Major limb amputation and mortality in patients with neuro‐ischaemic lower extremity wounds managed in a tertiary hospital: Focus on the differences among patients with diabetes, peripheral arterial disease and both

Abstract

A majority of lower extremities neuro-ischaemic wounds (NIU) are related to:(a) only diabetes (DM); (b) only peripheral artery disease (PAD); (c) co-existing diabetes and peripheral artery disease (DM-PAD). This study aims to characterise the major clinical outcomes of forementioned three groups of lower extremity wound patients in Singapore. Patients hospitalised for lower extremity NIU between January 2014 and October 2017 in a tertiary hospital in Singapore were analysed. Patients' major limb amputation and mortality were assessed using Cox regression models. Cumulative survival and amputationfree survival among the three classified groups were calculated using Kaplan-Meier analysis. Compared with patients with only DM, those in the PAD group and the DM-PAD group had higher risk of major limb amputation (adjusted hazard ratio: 2.47, 95% CI: 1.65-3.70; adjusted hazard ratio: 2.01, 95% CI: 1.53-2.65 respectively) and mortality (adjusted hazard ratio: 2.36, 95% CI: 1.57-3.55; adjusted hazard ratio: 2.46, 95% CI: 1.86-3.26 respectively). The 3-year survival and amputation-free survival were lowest in the DM-PAD group (52.1% and 41.5% respectively), followed by the PAD group (53.3% and 44.6% respectively) and the DM group (74.2% and 68.5% respectively). Lower extremity NIU patients with PAD or DM-PAD were found to have poorer clinical prognosis than those with DM only.

Global mortality of diabetic foot ulcer: A systematic review and meta‐analysis of observational studies

“…Kaplan–Meier was used to describe the survival of DFU in 28 of the included studies 9,10,12‐21,23‐25,27,29‐38,40,41 . Of these studies, the number at risk and survival proportions could be estimated in 27 studies 9,10,12‐21,23‐25,27,29‐31,33‐38,40,41 . The pooled 1‐, 3‐, 5‐ and 10‐year Kaplan–Meier‐based survival rates, including 21 171 patients, were 86.9% (95% CI 82.6%‐91.5%), 66.9% (95% CI 59.3%‐75.6%), 50.9% (95% CI 42.0%‐61.7%) and 23.1% (95% CI 15.2%‐34.9%), respectively.…”

“…40 Thirteen studies assessed the impact of cardiovascular disease history on mortality. 8,9,[15][16][17][18]21,24,27,32,33,36,40 The pooled HR was 1.449 (95% CI 1.276-1.645, P < .001, I 2 = 74.9%) (Figure 5D). In sensitivity analysis, the pooled HR was stable after omitting any one of the included studies (Figure S11).…”

“…The other three studies showed that the HRs and 95% respectively. 15,26,31 Nine studies reported the effect of gender on mortality. 16,18,21,23,26,30,37,40,44 The study by Iacopi et al 44 was a secondary analysis of the same population in the study performed by Piaggesi et al 38 The pooled HR showed that there was no difference in mortality between the two genders (HR 1.124, 95% CI 0.832-1.519, P = .447) (Figure S5).…”

The burden of costs on health services by patients with neuro‐ischaemic ulcers in Singapore

“…6 Neuro-ischemic ulcer (NIU) is one of the main subtypes of chronic leg ulcers and is associated with patients with diabetes (DM) and/or peripheral artery disease (PAD). 7 NIU consists of a spectrum that can be predominantly neuropathic (those with diabetes only), predominantly ischaemic (those with the peripheral arterial disease only) or has both components (those with both diabetes and peripheral arterial disease). 8,9 The prevalence of diabetic foot ulcers (DFUs) among DM patients is 4% to 10%, 10 and an estimated 50% of patients with foot ulceration are diagnosed with PAD in developed countries, while neuropathic ulcers are more prevalent in developing countries.…”

“…Neuro‐ischemic ulcer (NIU) is one of the main subtypes of chronic leg ulcers and is associated with patients with diabetes (DM) and/or peripheral artery disease (PAD) 7 . NIU consists of a spectrum that can be predominantly neuropathic (those with diabetes only), predominantly ischaemic (those with the peripheral arterial disease only) or has both components (those with both diabetes and peripheral arterial disease) 8,9 .…”