1. |
- Apelqvist, Jan, et al.
(författare)
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Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients.
- 2011
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Ingår i: Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. - : Elsevier BV. - 1097-6809. ; 53, s. 1582-1588
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: Peripheral vascular disease (PVD) is an important limiting factor for healing in neuroischemic or ischemic diabetic foot ulcer. The purpose of this study was to identify factors related to healing in patients with diabetes with foot ulcers and severe PVD. METHODS: Patients with diabetes with a foot ulcer, consecutively presenting at a multidisciplinary foot center with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg were prospectively included, followed according to a preset program, and with the exception of specified exclusions, subjected to angiography offered vascular intervention when applicable. All patients had continuous follow-up until healing or death irrespective of the type of vascular intervention. RESULTS: One thousand one hundred fifty-one patients were included. Eighty-two percent had a toe pressure <45 mm Hg and 49% had an ankle pressure <80 mm Hg. Eight hundred one patients (70%) underwent an angiography. Out of these, 63% had vascular intervention, either percutaneous transluminal angioplasty (PTA; 39%) or reconstructive surgery (24%). Nine percent of the patients had one or more complications after angiography. PTA was multisegmental in 46% and to the crural arteries in 46%. Reconstructive surgery was distal in 51%. Age (P < .001), renal function impairment (P = .005), congestive heart failure (P = .01), number and type of ulcer (P < .001), and severity of PVD (P = .003) affected the outcome of ulcers. PTA and reconstructive vascular surgery increased the probability of healing without amputation (odds ratio [OR], 1.77 and 2.05, respectively). CONCLUSION: Probability of ulcer healing is strongly related to comorbidity, extent of tissue involvement, and severity of PVD in patients with diabetes with severe PVD.
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2. |
- Apelqvist, Jan, et al.
(författare)
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Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome
- 1992
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Ingår i: Journal of Diabetes and its Complications. - 1873-460X. ; 6:3, s. 167-174
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Tidskriftsartikel (refereegranskat)abstract
- The association between medical risk factors and the outcome of foot ulcers was evaluated in 208 consecutive diabetic patients with severe peripheral vascular disease (systolic toe blood pressure < or = 45 mm Hg). All patients were treated and followed by the same foot care team. Eighty patients healed primarily, 83 healed after a minor or major amputation, and 45 died. The systolic toe blood pressure was higher among primary healed (30 +/- 13 mm Hg) compared with amputated (22 +/- 15 mm Hg; p < 0.001) and deceased patients (20 +/- 14 mm Hg; p < 0.001). The patients were comparable regarding age, sex, and diabetes and wound duration. Only 41 (19%) patients had intermitten claudication, whereas 153 (77%) lacked palapble pedal pulses, 36% of whom healed primarily. Rest pain occurred in 72 (33%) patients, 38 (47%) of whom had an amputation and 18 (25%) who healed primarily (p < 0.01). Peripheral edema and proteinuria were more common among patients who healed after amputation compared with those who healed primarily (p < 0.001 and p < 0.01, respectively). Signs of sensory neuropathy were found in 158 (77%) patients. There were no differences concerning cardiovascular disease, smoking habits, or short-term metabolic control between patients who healed primarily or after an amputation. In conclusion, diabetic patients with foot ulcers and severe peripheral vascular disease with low systolic toe blood pressure were not excluded from the possibility of primary healing. The most important risk factors for amputation were a systolic toe pressure of less than 30 mm Hg, peripheral edema, rest pain, and proteinuria.
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3. |
- Apelqvist, Jan, et al.
(författare)
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The Diabetic Foot Syndrome Today : A Pandemic Uprise
- 2017
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Ingår i: The Diabetic Foot Syndrome. - : S. Karger AG. - 0251-5342. - 9783318061451 ; 26, s. 1-18
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Bokkapitel (refereegranskat)abstract
- Diabetes mellitus is growing at epidemic proportions worldwide; currently 415 million adults are estimated to have diabetes and by 2040, this number is estimated to increase to 642 million. As a consequence, the prevalence of diabetes-related complications is bound to increase. Diabetic foot disorders are common throughout the world, resulting in major medical, social and economic consequences for the patients, and a public health problem. The risk for ulceration and amputation is much higher in individuals with diabetes compared to that of the non-diabetic population: it is estimated that every 20 s an amputation is performed on an individual with diabetes somewhere in the world. Foot ulceration is the commonest major end point among diabetic complications. More than 5% of diabetic patients have a history of foot ulceration and the cumulative lifetime incidence may be as high as 25%. Incidence and prevalence figures related to both foot ulcerations and lower extremity amputations have been reported worldwide. There is a substantial global variation in the incidence and prevalence of amputation and diabetic foot ulcer (DFU). The variation may be partially explained by differences in the measurement of amputation and DFU, as well as the ascertainment of diabetes, demographic factors, setting or other confounders. There is an urgent need to determine a standardized way to report the incidence and prevalence of diabetes-related amputation and foot ulcer in order to be able to be used as a marker of quality of care.
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4. |
- Apelqvist, Jan, et al.
(författare)
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The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers
- 1990
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Ingår i: Journal of Diabetic Complications. - 0891-6632. ; 4:1, s. 21-25
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Tidskriftsartikel (refereegranskat)abstract
- The influence of external precipitating factors and the presence of peripheral neuropathy on the development and outcome of foot ulcers were evaluated in 314 consecutive diabetic patients. All patients were treated by the same foot care team. Each patient was represented by one ulcer, and primary healing was defined as intact skin for at least six months. External precipitating factors were identifiable in 264 of 314 patients. The most common factors were ill fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia. The highest primary healing rates were seen in lesions caused by paronychia (84%) and stress ulcer (76%). Clinical signs of sensory and muscular disturbances were seen in the majority of patients (96%). Sensory neuropathy, evaluated with a biothesiometer, was more common among patients who had had amputations or, died subsequently compared to those who healed. This study suggests that a majority of diabetic foot ulcers might have been prevented, since a precipitating external factor was identified in four of five patients, stressing the importance of preventive foot care.
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5. |
- Elgzyri, Targ, et al.
(författare)
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Outcome of Ischemic Foot Ulcer in Diabetic Patients Who Had no Invasive Vascular Intervention.
- 2013
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1532-2165 .- 1078-5884. ; 46:1, s. 110-117
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE/BACKGROUND: There is limited information regarding outcome in patients not available for revascularisation. Our aim was to identify factors related to ulcer healing in diabetic patients with severe peripheral arterial disease who were not available for revascularisation. METHODS: Diabetic patients with a foot ulcer, consecutively presenting at a multidisciplinary foot centre with systolic toe pressure <45 mmHg or an ankle pressure <80 mmHg were prospectively included. Patients who received revascularisation were excluded. All patients had continuous follow-up until healing or death. RESULTS: Out of 602 patients (median age: 76 years) included in this study, 50% healed either primarily (76%) or with a minor amputation (24%). Seventeen percent of patients healed after major amputation and 33% died unhealed. By regression analysis, rest pain, impaired renal function, ischemic heart disease, cerebral vascular disease, extent of tissue destruction, and ankle pressure >50 mmHg affected the outcome of the ulcers. CONCLUSION: Diabetic patients with ischemic foot ulcers not available for revascularisations are not excluded from healing without major amputation. Factors strongly related to outcome were co-morbidity, severity of peripheral arterial disease, and extent of tissue destruction. Our findings reinforce the need for a classification system considering these factors at decision-making for vascular intervention.
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6. |
- Kalani, Majid, et al.
