Risk Factors for Below-the-Knee Amputation in Diabetic Foot Osteomyelitis After Minor Amputation

2019 ◽  
Vol 109 (2) ◽  
pp. 91-97 ◽  
Author(s):  
Whitney Miller ◽  
Chrystal Berg ◽  
Michael L. Wilson ◽  
Susan Heard ◽  
Bryan Knepper ◽  
...  
Keyword(s):  
Risk Factors ◽  
Diabetic Foot ◽  
Interquartile Range ◽  
Knee Amputation ◽  
Below The Knee ◽  
Minor Amputation ◽  
Increased Risk ◽  
Transmetatarsal Amputation ◽  
The Impact ◽  
Diabetic Foot Osteomyelitis

Background:Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO.Methods:This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation.Results:Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32–47 days) and 16 days for negative margin (interquartile range, 8–29 days). Longer duration of antibiotics was not associated with lower risk of BKA.Conclusions:Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.

scholarly journals Risk Factors for Below the Knee Amputation in Diabetic Foot Osteomyelitis

2015 ◽  
Vol 2 (suppl_1) ◽  
Author(s):  
Whitney Hernandez ◽  
Heather Young ◽  
Bryan Knepper ◽  
Susan Heard ◽  
Michael Wilson
Keyword(s):  
Risk Factors ◽  
Diabetic Foot ◽  
Knee Amputation ◽  
Below The Knee ◽  
Diabetic Foot Osteomyelitis

Successful Limb-sparing Treatment Strategy for Diabetic Foot Osteomyelitis

2012 ◽  
Vol 102 (4) ◽  
pp. 273-277 ◽  
Author(s):  
Alison M. Beieler ◽  
Timothy C. Jenkins ◽  
Connie S. Price ◽  
Carla C. Saveli ◽  
Merribeth Bruntz ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Antimicrobial Therapy ◽  
Diabetic Foot ◽  
Surgical Margin ◽  
Initial Therapy ◽  
Surgical Debridement ◽  
Knee Amputation ◽  
End Point ◽  
Below The Knee ◽  
Diabetic Foot Osteomyelitis

Background: Diabetic foot osteomyelitis is common and causes substantial morbidity, including major amputations, yet the optimal treatment approach is unclear. We evaluated an approach to limb salvage that combines early surgical debridement or limited amputation with antimicrobial therapy. Methods: We conducted a retrospective cohort study of patients treated between May 1, 2005, and May 31, 2007. The primary end point was cure, defined as not requiring further treatment for osteomyelitis of the affected limb. The secondary end point was limb salvage, defined as not requiring a below-the-knee amputation or a more proximal amputation. Results: Fifty patients with diabetic foot osteomyelitis met the study criteria. Initial surgical management included local amputation in 43 patients (86%) and debridement without amputation in seven (14%). Most infections (n = 30; 60%) were polymicrobial, and Staphylococcus aureus was the most common pathogen (n = 23; 46%). Parenteral antibiotics were used in 45 patients (90%). Patients who had pathologic evidence of osteomyelitis at the surgical margin received therapy for a median of 43 days (interquartile range [IQR], 36–56 days), whereas those without evidence of residual osteomyelitis received therapy for a median of 19 days (IQR, 13–40 days). Overall, 32 patients (64%) were considered cured after a median follow-up of 26 months (IQR, 12–38 months). Fifteen of 18 patients (83%) who failed initial therapy were treated again with limb-sparing surgery. Limb salvage was achieved in 47 patients (94%), with only three patients (6%) requiring below-the-knee amputation. Conclusions: In patients with diabetic foot osteomyelitis, surgical debridement or limited amputation plus antimicrobial therapy is effective at achieving clinical cure and limb salvage. (J Am Podiatr Med Assoc 102(4): 273–277, 2012)

scholarly journals Mortality and Conversion Rate to Below Knee or Above Knee Amputation Following Transmetatarsal Amputation

2020 ◽  
Vol 5 (4) ◽  
pp. 2473011420S0011
Author(s):  
D. Anthony Barcel ◽  
Susan M. Odum ◽  
Taylor Rowe ◽  
Jefferson B. Sabatini ◽  
Samuel E. Ford ◽  
...  
Keyword(s):  
Risk Factors ◽  
Conversion Rate ◽  
Significant Risk ◽  
High Rate ◽  
Administrative Database ◽  
Categorical Variables ◽  
Diabetic Patients ◽  
Knee Amputation ◽  
History Of ◽  
Transmetatarsal Amputation

