Purpose: Diabetic foot ulcers (DFUs) are a leading cause of lower extremity amputations among persons with diabetes (PWD) and a common cause of hospitalizations. This study identified demographic characteristics, lab values, and comorbidities associated with 30-day and 90-day hospital readmission in persons with DFU. Methods: A retrospective chart review at our institution examined 397 patients with type 2 diabetes admitted with DFU between January 2014 and December 2018. Variables were analyzed using descriptive statistics, t-tests, and logistic regressions. Results: None of the studied demographic, laboratory (including Hemoglobin A1c) or comorbid diseases were associated with 30-day readmission in persons with DFU. Risk factors for 90-day readmission included discharge location to home with health care (OR: 2.62, 95% CI: 1.39, 4.95), anticoagulant use (OR: 2.36, 95% CI: 1.27, 4.39), and SQ insulin use (OR: 2.08, 95% CI: 1.20, 3.61). Conclusions: None of the variables examined were associated with 30-day readmission; however, potential predictors for 90-day readmission included anticoagulation or insulin use and discharge home with healthcare services. Future studies should devise interventions to improve transition of care in patients with DFU to further assess the role of medications and home health care as a potential predictor of 90-day hospital readmission.
Objective: The purpose of this study is to determine the utility of using indocyanine green fluorescence angiography (IGFA) in assessing perfusion of chronic wounds after hyperbaric oxygen (HBO2) therapy. Method: From May 2016 to January 2018, 26 patients underwent both HBO2 and IGFA. A near-infrared charge- coupled camera measured the flow of intravenous indo- cyanine green into the wound. IGFA was done pre-HBO2, after approximately 10 HBO2 sessions, and upon completion of HBO2. The ingress rate at baseline, mid-therapy and post-HBO2 values were compared using descriptive statistics. Results: A total of 26 chronic wounds were identified. Baseline median ingress rate was 0.90 units/second (IQR: 0.28 to 6.10). Median ingress rate after approximately of 10 HBO2 sessions was 2.45 units/sec (IQR: 0.48 to 6.35). Six of 11 patients, however, exhibited a decrease in ingress rate from baseline to mid-therapy. Finally, median ingress rate post-HBO2 was 3.70 units/second (IQR: 0.30 to 9.90). Median increase in ingress and rate from baseline to mid-HBO2 treatment 0.30 units/second (IQR: -0.25 to 3.10) and from mid- to post-HBO2 was -0.40 units/second (IQR: -1.50 to 2.60). Conclusion: This preliminary study shows capability of IGFA to detect changes in blood flow to wounds following HBO2 therapy. Results support the use of IGFA to evaluate the changes in perfusion of patients undergoing HBO2 for chronic wounds. A larger sample size may help clarify the benefit of IGFA to predict potential for wound healing.
Background Diabetic foot ulcers (DFU) are the leading cause of lower-extremity amputations among patients with diabetes (DM)1. 15% of patients with DM develop DFU, with the potential for progression to osteomyelitis or gangrene with suboptimal glycemic control. Repeated readmissions are not only a negative prognostic indicator for these patients, but also contributes to increasing healthcare costs. Areas of Uncertainty Previous studies have examined associations among demographics, comorbidities and DFU, and the value of Hemoglobin A1c (HbA1c) and C-reactive protein (CRP) as a prognostic indicator and monitoring tool for progression and regression, respectively3,4. However, no studies to date have examined medical or pharmaceutical factors contributing to 30-day and 90-day readmission. Methods A retrospective chart review was conducted examining 397 patients with type 2 diabetes readmitted for DFU between 2014 and 2019. Variables were summarized using descriptive statistics, t-tests, chi-square, and logistic regressions. Results Majority of patients were white males with a BMI over 30 and HbA1c >7%. Patients with 30-day readmission were more likely to be using anticoagulants (30.00% vs. 17.24%, p= 0.0493). Patients with 90-day readmission were more likely to be discharged home with healthcare services (55.67% vs. 39.85%, p=0.0341) or to a skilled nursing facility (7.22% vs. 6.02%, p=0.0341). Although not statistically significant, patients with both 30-day and 90-day readmissions were also more likely to have HbA1c >7, while those with a 90-day readmission had higher CRP levels. Conclusions DFU patients with suboptimal glycemic control were more likely to experience a 30-day and 90-day readmission. Predicators for readmission in this population include: anticoagulation use, discharge to a skilled nursing facility or discharge home with healthcare services. As a result, patients not on anticoagulation, as well as those discharged home without services or to rehabilitation facilities have a reduced risk of readmission. 1. Lazzarini PA, Clark D, Derhy PH. What are the major causes of lower limb amputations in a major Australian teaching hospital? The Queensland Diabetic Foot Innovation Project, 2006 – 2007. 2011;4(1):O24. doi:10.1186/1757-1146-4-S1-O24 2. Vella L, Gatt A, Formosa C. Does Baseline Hemoglobin A1c Level Predict Diabetic Foot Ulcer Outcome or Wound Healing Time? Journal of the American Podiatric Medical Association. https://www.ncbi.nlm.nih.gov/pubmed/28880596. Published July 2017. Accessed September 28, 2019. 3. King DE, Mainous AG, Buchanan TA, Pearson WS. C-Reactive Protein and Glycemic Control in Adults With Diabetes. Diabetes Care. https://care.diabetesjournals.org/content/26/5/1535. Published May 1, 2003. Accessed September 28, 2019.