(författare)
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Beneficial effects of dalteparin on haemostatic function and local tissue oxygenation in patients with diabetes, severe vascular disease and foot ulcers.
- 2007
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Ingår i: Thrombosis research. - : Elsevier BV. - 0049-3848 .- 1879-2472. ; 120:5, s. 653-61
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: A state of hypercoagulation and fibrinolytic dysfunction is present in individuals with diabetes, which may contribute to disturbed skin microcirculation and impaired ulcer healing. We have previously reported an improved outcome of chronic diabetic foot ulcers during treatment with dalteparin. In the present study we investigated the effects of dalteparin on skin microcirculation and haemostatic function. MATERIALS AND METHODS: 87 patients with diabetes, peripheral arterial obliterative disease and chronic foot ulcers were investigated in a prospective, randomised, double-blind and placebo-controlled study. They were randomised to treatment with subcutaneous injections of 5000 U dalteparin (n=44) or placebo (n=43), once daily until ulcer healing or for a maximum of six months. Plasma fibrinogen, fibrin gel structure [permeability coefficient (Ks) and fiber mass/length ratio (mu)], prothrombin fragment 1+2 (F1+2) antigen, plasminogen activator inhibitor-1 (PAI-1) activity and tissue plasminogen activator (tPA) antigen were analysed before randomization (baseline value), and at the end of the treatment period. The skin microcirculation of the foot was investigated by transcutaneous oxygen tension (TcPO(2)) and laser Doppler fluxmetry (LDF). RESULTS: The changes (Delta-values) of Ks, mu, tPA and TcPO(2) were higher (p<0.05) during treatment with dalteparin, as compared to the changes during treatment with placebo. At baseline, plasma fibrinogen and Ks were significantly correlated to TcPO(2). CONCLUSIONS: Local skin oxygenation improved and a less thrombogenic fibrin gel structure was formed in patients treated with dalteparin. Beneficial effects on haemostatic function are likely to contribute to the improved skin oxygenation observed during treatment with dalteparin.
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7. |
- Kalani, Majid, et al.
(författare)
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Effect of dalteparin on healing of chronic foot ulcers in diabetic patients with peripheral arterial occlusive disease: a prospective, randomized, double-blind, placebo-controlled study.
- 2003
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Ingår i: Diabetes care. - : American Diabetes Association. - 0149-5992 .- 1935-5548. ; 26:9, s. 2575-80
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: Chronic foot ulcers are a common, severe, and expensive complication threatening life and limb in patients with diabetes. The aim of the present study was to investigate the effect of dalteparin on ulcer outcome in patients with diabetes, peripheral arterial occlusive disease, and chronic foot ulcers. RESEARCH DESIGN AND METHODS: A total of 87 patients were investigated in a prospective, randomized, double-blind, placebo-controlled trial. Participants were randomized to treatment with subcutaneous injection of 5000 units dalteparin (Fragmin, Pharmacia Corporation; n = 44) or an equivalent volume of physiological saline (n = 43) once daily until ulcer healing or for a maximum of 6 months. Ulcer outcome was investigated by evaluating the number of patients 1). who healed with intact skin; 2). in whom the study ulcer was improved, unchanged, or impaired; or 3). who were amputated above or below the ankle level, as compared with control subjects. RESULTS: Two patients, one on dalteparin and one on placebo, dropped out of the study. Ulcer outcome was significantly better (P = 0.042, two-sided chi(2) test for trend) in the dalteparin group (n = 43) compared with the placebo group (n = 42). A total of 29 patients healed with intact skin (n = 14) or decreased the ulcer area >or=50% (n = 15) in the dalteparin group compared with 20 (n = 9 and 11, respectively) in the placebo group. Five patients in each group showed impaired ulcer healing, i.e., the ulcer area increased >or=50%. Two patients in the dalteparin group were amputated compared with eight in the placebo group. Time to healing with intact skin was 17 +/- 8 weeks in the dalteparin group compared with 16 +/- 7 weeks in placebo group (NS). CONCLUSIONS: The results of the present study indicate that dalteparin improves the outcome of chronic foot ulcers in diabetic patients with peripheral arterial occlusive disease.
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8. |
- Larsson, Jan, et al.
(författare)
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Local signs and symptoms in relation to final amputation level in diabetic patients. A prospective study of 187 patients with foot ulcers
- 1994
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Ingår i: Acta Orthopaedica Scandinavica. - : Medical Journals Sweden AB. - 0001-6470 .- 1745-3674. ; 65:4, s. 387-393
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Tidskriftsartikel (refereegranskat)abstract
- Local signs and symptoms were evaluated in 187 consecutively presenting diabetic patients undergoing amputation for foot ulcers. From admission until final outcome the patients were treated by the same multidisciplinary team both as in- and out-patients. At the time of amputation, the types of lesions were superficial/deep ulcer (n 17), ulcer with deep infection, but without gangrene (n 40), and gangrene with or without infection (n 130). Healing after a minor amputation (below the ankle) occurred in 74 patients, while 88 patients healed after a major amputation (above the ankle), and 25 patients died before healing had occurred. Deep infection and presence of popliteal or pedal pulses were associated with healing after minor amputation and so were ulcers on the small toes, metatarsal head area and midfoot. Pain, progressive gangrene, intermittent claudication, and decubital and multiple ulcers were related to healing after major amputation. In a logistic regression analysis, pain, progressive gangrene and intermittent claudication remained. However, none of these factors excluded healing of a minor amputation and thus selection of amputation level in diabetic patients with foot ulcers cannot be based upon these factors exclusively.
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9. |
- Larsson, Jan, et al.
(författare)
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Long-term prognosis after healed amputation in patients with diabetes
- 1998
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Ingår i: Clinical Orthopaedics and Related Research. - 0009-921X. ; :350, s. 149-158
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Tidskriftsartikel (refereegranskat)abstract
- In this prospective study, mortality, rehabilitation, and new amputations on the same or on the contralateral leg were studied in 189 patients with diabetes who had achieved healing of an index amputation. Ninety-three patients had achieved healing after an index minor (below the ankle) and 96 after an index major (above the ankle) amputation, precipitated by a foot ulcer. The healing time was 29 weeks (range, 3-191 weeks) with a minor amputation and 8 weeks (range, 3-104 weeks) with a primary major amputation. The mortality 1, 3, and 5 years after the index amputation was 15%, 38%, and 68%, respectively, and was higher in patients who had achieved healing after major amputation than in patients achieving healing after minor amputation. The rate of new amputations after 1, 3, and 5 years of observation was 14%, 30%, and 49%, respectively. There was no difference among patients with an index minor and those with an index major amputation. The rate of new major amputations was 9%, 13%, and 23%, respectively, and was higher in patients with an index major amputation. Eighty-five percent of new amputations were precipitated by a foot ulcer. Patients living independently before the index amputation returned to living independently more often after a minor than a major amputation (93% versus 61%). One year after the index amputation, 70% of patients who had achieved healing after having a minor amputation and who could walk 1 km or more before amputation had regained this walking capacity, compared with 19% of patients having a major amputation. Seventy percent of patients with an index transtibial amputation who could walk before amputation were fitted with a prosthesis, and 52% were using it regularly. Patients with diabetes who had an index major amputation had a higher mortality, an equal rate of new amputation, and a lower rehabilitation potential than did patients who had an index minor amputation.
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10. |
- Larsson, Jan, et al.