Category: Midfoot/Forefoot; Diabetes; Other Introduction/Purpose: Non-traumatic lower extremity amputations (LEA), especially those performed in dysvascular and diabetic patients, are known to have poor long-term prognosis. Perioperative mortality has been reported at between 4 and 10%, and the 1 and 5 year mortality rates range between 22-33% and 39-69%, respectively. While poor outcomes in these patients have been described, there is no consensus as to the predictors of mortality. The purpose of the study is to determine the percentage of patients who had a complication following transmetatarsal amputation (TMA) and identify associated risk factors for complications and mortality. Methods: We queried our institution’s administrative database to identify 247 TMA procedures performed in 229 patients between January, 2002 and December, 2016. Electronic health records were reviewed to document complications defined as reoperation, amputation and mortality. Mortality was also verified using the National Death Index. Additionally, we recorded risk factors including diabetes, A1c level, end stage renal disease (ESRD), cardiovascular disease (CVD), peripheral vascular disease (PVD), history of revascularization, contralateral amputation, and neuropathy. The majority of the study patients were males (157, 69%) and the average age was 57 years (range 24-91). The median BMI was 28 (range 16-58) and 29% of the study patients were obese with a BMI ≥ 30. Fishers Exact tests were used to compare categorical variables. Kruskal-Wallis and Independent T-tests were used to compare numeric data. All data were analyzed using SAS/STAT software version 9.4 (Carey, NC) and a 0.05 level of significance was defined apriori. Results: The conversion rate to below (BKA) or above knee amputation (AKA) was 26% (64 of 247). Males (p=.0274), diabetics (p=.0139), patients in ESRD (p=.019), and patients with a history of CVD (p=.0247) or perioperative revascularization (p=.022) were more likely to undergo further amputation following an index TMA. BMI was significantly higher in patients requiring BKA/AKA (p=.0305). There were no significant differences in age (p=.2723) or A1c levels (p=.4219). The overall mortality rate was 35% (84 of 229). Diabetes (p=.0272), ESRD (p=.0031), history of CVD (p<.0001) or PVD (p=.0179) were all significantly associated with mortality. Patients who died were significantly older (p=.0006) and had significantly higher A1c levels (p=.0373). BMI was not significantly associated with mortality. Twenty-two patients who had 23 further amputations subsequently died. Conclusion: In our series of patients undergoing TMA, 26% underwent further amputation and 35% of patients died. Conversion rate to BKA or AKA occurred at a high rate regardless of preoperative revascularization or the use of tendo-achilles or gastrocnemius lengthening procedures. Male sex, diabetes, ESRD, history of CVD or revascularization are significant risk factors for further amputation. ESRD, diabetes, history of CVD or PVD, older age and higher A1c levels are significant risk factors for mortality. These data provide useful insight into risk factors to be emphasized when counseling patients and their families to establish realistic postoperative expectations.

scholarly journals 318. Deferring Amputation in Diabetic Foot Osteomyelitis: Doing more Harm than Good?

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S231-S232
Author(s):  
Shiwei Zhou ◽  
Brian M Schmidt ◽  
Oryan Henig ◽  
Keith S Kaye
Keyword(s):  
Diabetic Foot ◽  
Medical Management ◽  
Wound Care ◽  
Cohort Analysis ◽  
Severity Of Illness ◽  
Complete Healing ◽  
Knee Amputation ◽  
Management Group ◽  
One Year ◽  
Diabetic Foot Osteomyelitis