Background: Enhanced recovery protocols (ERP) are designed to achieve early improvement post-operatively by maintaining organ function and reducing stress response. Stress stimulates the hypothalamus-pituitary-adrenal (HPA) axis resulting in marked hyperglycemia 1 . Previous studies have shown that patients experience better outcomes and fewer complications when they use ERP 2,3 . ERP utilizes a high carbohydrate load in the form of liquid shakes or juice the night before and the morning of surgery. It remains to be seen how the use of this carbohydrate load can affect outcomes in persons with diabetes. The goal of this study is to determine the effectiveness of ERP on the length of stay (LOS) in persons with diabetes requiring colorectal surgery. Methods: A retrospective chart review was performed on 74 patients with diabetes: 37 received ERP and 37 did not. The participants had their surgery between September 2012 and February 2018. Both groups were matched according to age and sex and LOS was compared as the primary outcome. Secondary variables explored were race, insurance, and benign vs. malignant pathology results. A p-value of <0.05 was considered statistically significant. Results: Majority of patients were white (76%) and male (57%) with Medicare insurance. In the group of persons with diabetes who received the ERP, the average LOS was three days (95% CL of 3.0324-5.7244) as compared to an average of eight days (95% CL of 6.6450-10.5442) in the group who did not receive ERP (p=0.0006). Older age was the only variable which correlated positively (p=0.046) and significantly with LOS; there was no difference seen amongst race, insurance or pathology results. Conclusion: This study showed that using ERP in the form of carbohydrate loading in patients with diabetes can significantly reduce LOS as compared to those who did not receive the protocol. Utilization of an ERP has the potential to improve patient outcomes, especially in persons with diabetes. The limitations of our study include that it was retrospective in design and had a small sample size. As a result, future research should include large prospective trials which would help to determine the safety and efficacy of ERP in patients with diabetes. REFERENCES: 1) Hall GM. The anesthetic modification of the endocrine and metabolic response to surgery. Ann R Coll Surg Engl . 1985;67(1):25-9. 2) Cakir H, et al. Adherence to Enhanced Recovery after Surgery and length of stay after colonic resection. Colorectal Dis . 2013:15:1019-1025. 3) Ljungqvist O, et al. Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proc Nutr Soc . 2002; 61(3): 329-336.
Background : The perioperative use of Enhanced Recovery Protocol (ERP) has demonstrated improvement in the length of stay (LOS) and the rate of complications in multiple Randomized Control Trials (RCT) 1 . One of the components of this protocol is supplementation of carbohydrate solution (low dose: 10-44g or high dose: 45g or more) the night before and to two hours prior to the surgery. Carbohydrate rich drink as part of ERP improves glycemic control post-operatively most likely by inducing endogenous insulin release. This markedly improves the protein synthesis in first 24 hours after the surgery thereby improving muscle strength and nitrogen economy. However, most of the RCTs examining the impact of ERP have excluded the patients with diabetes 2 due to concerns about an increased risk of poor outcomes. Patients with hyperglycemia are more likely to develop immunosuppression, impaired wound healing and perioperative infections 3,4 . Here we aim to study retrospectively the clinical outcomes of glucose supplementation in patients with diabetes compared to those without undergoing ERP for colorectal surgery. Methods : We conducted a retrospective chart review of 88 patients with diabetes and 437 patients without diabetes who used the ERP perioperatively for a colorectal surgery between September 2012 and February 2018. We performed an age and sex related cross match between 108 patients with diabetes (N=54) who received ERP to those without diabetes (N=54) who received ERP and compared the LOS as primary outcome. Data was summarized using descriptive statistics. Two-sample t-test/Wilcoxon rank sum test was used to compare the continuous variables including length of stay between diabetic and non-diabetic patients. Chi-squared/ Fisher’s exact test was used to see whether being diabetic or not was associated with other categorical variables such as gender. Results : Majority of the patients were white (83%) with private insurance (55%) and a mean age of 67.1 years. There was even distribution of males and females. There was no difference in the mean LOS of the patients with diabetes vs. those without diabetes (4.0 days [95% CI: 3.18 to 4.81 days] vs 4.03 days [95% CI: 3.09 to 4.98 days], P=0.95). Older age positively correlated with increased LOS, but race, insurance type and tumor pathology did not. Conclusions : Patients with diabetes undergoing colorectal surgery with use of an ERP protocol perioperatively have no significant difference in their length of stay as compared to those without diabetes. Although our study included only a small sample size, it supports the need to conduct an RCT that would further help to establish safety of utilization of ERP in patients with diabetes. References: (1) Liang et al. Int J Colorectal Dis (2012) 27:1549-1554 (2) Crowe PJ et al. Br J Surg ...
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