(författare)
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Sustained reduction in major amputations in diabetic patients - 628 amputations in 461 patients in a defined population over a 20-year period
- 2008
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Ingår i: Acta Orthopaedica. - : Medical Journals Sweden AB. - 1745-3682 .- 1745-3674. ; 79:5, s. 665-673
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Tidskriftsartikel (refereegranskat)abstract
- Background and purpose With an ageing population and an increasing incidence of diabetes, reduction of the number of diabetes-related amputations becomes increasingly difficult to achieve and maintain. There is controversy in this respect regarding the degree of success. We started a multidisciplinary treatment program for diabetic foot ulcers in 1982, and have now assessed incidence rates of amputations from 1982 through 2001. Methods In a defined population, gradually increasing from 199,000 to 234,000, all diabetes-related amputations of the lower extremity from toe to hip were recorded from January 1, 1982 to December 31, 2001, using several sources of information. Results The incidence of major amputations decreased by 0.57 from 16 (11-22) to 6.8 (6.1-7.5) per 100,000 inhabitants between the first and last 4-year period. The most substantial decrease was seen in patients aged 80 years and older. The fraction of amputations with a final level at or below the ankle (n = 240) increased from 0.23 in the first 4-year period to 0.31, 0.49, 0.47, and 0.49 in the following 4-year periods. The overall fraction of re-amputation was 0.34 in the first 4-year period and 0.27, 0.21, 0.32, and 0.21 in the following 4-year periods. The fraction of amputations in diabetic patients that were channeled through the footcare team prior to amputation increased from 0.51 in the first 4-year period to 0.83, 0.86, 0.90, and 0.90 in the following 4-year periods. Interpretation Our findings indicate that a substantial decrease in the incidence of major lower extremity amputations in diabetic patients has been achieved and maintained.
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11. |
- Melhus, Åsa, et al.
(författare)
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Levofloxacin-associated Achilles tendon rupture and tendinopathy
- 2003
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Ingår i: Scandinavian Journal of Infectious Diseases. - : Informa UK Limited. - 0036-5548 .- 1651-1980. ; 35:10, s. 768-770
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Tidskriftsartikel (refereegranskat)abstract
- Fluoroquinolones have a documented ability to induce Achilles tendinopathy. Hitherto, few published reports have implicated levofloxacin. This article reports 5 cases of Achilles tendon disorders, including 3 complicated by rupture of the tendon, during levofloxacin treatment of patients with chronic obstructive pulmonary disease.
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12. |
- Torffvit, Ole, et al.
(författare)
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Increased Urine IgM and IgG2 Levels, Indicating Decreased Glomerular Size Selectivity, Are Not Affected by Dalteparin Therapy in Patients with Type 2 Diabetes
- 2012
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Ingår i: Biochemistry Research International. - : Hindawi Limited. - 2090-2247 .- 2090-2255. ; 2012, s. 480529-
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Tidskriftsartikel (refereegranskat)abstract
- Fifty-four type 2 diabetic patients with neuroischemic foot ulcers were randomised to treatment with 5000 IU of dalteparin, (n = 28), or physiological saline, (n = 26), once daily until ulcer healing or for a maximum of 6 months. Thirty-three patients had normo-, 15 micro-, and 6 macroalbuminuria. The urinary levels of IgM and IgG2 were elevated in 47 and 50 patients, respectively. Elevated urinary levels of IgM and IgG2 indicate decreased glomerular size selectivity. Urine IgM levels were associated with IGF-1/IGFBP-1 and IGFBP-1 levels. Dalteparin treatment increased urinary levels of glycosaminoglycans (P < 0.001) and serum IGFBP-1 (P < 0.05) while no significant effects were seen in any of the other studied parameters. In conclusion, dalteparin therapy in patients with type 2 diabetes had no effects on urinary levels of albumin, IgM, or IgG2 despite significantly increased glycosaminoglycans in urine. Elevated urinary levels of IgM and IgG2 might be more sensitive markers of renal disease than albuminuria in patients with type 2 diabetes and antihypertensive therapy.
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13. |
- Örneholm, Hedvig, et al.
(författare)
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Heel ulcers do heal in patients with diabetes
- 2017
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Ingår i: International Wound Journal. - : Wiley. - 1742-4801. ; 14:4, s. 629-635
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Tidskriftsartikel (refereegranskat)abstract
- A heel ulcer is considered to be a serious complication in patients with diabetes, and there is limited information regarding outcome. In most of the literature, a poor prognosis is described. The aim of this study was to investigate a large cohort of ulcers located in the heel in patients with diabetes. Seven hundred and sixty-eight patients [median age 73 (17-98)], presenting with a heel ulcer at a multidisciplinary diabetes foot clinic, fulfilled the inclusion criteria and were followed-up until final outcome. Fifty-eight per cent of the patients healed primarily; 7% healed after major debridement; 9% healed after amputation and 25% died unhealed. Median healing time was 17 weeks. Ulcer progression was seen in 19% of patients. Thirty-one percent of patients had severe peripheral vascular disease. A creatinine level below 91 μmol/l was related to a higher probability for healing without major debridement or amputation, whereas vascular surgery, nephropathy and oedema were related to a lower probability for healing without major debridement or amputation. Two thirds of heel ulcers do heal in patients with diabetes despite patients being elderly and with extensive comorbidity. The extent of peripheral vascular disease, nephropathy, oedema and decreased renal function are important factors influencing outcome.
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14. |
- Örneholm, Hedvig, et al.
(författare)
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High probability of healing without amputation of plantar forefoot ulcers in patients with diabetes.
- 2015
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Ingår i: Wound Repair and Regeneration. - : Wiley. - 1524-475X .- 1067-1927. ; 23:6, s. 922-931
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Tidskriftsartikel (refereegranskat)abstract
- Diabetic foot ulcer is an important entity which in many cases is the first serious complication in diabetes. Although a plantar forefoot location is common, there are few studies on larger cohorts and in such studies there is often a combination of various types of ulcer and ulcer locations. The purpose of this study is to discern the outcome of plantar forefoot ulcers and their specific characteristics in a large cohort. All patients (n=770), presenting with a plantar forefoot ulcer at a multidisciplinary diabetes foot clinic from January 1(st) 1983 to December 31(st) 2012 were considered for the study. 701 patients (median age 67 (22-95) fulfilled the inclusion criteria and were followed according to a pre-set protocol until final outcome (healing or death). Severe peripheral vascular disease (SPVD) was present in 26% of the patients and 14% had evidence of deep infection upon arrival at the foot clinic. Fifty-five per cent (385/701) of the patients healed without foot surgery, 25% (173/701) healed after major debridement, nine per cent (60/701) healed after minor or major amputation and 12% (83/701) died unhealed. Median healing time was 17 weeks. An ulcer classified as Wagner grade 1 or 2 at inclusion and independent living were factors associated with a higher healing rate. Seventy-nine per cent of 701 patients with diabetes and a plantar forefoot ulcer treated at a multidisciplinary diabetes foot clinic healed without amputation. For one third some form of foot surgery was needed to achieve healing. This article is protected by copyright. All rights reserved.
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15. |
- Örneholm, Hedvig, et al.