Abstract Background Diabetic foot osteomyelitis (DFO) is a leading cause of below knee amputation (BKA). Even when medical treatment is deemed unlikely to succeed, patients with DFO are often resistant to amputation. Methods An observational cohort analysis was done on patients with DFO at Michigan Medicine who were evaluated by podiatry and recommended BKA from Oct 2015 - Jun 2019. Primary outcome was mortality after BKA recommendation. Secondary outcomes were healing of affected limb, rate of BKA or above knee amputation (AKA) and total antibiotic days in the 6 months following. All intravenous antibiotics and oral courses of linezolid and fluoroquinolones were captured. Results Of 44 patients with DFO, 18 chose BKA, 26 chose medical management with wound care. Mean age of the cohort was 61, 68% male, 80% white with a median Charlson Comorbidity Index of 6 (IQR 4,7). The two groups were similar with regards to demographics and comorbid conditions. Those who chose medical management did so because their infection was non-life-threatening and they desired to avoid amputation. One-year mortality was greater in patients who were medically managed compared to those who had BKA (23.1% vs 0%, OR 11.7, 95% CI 0.6–222.9). Considering only the 33 patients who were followed for at least 2 years, 2-year mortality was also greater in the medically managed group compared to the BKA group (38.5% vs 5.6%, OR 10.6, 95% CI 1.2–92.7, Figure 1). Fewer patients in the medical management group had complete healing of their wound/stump compared to the BKA group (46.2% vs 88.9%, OR 9.3, 95% CI 1.8–49.1). In the medically managed group, 18 (69%) patients went on to require BKA or AKA at a median of 76.5 days compared to 2 (11%) in the BKA group who required AKA at 1 and 11 days following recommendation. Median antibiotic days were significantly greater in the medically managed group compared to the BKA group (55 IQR 42,78 vs 17 IQR 10,37, p=0.0017). Conclusion In this cohort of DFO patients where BKA was recommended, medical management was associated with increased mortality, poor healing of the affected limb, and excess antibiotic exposure compared to BKA. These findings are particularly notable as case mix and severity of illness were similar between the two groups. This study can be used to inform providers and patients in cases where BKA is recommended. Disclosures All Authors: No reported disclosures

Abstract T P136: Potential Contributors to the Declining Impact of Stroke Risk Factors with Age: Implications for Stroke Epidemiology in the Elderly

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
George Howard ◽  
Mary Cushman ◽  
Maciej Banach ◽  
Brett M Kissela ◽  
David C Goff ◽  
...  
Keyword(s):  
Risk Factors ◽  
Risk Factor ◽  
Stroke Risk ◽  
Multivariable Analysis ◽  
The Elderly ◽  
Stroke Risk Factors ◽  
Age Related ◽  
Increased Risk ◽  
The Impact ◽  
Age Related Changes

Purpose: The importance of stroke research in the elderly is increasing as America is “graying.” For most risk factors for most diseases (including stroke), the magnitude of association with incident events decreases at older ages. Potential changes in the impact of risk factors could be a “true” effect, or could be due to methodological issues such as age-related changes in residual confounding. Methods: REGARDS followed 27,748 stroke-free participants age 45 and over for an average of 5.3 years, during which 715 incident strokes occurred. The association of the “Framingham” risk factors (hypertension [HTN], diabetes, smoking, AFib, LVH and heart disease) with incident stroke risk was assessed in age strata of 45-64 (Young), 65-74 (Middle), and 75+ (Old). For those with and without an “index” risk factor (e.g., HTN), the average number of “other” risk factors was calculated. Results: With the exception of AFib, there was a monotonic decrease in the magnitude of the impact across the age strata, with HTN, diabetes, smoking and LVH even becoming non-significant in the elderly (Figure 1). However, for most factors, the increasing prevalence of other risk factors with age impacts primarily those with the index risk factor absent (Figure 2, example HTN as the “index” risk factor). Discussion: The impact of stroke risk factors substantially declined at older ages. However, this decrease is partially attributable to increases in the prevalence of other risk factors among those without the index risk factor, as there was little change in the prevalence of other risk factors in those with the index risk factor. Hence, the impact of the index risk factor is attenuated by increased risk in the comparison group. If this phenomenon is active with latent risk factors, estimates from multivariable analysis will also decrease with age. A deeper understanding of age-related changes in the impact of risk factors is needed.

Tobacco Use Is Associated with More Severe Adverse Outcomes Than Morbid Obesity after Aseptic Revision TKA

2021 ◽  
Author(s):  
Michael P. Hagerty ◽  
Rafael Walker-Santiago ◽  
Jason D. Tegethoff ◽  
Benjamin M. Stronach ◽  
James A. Keeney
Keyword(s):  
Risk Factors ◽  
Morbid Obesity ◽  
Tobacco Use ◽  
Adverse Outcomes ◽  
Smoking History ◽  
Morbidly Obese ◽  
Knee Amputation ◽  
Increased Risk ◽  
Aseptic Revision ◽  
Component Revision

