OBJECTIVE -To assess changes in diabetic lower-extremity amputation rates in a defined relatively static population over an 11-year period following the introduction of a multidisciplinary foot team.RESEARCH DESIGN AND METHODS -All diabetic patients with foot problems admitted to Ipswich Hospital, a large district general hospital, were identified by twice-weekly surveillance of all relevant in-patient areas and outcomes including amputations recorded.RESULTS -The incidence of major amputations fell 62%, from 7.4 to 2.8 per 100,000 of the general population. Total amputation rates also decreased (40.3%) but to a lesser extent due to a small increase in minor amputations. Expressed as incidence per 10,000 people with diabetes, total amputations fell 70%, from 53.2 to 16.0, and major amputations fell 82%, from 36.4 to 6.7.CONCLUSIONS -Significant reductions in total and major amputation rates occurred over the 11-year period following improvements in foot care services including multidisciplinary team work. Diabetes Care 31:99-101, 2008A mputation is one of the most feared diabetes complications. The economic burden is immense, and survival is bleak, with a 2-year mortality up to 50% (1-6). There is an urgent need to reduce amputation rates, which vary considerably globally and nationally (7-13). Though often attributed to differences in ethnicity and local practice, such variability could be due to other factors. These include differences in defining minor versus major amputations and in assessing the denominator, i.e., 1) the size of the general population (often ill defined, particularly in cities because of overlap with other institutions) and 2) the diabetic population (sometimes simply estimated from the expected prevalence) (14). Finally, of considerable importance is the accuracy of ascertainment. Nearly all studies have been retrospective, collected from a variety of sources including theater and limb-fitting records, anesthetic databases, and hospital activity coding. In 2004, we demo n s t r a t e d t h a t c o m p a r e d w i t h prospective data collection, such methods underestimated the incidence by 4.2-90.6% and misclassified 4.5-17.4% of amputations (15). Others have reported similar inaccuracies (16,17). We therefore recommended that future studies should be prospective.This study of the impact of improvements in foot care on lower-extremity amputations (LEAs) addresses these problems; it is prospective, amputation levels are made clear, and the population is well defined.RESEARCH DESIGN AND METHODS -The survey was conducted between 1995 and 2005 in a defined, predominantly Caucasian (95%), mixed rural/urban population served by Ipswich Hospital from which there are few cross-boundary referrals. Over the period, the population grew from 330,462 to 345,890. In contrast, the diabetic population rose dramatically from 6,768 to 11,906. The largest increase followed introduction of the Quality and Outcomes Framework in 2005, whereby practitioners are paid to achieve diabetes targets (18).An LEA was de...
OBJECTIVE—The aim of this study was to evaluate a novel method for assessing the axon reflex and to determine its value in detecting neuropathy in type 2 diabetes. RESEARCH DESIGN AND METHODS—The neurogenic flare response to nociceptive stimuli is mediated by an axon reflex involving small unmyelinated C-fibers. We developed a method to assess this reflex involving skin heating to 44°C to evoke the flare followed by scanning the site using a laser Doppler imager (LDI) to measure the area; we termed this method LDIflare. To confirm its neurogenic nature, we examined the LDIflare in eight healthy subjects before and after topical administration of anesthesia. We used this technique to detect C-fiber neuropathy in people with type 2 diabetes. A total of 36 subjects were studied: 12 subjects with neuropathy (group DN), 12 subjects without neuropathy (group DC), and 12 age- and sex-matched control subjects (group NC). For comparison, small-fiber function was also assessed using the Computer Aided Sensory Evaluator–IV (CASE IV) (WR Medical Electronics, Stillwater, MN). RESULTS—In the eight healthy control subjects, LDIflare was markedly reduced after topical administration of anesthesia (1.62 [1.45–1.72] vs. 5.2 cm2 [3.9–5.9], P < 0.0001), confirming its neurogenic nature. Similarly, in neuropathic subjects, LDIflare was significantly smaller compared with normal and diabetic control subjects (LDIflare area: DN 1.3 cm2 [0.9–1.8], NC 5.5 cm2 [3.9–5.8], and DC 2.8 cm2 [2.5–3.8]; P < 0.0001 and P = 0.01, respectively). The group without neuropathy (DC) also demonstrated a reduced flare compared with the NC group (P = 0.01). In contrast, C-fiber function assessed by evaluating the quantitative thermal thresholds (CASE IV) did not detect a difference between the latter two groups. CONCLUSIONS—This study confirms the neurogenic nature of the LDIflare and clearly demonstrates loss of C-fiber function in neuropathic subjects with type 2 diabetes. Moreover, it demonstrates C-fiber dysfunction before its detection by other currently available methods, including CASE IV. The LDIflare seems to be a simple objective method to detect early neuropathy and may be of value in assessing therapeutic interventions aimed at preventing or reversing C-fiber dysfunction.