(författare)
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Recurrent and other new foot ulcers after healed plantar forefoot diabetic ulcer
- 2017
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Ingår i: Wound Repair and Regeneration. - : Wiley. - 1067-1927. ; 25:2, s. 309-315
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Tidskriftsartikel (refereegranskat)abstract
- Diabetic foot ulcer is a serious complication in patients with diabetes. In most outcome studies of this condition, there is a combination of various types of ulcer and ulcer locations. Plantar ulcers are usually localized to the forefoot, and constitute a quarter of all diabetic foot ulcers. There are a limited number of studies regarding development of new ulcers following healing of a plantar forefoot ulcer, and there are no uniform definitions of recurrent and other new ulcers. The aim of this study was to evaluate the outcome of a large cohort of consecutively treated patients with diabetes mellitus and a healed planter forefoot ulcer (n = 617) with regard to development, characteristics, and outcome of recurrent and other new ulcers. Patients were followed consecutively and prospectively with a 2-year follow-up, according to a preset protocol. Out of 617 patients, 250 (41%) did not develop any new ulcer, 262 (42%) developed a new ulcer, 87 (14%) died and 18 (3%) were lost at 2 years following healing of a plantar forefoot ulcer. Thirty-four percent developed other new ulcers (112 on the same foot and 99 on the contralateral foot), whereas 51 patients (8%) developed a recurrent ulcer (at the same site and foot). Of the patients who died within 2 years, 30 patients had developed other new ulcers. The risk of a recurrent ulcer in patients with diabetes and a healed plantar forefoot ulcer was only 8% within 2 years, whereas other new ulcers, on the same foot or on the contralateral foot, was seen in 4 out of 10 patients indicating the need for further preventive measures and surveillance in these patients. We suggest a concise definition for new ulcer to be used in future research.
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16. |
- Akhtar, Simeen, et al.
(författare)
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A Review of the Eurodiale Studies: What Lessons for Diabetic Foot Care?
- 2011
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Ingår i: Current Diabetes Reports. - : Springer Science and Business Media LLC. - 1539-0829 .- 1534-4827. ; 11:4, s. 302-309
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Tidskriftsartikel (refereegranskat)abstract
- The prevalence of diabetes has been increasing at an alarming rate worldwide. Treatment of diabetes-related complications adds a huge financial burden on our health services, made worse in the current financial climate. The Eurodiale (European Study Group on Diabetes and the Lower Extremity) study was a prospective observational study conducted in 14 European centers in 2003 to 2004 and included data on characteristics of diabetic patients with foot ulcers, diagnostic and management procedures, health care organization, quality of life, and resource use. This was the first large multicenter study, included 1232 patients, and used an integrated approach for a multiorgan disease. The study has provided new insights into the intricacies involved in managing diabetic foot ulcers and how care can be improved. It has shown the differences in quality of care provided in different centers and also highlighted the need for more specific guidance related to diabetic foot disease.
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17. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study
- 2009
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Ingår i: Diabetologia. - : Springer Science and Business Media LLC. - 1432-0428 .- 0012-186X. ; 52:3, s. 398-407
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Tidskriftsartikel (refereegranskat)abstract
- We sought to identify factors related to short-term outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1-5, below ankle) (n = 2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31. The characteristics of the remaining 2,480 patients were: 1,465 men, age 68 +/- 15 years (range 18-96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. The healing rate without major amputation in surviving patients was 90.6% (n = 1,867). Sixty-five per cent (n = 1,617) were healed primarily, 9% (n = 250) after minor amputation and 8% after major amputation; 17% (n = 420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to co-morbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.
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18. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Elderly individuals with diabetes and foot ulcer have a probability for healing despite extensive comorbidity and dependency
- 2021
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Ingår i: Expert review of pharmacoeconomics & outcomes research. - : Taylor & Francis. - 1473-7167 .- 1744-8379. ; 21:2, s. 277-284
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Limited scientific evidence for prevention and treatment of diabetic foot ulcers in elderly with comorbidities.AIM: To explore patient-related factors and outcomes in patients ≥75 years with diabetes and a foot ulcer.METHOD: Sub-analysis of consecutively presenting patients ≥75 years (N = 1008) from a previous study on 2,480 patients with diabetic foot ulcer treated in a multidisciplinary system until healing. Patient characteristics: age - 81(75-96); diabetes type 2-98.7%; male/female - 49/51%; living with a spouse - 47%; nursing home 16%; or with home nursing 64%.RESULT: Primary healing was achieved in 54%, minor amputation 8%, major amputation 9%, auto-amputation 2%, and 26% of the patients died unhealed. Among the oldest (88-96 years), 31% healed without any amputation. Extensive comorbidities were frequent: neuropathy 93%, visual impairment 73%, cardiovascular disease 60%, cerebrovascular disease 34%, and severe peripheral disease in 29% of the patients. Out of patients (80%) living in institutions or dependent on home nursing, 56% healed without amputation, compared to 44% of patients living in their own home without any support from social services or home nursing.CONCLUSION: Healing without major amputation was achieved in 84% of surviving patients ≥75 years, despite extensive comorbidity and dependency.
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19. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Patient education for the prevention of diabetic foot ulcers. Interim analysis of a randomised controlled trial due to morbidity and mortality of participants
- 2011
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Ingår i: European Diabetes Nursing. - : John Wiley & Sons. - 1551-7853 .- 1551-7861. ; 8:3, s. 102-107b
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Tidskriftsartikel (refereegranskat)abstract
- This study was designed to explore whether participant-driven patient education in group sessions, compared to provision of standard information, will contribute to a statistically significant reduction in new ulceration during 24 months in patients with diabetes and high risk of ulceration. This is an interim analysis after six months. A randomised controlled study was designed in accordance with CONSORT criteria. Inclusion criteria were: age 35–79 years old, diabetes mellitus, sensory neuropathy, and healed foot ulcer below the ankle; 657 patients (both male and female) were consecutively screened. A total of 131 patients (35 women) were included in the study. Interim analysis of 98 patients after six months was done due to concerns about the patients’ ability to fulfil the study per protocol. After a six-month follow up, 42% had developed a new foot ulcer and there was no statistical difference between the two groups. The number of patients was too small to draw any statistical conclusion regarding the effect of the intervention. At six months, five patients had died, and 21 had declined further participation or were lost to follow up. The main reasons for ulcer development were plantar stress ulcer and external trauma. It was concluded that patients with diabetes and a healed foot ulcer develop foot ulcers in spite of participant-driven group education as this high risk patient group has external risk factors that are beyond this form of education. The educational method should be evaluated in patients with lower risk of ulceration. Eur Diabetes Nursing 2011; 8(3): 102–107
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20. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Prévention des ulcères du pied diabétique [Prevention of diabetic foot ulcers]
- 2009
-
Ingår i: Journal des Plaies et Cicatrisations. - : Editions MF. - 1268-8924. ; XIV:71, s. 37-40
-
Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- ARTICLE IN FRENCH. Foot problems in people with diabetes are common,expensive and life-threatening. Eightyfive per cent of all amputations in diabetic patients are preceded by an ulcer, deteriorated to a severe infection or gangrene. The complexity of diabetes foot ulcers necesitates an intrinsic knowledge of underlying pathophysiology and a multi-factorial approach to achieve an effective strategy with regard to prevention and treatment. The most important factors related to development of foot ulcers are peripheral neuropathy, minor foot trauma, foot deformity and decreased tissue perfusion. The International Working Group for the Diabetic Foot Consensus Group has suggested a simple risk classification with regard to prevention of diabetes related amputations and foot ulcers. Identification of the high risk patient can only be detected from a history and clinical examination of the feet, as many foot ulcers in diabetes can potentially be prevented by regular foot inspections, access to foot care for non ulcer pathology and use of adequate foot wear. The feet of diabetic patients should be inspected at every visit to primary health care and specialist care providers and also at every visit from home care service. Assessment of the feet, education to the patient to eprform daily inspections, washing the feet daily, use of foot cream, and use of appropriate shoes requires a multidisciplinary approach including appropriate education of involved health care professionals and patients.