AbstractThe association of morbid obesity with increased revision total knee arthroplasty (rTKA) complications is potentially confounded by concurrent risk factors. This study was performed to evaluate whether morbid obesity was more strongly associated with adverse aseptic rTKA outcomes than diabetes or tobacco use history—when present as a solitary major risk factor. Demographic characteristics, surgical indications, and adverse outcomes (reoperation, revision, infection, and amputation) were compared between 270 index aseptic rTKA performed for patients with morbid obesity (n = 73), diabetes (n = 72), or tobacco use (n = 125) and 239 “healthy” controls without these risk factors at a mean 75.7 (range: 24–111) months. There was no difference in 2-year reoperation rate (17.8 vs. 17.6%, p = 1.0) or component revision rate (8.2 vs. 8.4%) between morbidly obese and healthy patients. However, higher reoperation rates were noted in patients with diabetes (p = 0.02) and tobacco use history (p < 0.01), including higher infection (p < 0.05) and above knee amputation (p < 0.01) rates in patients with tobacco use history. Multivariate analysis retained an independent association between smoking history and amputation risk (odds ratio: 7.4, 95% confidence interval: 1.7–55.2, p < 0.01). Morbid obesity was not associated with an increased risk of reoperation or component revision compared with healthy patients undergoing aseptic revision. Tobacco use was associated with increased reoperation and above knee amputation. Additional study will be beneficial to determine whether risk reduction efforts are effective in mitigating postoperative complication risks.

scholarly journals High Rate of Fatal Overdose After Release from Prison In BC, Canada: A Data Linkage Study

2020 ◽  
Vol 5 (5) ◽  
Author(s):  
Stuart A Kinner ◽  
Wenqi Gan ◽  
Amanda Slaunwhite
Keyword(s):  
Risk Factors ◽  
Target Population ◽  
Linkage Study ◽  
High Rate ◽  
Physical And Mental Health ◽  
Overdose Death ◽  
Fatal Overdose ◽  
Increased Risk ◽  
The Impact ◽  
Release From Prison

IntroductionThe province of BC, Canada is in the grips of a sustained overdose epidemic. People released from prison are at increased risk of fatal drug overdose, but the impact of the overdose epidemic on mortality after release from prison in BC is poorly understood. Few studies have been able to examine risk factors for overdose death in this population. Objectives and ApproachWe aimed to (a) measure risk of overdose-related and all-cause death in different time periods after release from prison; and (b) identify risk factors for overdose-related and all-cause death. In a random 20% sample of the population of BC, Canada, we identified those released from prison 2015-2017 and examined linked health and correctional records for this cohort. ResultsOf 6106 persons released from prison 2015-2017, 77 (1.3%) died from any cause and 48 (0.8%) died from overdose 2015-2017. The incidence of all-cause death was 16.1 (95%CI 13.7-18.8) per 1000 person years, and the incidence of overdose death was 11.2 (95%CI 9.2-13.5) per 1000 person years. Risk factors for overdose death included a history of 3 or more incarcerations (HR=3.00, 95%CI 1.67-5.39), co-occurring substance use disorder and mental illness (HR=4.73, 95%CI 2.94-7.62), chronic physical morbidity (HR=3.10, 95%CI 1.97-4.88), and being dispensed benzodiazepines (HR=3.31, 95%CI 2.27-4.84) or opioids for pain (HR=6.77, 95%CI 3.86-11.89). The incidence of fatal overdose was significantly higher in the first two weeks post-release than at any other time during follow-up. ConclusionPeople released from prison in BC are at markedly increased risk of preventable death, mainly due to overdose. As such, people transitioning from prison to the community should be a key target population for overdose prevention efforts. To be maximally effective, these efforts must go beyond provision of methadone and naloxone on release, to consider physical and mental health comorbidities, and psychosocial disadvantage.

scholarly journals 575. Evaluation of Risk Factors and Clinical Outcomes of Patients with Vancomycin-Resistant Enterococcus Infections

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S271-S271
Author(s):  
Gauri Chauhan ◽  
Nikunj M Vyas ◽  
Todd P Levin ◽  
Sungwook Kim
Keyword(s):  
Risk Factors ◽  
Hospital Mortality ◽  
Clinical Outcomes ◽  
Subgroup Analysis ◽  
Term Care ◽  
Treatment Groups ◽  
Increased Risk ◽  
History Of ◽  
Vancomycin Resistant ◽  
The Impact

