adult DFU and amputation.
A systematic review and meta-analysis of randomised clinical trials (RCTs) in adults aged 18+ who have diabetes mellitus (type 1 or type 2) or DFU. CINAHL, EMBASE, MEDLINE, PSYCINFO, Cochrane Library and Evidence-Based Nursing, National Library for Health, Medica and Google Scholar were searched. Only English language studies were considered. Databases were searched from their inception to September 2017.
Six RCTs met the inclusion criteria. Only five RCTs reported on the incidence of DFU whilst only two reported on amputation rates. There was no advantage of combining different educational approaches in preventing/reducing DFU, relative risk (RR) of 0.50 (95%CI 0.21, 1.17) (P = 0.11). Two RCTs based on foot care education alone were compared with usual care; the result showed a non-significant effect (P = 0.57) with high heterogeneity of 77%.
Analysis based on intensive versus brief educational approach showed a statistically reduced risk of incidence of DFU in the intervention group when compared to the control group; (RR, 0.37, 95%CI 0.14, 1.01) (P = 0.05) with high heterogeneity of 91%.
The intensive educational intervention was associated with reduced incidence of DFU.
Effectiveness of educational interventions for diabetes-related foot disease: A systematic review and meta-analysis
2024, Diabetes/Metabolism Research and Reviews

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^☆: Supported in part by a grant from the Veterans Administration, Washington, D.C.

^☆☆: Presented at the 41st Annual Meeting of the Southwestern Surgical Congress, Monterey, California, April 23–26, 1989.

¹: From the Department of Surgery, Maricopa Medical Center, the Tucson Veterans Administration Medical Center, and the Departments of Internal Medicine and Orthopedic Surgery, University of Arizona, Tucson, Arizona.

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Scientific paperPrevention of amputation by diabetic education☆,☆☆

Abstract

Am J Surg

Am J Surg

Lancet

The treatment of diabetes mellitus

Diabetic foot disease: a major problem

Round-up

Maricopa County Medical Society Newsletter

Collected study of 9 hospitals in Boston area

N Engl J Med

Chronic atherosclerotic occlusion of femoral artery

JAMA

Gangrene of the feet in diabetics

Arch Surg

Lower extremity amputation

Midleg amputation for gangrene in the diabetic

Ann Surg

Results of midleg amputations for gangrene in diabetics

JAMA

Scientific paper
Prevention of amputation by diabetic education☆,☆☆