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21. |
- Annersten Gershater, Magdalena, et al.
(författare)
-
Re-ulceration is common in persons with diabetes and healed foot ulcer after participant-driven education in group : A randomized controlled trial.
- 2022
-
Ingår i: Advances in wound care. - : Mary Ann Liebert. - 2162-1918 .- 2162-1934. ; 12:3, s. 117-126
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To compare the number of ulcer-free days during 24 months in persons with diabetes and a healed foot ulcer below the ankle provided with adjusted therapeutic shoes who were given standard information and participated in participant-driven group education compared with standard information alone.METHOD: A randomized controlled trial was designed to evaluate the number of ulcer-free days after participant-driven group education in addition to standard information compared to standard information alone. The number needed to treat (N=174) was not met, as only n=138 persons with diabetes and previously healed foot ulcer were recruited (age median 63 years [34-79], 101 male/37 female).RESULT: 138 persons were recruited, of whom 107 (77.5%) completed the study, 7 (5%) dropped out, and 12 (9%) became deceased. No statistically significant difference was found between the intervention group compared to the control group after 6, 18, or 24 months. After 12 months, more patients in the intervention group had developed ulcers. Seventy-seven participants (56%) developed new foot ulcers, irrespective of side and site. Development of one ulcer appeared in 36 participants, two ulcers in 19, and 22 participants developed three ulcers. Forty-eight participants remained ulcer-free (35%) during the 24-month follow-up. Median ulcer-free days until first ulceration were 368 (4-720); until second ulceration, 404 (206-631); and until third ulceration, 660 (505-701). The participants wore prescribed therapeutic shoes during 88% of the follow-up visits.CONCLUSION: One third of the participants remained ulcer free for 24 months. Patient-driven education in groups did not give better results than standard information in this underpowered study. The present study illustrates the challenges to perform comparative preventive studies in this group of patients with extensive comorbidity. Further studies are needed to evaluate interventions on ulceration in persons with a healed foot ulcer.
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22. |
- Annersten Gershater, Magdalena, et al.
(författare)
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Treatment satisfaction with insulin glargine in patients with diabetes mellitus in a university hospital clinic in Sweden
- 2009
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Ingår i: European Diabetes Nursing. - : Wiley-Blackwell. - 1551-7853 .- 1551-7861. ; 6:1, s. 17-22
-
Tidskriftsartikel (refereegranskat)abstract
- Background: Few studies evaluate patients' perspectives when a new drug is introduced to treat chronic diseases such as diabetes mellitus. The clinical role of a new insulin treatment, in terms of the relationship between higher cost and better treatment outcomes (as defined from the patient perspective) has been discussed. We sought to explore patient satisfaction with a new insulin treatment (insulin glargine). At its launch in 2002/3 it was purported to provide constant, peakless insulin release following once- or twice-daily administration, thus leading to fewer hypoglycaemic episodes while providing metabolic control equivalent to that achieved with NPH human basal insulin. Aims: To investigate the indications used for prescription of a new drug and its clinical effects on glycosylated haemoglobin (HbA1c) levels, perceived hypoglycaemic events and patient satisfaction. Methods: The Diabetes Treatment Satisfaction Questionnaire (Status Version, DTSQ-s), which measures satisfaction with treatment regimen, and perceived frequency of hyperglycaemia and hypoglycemia, was circulated to all living patients who had ever started treatment with insulin glargine at the Department of Endocrinology at Malmö University Hospital. Medical records of 913 patients were assessed for HbA1c levels at 0 and 12 months after starting insulin glargine therapy. Results: Completed questionnaires were returned by 615 of 960 patients (64%) who had ever started insulin glargine. The main indications for starting treatment were physicians' or nurses' initiatives, desire for fewer fluctuations and improved metabolic control. HbA1c levels fell by 0.41% for patients with type 1 diabetes and by 0.68% for those with type 2 diabetes. The mean DTSQ-s score was 28.45 for satisfaction, whereas the mean perceived hypoglycaemic/hyperglycaemic events score was 3. Conclusion: Treatment satisfaction was very high and perceived frequency of hypoglycaemia/hyperglycaemia was very low. The indications for treatment of insulin glargine are being followed in accordance with national recommendations..
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23. |
- Annersten, Magdalena, et al.
(författare)
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Structured diabetes education in Sweden : a national inquiry involving 583 nurses working with diabetes patients in hospitals and primary care facilities.
- 2006
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Ingår i: Practical Diabetes International. - : John Wiley & Sons. - 1357-8170 .- 1528-252X. ; 23:3, s. 138-141
-
Tidskriftsartikel (refereegranskat)abstract
- The overall goals for the treatment of diabetes are to prevent acute and long-term complications and maintain a good quality of life. The St Vincent Declaration and the Swedish National Guidelines for the Treatment of Diabetes Mellitus describe patient education in self-treatment as a prerequisite for the achievement of these goals. This survey aimed to evaluate the presence of structured patient education (in advance planned education), its organisation, staffing and goals, and the results in out-patient diabetes care in Sweden.A questionnaire consisting of 35 open and closed questions was mailed to 1250 diabetes educated nurses working in hospitals and primary health care in the entire country.Responses were received from 583 (47%) nurses. Structured diabetes patient education was performed by 486 nurses. It was usually organised by nurses and performed in co-operation with doctors (55%), dietitians (38%), chiropodists (36%), and social workers (9%). The sessions took place individually at pre-scheduled visits (80%), or as group education (26%). Fifty-one percent described explicit goals for the education, most commonly: general knowledge about diabetes, improved metabolic control and increased safety. The structured education was evaluated by 51% of which the HbA[1]c level at the next scheduled visit was the most frequently used evaluation method (44%), followed by home monitored blood glucose values (37%) and a structured evaluation form (17%). The goals had been achieved to a great or quite great extent by 67% of the responding nurses.To the extent that structured patient education takes place, nurses are usually responsible for its performance. It takes place individually as well as in groups. Many nurses lack evident goals for the education and sufficient evaluation methods.It was concluded that there is confusion about the content of structured education vs information activity.
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24. |
- Apelqvist, Jan, et al.
(författare)
-
Diabetesfoten
- 2010. - 4:e uppl.
-
Ingår i: Diabetes. - Stockholm : Liber. - 9789147093311 - 9147093315 ; , s. 411-426
-
Bokkapitel (refereegranskat)
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25. |
- Apelqvist, Jan
(författare)
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Diagnostics and treatment of the diabetic foot.
- 2012
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Ingår i: Endocrine. - : Springer Science and Business Media LLC. - 1355-008X .- 1559-0100. ; 41:3, s. 384-397
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Tidskriftsartikel (refereegranskat)abstract
- Every 30 s, a lower limb is amputated due to diabetes. Of all amputations in diabetic patients 85% are preceded by a foot ulcer which subsequently deteriorates to a severe infection or gangrene. There is a complexity of factors related to healing of foot ulcers including strategies for treatment of decreased perfusion, oedema, pain, infection, metabolic disturbances, malnutrition, non-weight bearing, wound treatment, foot surgery, and management of intercurrent disease. Patients with diabetic foot ulcer and decreased perfusion do often not have rest pain or claudication and as a consequence non-invasive vascular testing is recommended for early recognition of ulcers in need of revascularisation to achieve healing. A diabetic foot infection is a potentially limb-threatening condition. Infection is diagnosed by the presence or increased rate of signs inflammation. Often these signs are less marked than expected. Imaging studies can diagnose or better define deep, soft tissue purulent collections and are frequently needed to detect pathological findings in bone. The initial antimicrobial treatment as well as duration of treatment is empiric. There is a substantial delay in wound healing in diabetic foot ulcer which has been related to various abnormalities. Several new treatments related to these abnormalities have been explored in wound healing with various successes. An essential part of the strategy to achieve healing is an effective offloading. Many interventions with advanced wound management have failed due to not recognizing the need for effective offloading. A multidisciplinary approach to wounds and foot ulcer has been successfully implemented in different centres with a substantial decrease in amputation rate.