Abstract Background Vancomycin-resistant Enterococci (VRE) occurs with enhanced frequency in hospitalized patients and are usually associated with poor clinical outcomes. The purpose of this study was to evaluate the risk factors and clinical outcomes of patients with VRE infections. Methods This study was an IRB-approved multi-center retrospective chart review conducted at a three-hospital health system between August 2016-November 2018. Inclusion criteria were patients ≥18 years and admitted for ≥24 hours with cultures positive for VRE. Patients pregnant or colonized with VRE were excluded. The primary endpoint was to analyze the association of potential risk factors with all-cause in-hospital mortality (ACM) and 30-day readmission. The subgroup analysis focused on the association of risk factors with VRE bacteremia. The secondary endpoint was to evaluate the impact of different treatment groups of high dose daptomycin (HDD) (≥10 mg/kg/day) vs. low dose daptomycin (LDD) (< 10 mg/kg/day) vs. linezolid (LZD) on ACM and 30-day readmission. Subgroup analysis focused on the difference of length of stay (LOS), length of therapy (LOT), duration of bacteremia (DOB) and clinical success (CS) between the treatment groups. Results There were 81 patients included for analysis; overall mortality was observed at 16%. Utilizing multivariate logistic regression analyses, patients presenting from long-term care facilities (LTCF) were found to have increased risk for mortality (OR 4.125, 95% CI 1.149–14.814). No specific risk factors were associated with 30-day readmission. Patients with previous exposure to fluoroquinolones (FQ) and cephalosporins (CPS), nosocomial exposure and history of heart failure (HF) showed association with VRE bacteremia. ACM was similar between HDD vs. LDD vs. LZD (16.7% vs. 15.4% vs. 0%, P = 0.52). No differences were seen between LOS, LOT, CS, and DOB between the groups. Conclusion Admission from LTCFs was a risk factor associated with in-hospital mortality in VRE patients. Individuals with history of FQ, CPS and nosocomial exposure as well as history of HF showed increased risk of acquiring VRE bacteremia. There was no difference in ACM, LOS, LOT, and DOB between HDD, LDD and LZD. Disclosures All authors: No reported disclosures.

scholarly journals The Potential Therapeutic Value of Medicinal Plants in the Management of Metabolic Disorders

Molecules ◽  
2020 ◽  
Vol 25 (11) ◽  
pp. 2669 ◽  
Author(s):  
Trevor T. Nyakudya ◽  
Thulani Tshabalala ◽  
Rachael Dangarembizi ◽  
Kennedy H. Erlwanger ◽  
Ashwell R. Ndhlala
Keyword(s):  
Risk Factors ◽  
Medicinal Plants ◽  
South African ◽  
Health Benefits ◽  
Well Being ◽  
High Energy ◽  
Biologically Active ◽  
Potential Health ◽  
Increased Risk ◽  
The Impact

Metabolic syndrome (MetS) is a prevalent, multifactorial and complex disease that is associated with an increased risk of developing diabetes and other major cardiovascular complications. The rise in the global prevalence of MetS has been attributed to genetic, epigenetic, and environmental factors. The adoption of sedentary lifestyles that are characterized by low physical activity and the consumption of high-energy diets contributes to MetS development. Current management criteria for MetS risk factors involve changes in lifestyle and the use of pharmacological agents that target specific biochemical pathways involved in the metabolism of nutrients. Pharmaceutical drugs are usually expensive and are associated with several undesirable side effects. Alternative management strategies of MetS risk factors involve the use of medicinal plants that are considered to have multiple therapeutic targets and are easily accessible. Medicinal plants contain several different biologically active compounds that provide health benefits. The impact of phytochemicals present in local medicinal plants on sustainable health and well-being of individuals has been studied for many years and found to involve a plethora of complex biochemical, metabolic, and physiological mechanisms. While some of these phytochemicals are the basis of mainstream prescribed drugs (e.g., metformin, reserpine, quinine, and salicin), there is a need to identify more medicinal plants that can be used for the management of components of MetS and to describe their possible mechanisms of action. In this review, we assess the potential health benefits of South African ethnomedicinal plants in protecting against the development of health outcomes associated with MetS. We aim to provide the state of the current knowledge on the use of medicinal plants and their therapeutically important phytochemicals by discussing the current trends, with critical examples from recent primary references of how medicinal plants are being used in South African rural and urban communities.

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