OBJECTIVE -The objective of this study was to accurately determine the incidence of lower-extremity amputation using prospective data collection and to compare the results with those obtained by retrospective methods.RESEARCH DESIGN AND METHODS -The study was carried out over a 3-year period in a large district general hospital covering a clearly defined and relatively static population. All diabetic inpatients with foot problems were identified and followed-up until discharge or death. The demographic and admission details, medical history, investigations, procedures, and history and etiology of the foot lesion were collected twice weekly by a specialist nurse and podiatrist from all relevant wards. Thus, all subjects who underwent amputation could be identified. For comparison, retrospective data were collected from the hospital coding activities database, operating theater log books, anesthetic database, and limb-fitting records.RESULTS -The total population of the region in 2000 was 337,859, of which 9,183 were known to have diabetes. The total number of amputations during the 3-year survey period was 79, of which 45 were major and 34 minor. In our local population, the mean incidence during the survey period (1997)(1998)(1999)(2000) equates to 7.8/100,000 general population and 2.85/1,000 diabetic population for all amputations, 4.5/100,000 general population and 1.62/1,000 diabetic population for major amputations, and 3.3/100,000 general population and 1.23/1,000 diabetic population for minor amputations. The prospective survey detected all lower-extremity amputations identified by the various retrospective methods; however, for the reverse, this was not the case. All of the retrospective methods, including the most commonly used (ICD-9 and OPCS-4 coding), failed to detect all of the cases revealed by the prospective survey (error rate ranging from 4.2 to 90.6%), and between 4.5 and 17.4% of amputations were misclassified.CONCLUSIONS -This study demonstrates the advantages of prospective data collection as a means of determining the incidence of lower-extremity amputations and highlights the limitations of retrospective data collection methods, which underestimate the incidence. In particular, the operating theater records, which have been the gold standard for many surveys, were found to be unreliable. Moreover, we have shown a 47% reduction in the major amputations during the survey period. Thus, we recommend that a prospective audit be incorporated into the activities of the specialist foot care team as a means of assessing and improving clinical care. Diabetes Care 27:1892-1896, 2004F oot complications, including amputations and ulceration, are a major cause of morbidity and mortality in people with diabetes, as well as a source of considerable cost to health care agencies (1-10). Estimating the total burden of all foot complications is difficult because the associated problems are managed by different elements of the health services and by health professionals from various specialties. For these reas...
OBJECTIVEThis study explored the importance of glycemic burden compared with features of the metabolic syndrome in the pathogenesis of diabetic neuropathy by comparing C-fiber function in people with type 1 diabetes to that in people with impaired glucose tolerance (IGT).RESEARCH DESIGN AND METHODSThe axon reflex–elicited flare areas (LDIflares) were measured with a laser Doppler imager (LDI) in age-, height-, and BMI-matched groups with IGT (n = 14) and type 1 diabetes (n = 16) and in healthy control subjects (n = 16).RESULTSThe flare area was reduced in the IGT group compared with the control (2.78 ± 1.1 vs. 5.23 ± 1.7 cm2, P = 0.0001) and type 1 diabetic (5.16 ± 2.3 cm2, P = 0.002) groups, whereas the flare area was similar in the type 1 diabetic and control groups.CONCLUSIONSThis technique suggests that small-fiber neuropathy is a feature of IGT. The absence of similar small-fiber neuropathy in those with longstanding type 1 diabetes suggests that glycemia may not be the major determinant of small-fiber neuropathy in IGT.
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