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26. |
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27. |
- Apelqvist, Jan, et al.
(författare)
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Long-term prognosis for diabetic patients with foot ulcers
- 1993
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Ingår i: Journal of Internal Medicine. - 1365-2796. ; 233:6, s. 485-491
-
Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE. To evaluate the recurrence of foot ulcers as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers. DESIGN. A prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer with a median follow-up of 4 years. SETTING. A multidisciplinary foot-care team. POPULATION. Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these patients, 468 healed either primarily (n = 345) or after minor or major amputations (n = 123) and 90 died before healing had occurred. Those 468 patients who healed were included in this prospective study from the time of healing. MAIN OUTCOME MEASURES. Patients were followed according to a standardized protocol with registration of foot lesions, amputation, morbidity and mortality. Clinical examination was performed twice yearly. RESULTS. After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively, had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant, respectively). Among patients with previous primary healing the cumulative amputation rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%, 35% and 48% among those who previously healed after amputation, irrespective of previous amputation level (P < 0.001 at all time-points). All amputations except three were initiated by a foot ulcer deteriorating to deep infection or progressive gangrene. The long-term survival ratio was lower among patients healed after previous amputation (80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%, 58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and P < 0.001 respectively). The mortality rate was twice as high among primarily healed and four times as high among patients with amputation compared to an age- and sex-matched Swedish population. CONCLUSION. These findings stress the need for life-long surveillance of the diabetic foot at risk and the necessity of preventive foot care among diabetic patients with previous foot lesions, and particularly among those who had had a previous amputation.
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28. |
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29. |
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30. |
- Apelqvist, Jan, et al.
(författare)
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Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer
- 1989
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Ingår i: Diabetes Care. - : American Diabetes Association. - 1935-5548 .- 0149-5992. ; 12:6, s. 373-378
-
Tidskriftsartikel (refereegranskat)abstract
- The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.
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31. |
- Apelqvist, Jan, et al.
(författare)
-
Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds.
- 2008
-
Ingår i: The American Journal of Surgery. - : Elsevier BV. - 1879-1883 .- 0002-9610. ; 195, s. 782-788
-
Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: To evaluate resource utilization and direct economic costs of care for patients treated with negative-pressure wound therapy (NPWT), using the Vacuum-Assisted Closure (V.A.C.) system, compared to standard moist wound therapy (MWT). METHODS: A total of 162 diabetic patients with post-amputation wounds (up to the trans-metatarsal level) entered a 16-week, randomized clinical trial. Patients randomized to V.A.C. (n = 77) received therapy with dressing changes every 48 hours. Control patients (n = 85) received standard MWT. Resource utilization, procedures, and direct costs were calculated and analyzed in this post hoc retrospective study. RESULTS: There was no difference between groups for in-patient hospital stay (number of admissions or length of stay). More surgical procedures (including debridement) were required in the MWT group (120 vs 43 NPWT, P <.001). The average number of dressing changes performed per patient was 118.0 (range 12-226) for MWT versus 41 (6-140) for NPWT (P = .0001). The MWT group had 11 (range 0-106) outpatient treatment visits during the study versus 4 (range 0-47) in the NPWT group (P <.05). The average direct cost per patient treated for 8 weeks or longer (independent of clinical outcome) was $27,270 and $36,096 in the NPWT and MWT groups, respectively. The average total cost to achieve healing was $25,954 for patients treated with NPWT (n = 43) compared with $38,806 for the MWT group (n = 33). CONCLUSION: Treatment of diabetic patients with post amputation wounds using NPWT resulted in lower resource utilization and a greater proportion of patients obtaining wound healing at a lower overall cost of care when compared to MWT.
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32. |
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33. |
- Apelqvist, Jan, et al.
(författare)
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The association between clinical risk factors and outcome of diabetic foot ulcers
- 1992
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Ingår i: Diabetes Research and Clinical Practice. - 1872-8227. ; 18:1, s. 43-53
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE. The aim of the study was to describe the association between clinical risk factors in diabetic patients with food ulcers in relation to outcome. DESIGN. A prospective study of 314 consecutively presenting diabetic patients with foot ulcers referred to the Department of Internal Medicine between July 1, 1983 and June 30, 1987. All patients were followed to final outcome. SETTING. All patients were treated by the same multi-disciplinary foot care team at the Department of Medicine, both as in- and out-patients. Healing was defined as intact skin for at least 6 months. RESULTS. One hundred and ninety-seven patients healed primarily, 77 after amputation, and 40 died unhealed. Signs of macroangiopathy were more common among patients who healed after amputation. The outcome was strongly related to age, though 43% of the patients with an age over 80 years healed primarily. There was no difference in smoking habits between patients who healed primarily and those who required amputation to heal. Diabetic nephropathy was found in 26% of the patients and was strongly associated with amputation. Presence of retinopathy was found in 54% of the patients, but this finding was not related to the outcome. There were no differences in short-term metabolic control as assessed by hemoglobin A1c levels between patients who healed primarily and those who healed after amputation. CONCLUSION. The presence of diabetic foot ulcers was strongly associated with age and diabetic complications such as multiple cardiovascular disease and nephropathy, which were important factors related to amputation.
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34. |
- Apelqvist, Jan, et al.
(författare)
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The development of global consensus guidelines on the management of the diabetic foot
- 2008
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552 .- 1520-7560. ; 24:S1, s. 116-118
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Tidskriftsartikel (refereegranskat)abstract
- The future for diabetes is grave. Now described as the global epidemic of the 21st century, the increasing incidence of diabetes (in 2007 over 246 million people affected by diabetes) will place considerable strain on resources and will bring suffering to many if the preventative measures promoted by the International Diabetes Federation (IDF), the International Working Group on the Diabetic Foot (IWGDF) and other diabetes representative organizations are not put into effect. Ulcers of the foot in diabetes are a source of major suffering and cost. Investing in a diabetic foot care guideline can be one of the most cost-effective forms of healthcare expenditure, provided the guideline is goal-focused and properly implemented. The objective of the IWGDF, founded in 1996, is to develop guidelines that will reduce the impact of diabetic foot disease through cost-effective and quality healthcare, based on the principles of evidence-based medicine. Three IWGDF working groups were invited to write specific consensus guidelines on different subjects, according to the current standards of evidence based medicine. Therefore, for the first time, new 2007 texts were produced according to a systematic review of the literature, in order to inform protocols for routine care and to highlight areas which should be considered for further study. After reaching worldwide consensus, the review reports and specific guidelines were launched in May 2007.
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35. |
- Apelqvist, Jan
(författare)
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The foot in perspective.
- 2008
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552 .- 1520-7560. ; 24:1, s. 110-115
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Tidskriftsartikel (refereegranskat)abstract
- The diabetic foot constitutes a tremendous challenge for patients, caregivers and the health care system. The International Consensus Document of 1999 was a milestone in the recognition of the importance and consequences of the diabetic foot. Since then, many original papers have been published in this area.Large cohort studies have given us a deeper understanding regarding factors related to the outcome of diabetic foot ulcers: according to these studies, the severity of diabetic foot ulcers is greater than previously reported. More than 50% of individuals' foot ulcers have signs of infection at admission, and one-third have signs of both peripheral artery disease (PAD) and infection. The co-morbidities increase significantly with increasing severity of the foot disease. However, the trend in all these studies is a successive improvement in healing rate (50-60% at 20 weeks follow-up, > 75% at 1 year). It is important to differentiate between neuropathic and neuro-ischaemic ulcers with regard to factors related to outcome and co-morbidities.Recent research has emphasized the importance of psychological factors in the development and outcome of diabetic foot ulcers. Studies have shown that perceptions of the individual's own risks based on symptoms, and their own beliefs in the efficacy of self-care, can affect foot-care practice.The importance and influence of the health care organization and reimbursement should not be underestimated, both in the prevention and management of diabetic foot lesions. The diabetic foot should be considered a lifelong condition, as having had one ulcer dramatically increases the risk of developing a new ulcer.In an individual with diabetes and a foot ulcer, the ulcer should be considered as a sign of multi-organ disease, and a holistic approach to both management and prevention is recommended. Copyright (c) 2008 John Wiley & Sons, Ltd.
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36. |
- Apelqvist, Jan, et al.
(författare)
-
The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers
- 1990
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Ingår i: Diabetic Medicine. - 1464-5491. ; 7:7, s. 590-594
-
Tidskriftsartikel (refereegranskat)abstract
- In a prospective study, peripheral pulses, claudication, peripheral oedema, and rest pain were evaluated in 314 sequentially presenting diabetic patients with foot ulcers. In the ulcerated limb pedal pulses were found to be present in 44% of the patients, peripheral oedema in 38%, and rest pain in 19%. Twelve per cent had claudication. Presence of pedal pulses was more common in patients whose ulcers underwent primary healing (56%) than in those who healed after amputation (23%) or died (25%, p less than 0.001). Eighty per cent of the patients with pedal pulses present underwent primary healing. However, 49% of patients with absence of pedal pulses also underwent primary healing and 12 patients developed gangrene despite presence of pedal pulses. Peripheral oedema was more common in patients who required amputation (58%) or died (55%) than in patients with primary healing (26%, p less than 0.001). A tentative predisposing factor was identified in 95% of the patients, the most common factors being neuropathy, congestive heart failure, and previous deep venous thrombosis. Rest pain was more common in patients who required amputation (48%) or died (23%) than in those with primary healing (7%; p less than 0.001). Only 50% of patients with gangrene had rest pain and of these patients, only one underwent primary healing. The presence of pedal pulses, oedema, and rest pain give valuable but imperfect information on the possible primary healing of foot ulcers in diabetic patients.
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37. |
- Apelqvist, Jan, et al.
(författare)
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The ulcerated leg: when to revascularize
- 2012
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 28:Suppl. 1, s. 30-35
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Tidskriftsartikel (refereegranskat)abstract
- The role of peripheral arterial disease in ulcerated diabetic feet has long been underestimated. Progressive claudication, rest pain and the extent of irreversible tissue loss have frequently been indications for revascularization for neuroischaemic ulcers in diabetic patients. These typical ischaemic symptoms are warning signs that are less frequent in diabetic individuals with ischaemia than those without diabetes. Consequently, 30-50% of individuals with diabetes and foot ulcers already have gangrene at admission and are therefore often considered unsuitable for revascularization. Furthermore, the healing of a neuroischaemic ulcer is worsened by microvascular dysfunction, causing arteriovenous shunting, capillary ischaemia, leakage and venous pooling. Therefore, the threshold of revascularizing neuroischaemic ulcers should be lower than that of purely ischaemic ulcers. Comorbidity, ulcer characteristics and infection affect the decision as to when to intervene, as do the severity and extent of occlusive arterial lesions. The window of opportunity for vascular intervention in the neuroischaemic diabetic foot should not be missed, and the need for early vascular intervention as an integrated part of a strategy to achieve healing should be emphasized. Noninvasive vascular testing should be performed on all individuals with an ulcerated diabetic foot. The arterial tree should be imaged if noninvasive tests indicate ischaemia or when mild or questionable ischaemia is diagnosed and conservative treatment does not promote ulcer healing in 6 weeks. Revascularization should be performed whenever feasible to repair distal perfusion to achieve ulcer healing. Copyright (C) 2012 John Wiley & Sons, Ltd.
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38. |
- Apelqvist, Jan, et al.
(författare)
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Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers
- 1989
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Ingår i: Diabetic Medicine. - 1464-5491. ; 6:6, s. 526-530
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Tidskriftsartikel (refereegranskat)abstract
- The importance of wound classification and site of ulceration was evaluated in 314 consecutive diabetic patients with foot ulcers. The ulcers were classified as superficial (through the full thickness of the dermis; n = 150), deep (n = 50), osteomyelitis and/or abscess (n = 46), minor gangrene (n = 39) or major gangrene (n = 29). Wound healing was defined as intact skin for at least 6 months. In patients with superficial and deep ulcers, primary healing occurred in 88% and 78%, respectively, compared with 57% in those patient who developed an abscess and/or osteomyelitis. Only 2 out of 68 patients with gangrene healed (through mummification) without amputation. Patients with gangrene had lower ankle and toe blood pressure than patients with all other types of ulcers. There were only marginal differences in primary healing rate between different ulcer sites. The highest rate was seen in ulcers localized to the metatarsal heads (78%). Patients with multiple ulcers had the lowest primary healing rate (5%) compared with single ulcers at all sites. These differences were probably due to circulatory factors, since patients with multiple ulcers had lower distal perfusion pressures compared with all other groups.
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39. |
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40. |
- Bakker, K, et al.
(författare)
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The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus.
- 2016
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 32:Supplement S1, s. 2-6
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Tidskriftsartikel (refereegranskat)abstract
- Foot problems complicating diabetes are a source of major patient suffering and societal costs. Investing in evidence-based, internationally appropriate diabetic foot care guidance is likely among the most cost-effective forms of healthcare expenditure, provided it is goal-focused and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has been publishing and updating international Practical Guidelines since 1999. The 2015 updates are based on systematic reviews of the literature, and recommendations are formulated using the Grading of Recommendations Assessment Development and Evaluation (GRADE) system. As such, we changed the name from "Practical Guidelines" to "Guidance". In this article we describe the development of the 2015 IWGDF Guidance documents on prevention and management of foot problems in diabetes. This Guidance consists of five documents, prepared by five working groups of international experts. These documents provide guidance related to foot complications in persons with diabetes on: prevention; footwear and offloading; peripheral artery disease; infections; and, wound healing interventions. Based on these five documents, the IWGDF Editorial Board produced a summary guidance for daily practice. The resultant of this process, after review by the Editorial Board and by international IWGDF members of all documents, is an evidence-based global consensus on prevention and management of foot problems in diabetes. Plans are already under way to implement this Guidance. We believe that following the recommendations of the 2015 IWGDF Guidance will almost certainly result in improved management of foot problems in persons with diabetes and a subsequent worldwide reduction in the tragedies caused by these foot problems. This article is protected by copyright. All rights reserved.
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42. |
- Becker, F., et al.
(författare)
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Definitions, Epidemiology, Clinical Presentation and Prognosis
- 2011
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Ingår i: European Journal of Vascular and Endovascular Surgery. - 1532-2165. ; 42:Suppl. 2, s. 4-12
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Tidskriftsartikel (refereegranskat)abstract
- The concept of chronic critical limb ischaemia (CLI) emerged late in the history of peripheral arterial occlusive disease (PAOD). The historical background and changing definitions of CLI over the last decades are important to know in order to understand why epidemiologic data are so difficult to compare between articles and over time. The prevalence of CLI is probably very high and largely underestimated, and significant differences exist between population studies and clinical series. The extremely high costs associated with management of these patients make CLI a real public health issue for the future. In the era of emerging vascular surgery in the 1950s, the initial classification of PAOD by Fontaine, with stages III and IV corresponding to CLI, was based only on clinical symptoms. Later, with increasing access to non-invasive haemodynamic measurements (ankle pressure, toe pressure), the need to prove a causal relationship between PAOD and clinical findings suggestive of CLI became a real concern, and the Rutherford classification published in 1986 included objective haemodynamic criteria. The first consensus document on CLI was published in 1991 and included clinical criteria associated with ankle and toe pressure and transcutaneous oxygen pressure (TcPO(2)) cut-off levels (<= 50 mmHg, <= 30 mmHg and <= 10 mmHg respectively). This rigorous definition reflects an arterial insufficiency that is so severe as to cause microcirculatory changes and compromise tissue integrity, with a high rate of major amputation and mortality. The TASC I consensus document published in 2000 used less severe pressure cut-offs (<50-70 mmHg, <30-50 mmHg and <30-50 mmHg respectively). The thresholds for toe pressure and especially TcPO(2) (which will be also included in TASC II consensus document) are however just below the lower limit of normality. It is therefore easy to infer that patients qualifying as CLI based on TASC criteria can suffer from far less severe disease than those qualifying as CLI in the initial 1991 consensus document. Furthermore, inclusion criteria of many recent interventional studies have even shifted further from the efforts of definition standardisation with objective criteria, by including patients as CLI based merely on Fontaine classification (stage III and IV) without haemodynamic criteria. The differences in the natural history of patients with CLI, including prognosis of the limb and the patient, are thus difficult to compare between studies in this context. Overall, CLI as defined by clinical and haemodynamic criteria remains a severe condition with poor prognosis, high medical costs and a major impact in terms of public health and patients' loss of functional capacity. The major progresses in best medical therapy of arterial disease and revascularisation procedures will certainly improve the outcome of CLI patients. In the future, an effort to apply a standardised definition with clinical and objective haemodynamic criteria will be needed to better demonstrate and compare the advances in management of these patients. (C) 2011 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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43. |
- Bengtsson, L, et al.
(författare)
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Wound-related pain is underestimated in patients with diabetic foot ulcers.
- 2008
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Ingår i: Journal of Wound Care. - 0969-0700. ; 17:10, s. 433-435
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Tidskriftsartikel (refereegranskat)abstract
- Few studies have assessed pain in neuropathic and neuroischaemic foot ulcers. This pilot study found that patients with these ulcers do experience pain, and that the intensity and nature of the pain was similar in both types of ulcer.
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44. |
- Bergqvist, David, et al.
(författare)
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Klinisk värdering av kritisk ischemi skall alltid göras före amputation
- 1999
-
Ingår i: Läkartidningen. - 0023-7205 .- 1652-7518. ; 96:7, s. 727-729
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Patients with critical limb ischemia (rest pain and/or ulcer/gangrene, together with low ankle pressure) are at risk of amputation, and should therefore undergo arterial reconstruction if that is at all technically possible. Thorough clinical investigation will usually distinguish patients in need of further evaluation by a vascular surgeon. No amputation should be undertaken without such evaluation. Diabetic patients belong to a special category, in that neuropathy makes it difficult to evaluate pain, and ankle pressure is often falsely high due to medial arterios sclerosis.
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45. |
- Boulton, A J M, et al.
(författare)
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The global burden of diabetic foot disease
- 2005
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Ingår i: The Lancet. - 1474-547X. ; 366:9498, s. 1719-1724
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Forskningsöversikt (refereegranskat)abstract
- Diabetic foot problems are common throughout the world, resulting in major economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable, in developing countries, which will experience the greatest rise in the prevalence of type 2 diabetes in the next 20 years. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When assessing the economic effects of diabetic foot disease, it is important to remember that rates of recurrence of foot ulcers are very high, being greater than 50% after 3 years. Costing should therefore include not only the immediate ulcer episode, but also social services, home care, and subsequent ulcer episodes. A broader view of total resource use should include some estimate of quality of life and the final outcome. An integrated care approach with regular screening and education of patients at risk requires low expenditure and has the potential to reduce the cost of health care.
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46. |
- Brownrigg, J R W, et al.
(författare)
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Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review.
- 2015
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552.
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Tidskriftsartikel (refereegranskat)abstract
- Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus (DM) are important to estimate the risk of amputation, ulceration, wound healing and presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another. To evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction-angiography, colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies (QUADAS) instrument. Of 6629 studies identified, 10 met the criteria for inclusion. In these studies the patients had a median age of 60-74 years and a median duration of diabetes of 9-24 years. Two studies reported exclusively on patients with symptomatic (ulcerated/ infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) of an ABI threshold <0.9 ranged from 2 to 25 (median 8) and <0.1 to 0.7 (median 0.3), respectively. In patients with neuropathy the NLR of the ABI was generally higher (2 out of 3 studies) indicating poorer performance, and ranged between 0.3-0.5. A toe brachial index (TBI) <0.75 was associated with a median PLR and NLR of 3 and ≤0.1, respectively, and was less affected by neuropathy in one study. Also, in two separate studies pulse oximetry used to measure the oxygen saturation of peripheral blood and Doppler wave form analyses had NLRs of 0.2 and <0.1. The reported performance of ABI for the diagnosis of PAD in patients with DM is variable and is adversely affected by the presence of neuropathy. Limited evidence suggests that TBI, pulse oximetry and wave form analysis may be superior to ABI for diagnosing PAD in patients with neuropathy with and without foot ulcers. There was insufficient data to support the adoption of one particular diagnostic modality over another and no comparisons existed with clinical examination. The quality of studies evaluating diagnostic techniques for the detection of PAD in individuals with diabetes is poor. Improved compliance with guidelines for methodological quality is needed in future studies. This article is protected by copyright. All rights reserved.
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47. |
- Brownrigg, J. R. W., et al.
(författare)
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Evidence-based Management of PAD & the Diabetic Foot
- 2013
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Ingår i: European Journal of Vascular and Endovascular Surgery. - : Elsevier BV. - 1532-2165 .- 1078-5884. ; 45:6, s. 673-681
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Forskningsöversikt (refereegranskat)abstract
- Diabetic foot ulceration (DFU) is associated with high morbidity and mortality, and represents the leading cause of hospitalization in patients with diabetes. Peripheral arterial disease (PAD), present in half of patients with DFU, is an independent predictor of limb loss and can be difficult to diagnose in a diabetic population. This review focuses on the evidence for therapeutic strategies in the management of patients with DFU. We highlight the importance of timely referral of patients presenting with a new foot ulcer to a multidisciplinary team, which includes vascular surgeons and interventional radiologists. (C) 2013 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
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48. |
- Brownrigg, J R W, et al.
(författare)
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Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review.
- 2016
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Ingår i: Diabetes/Metabolism Research & Reviews. - : Wiley. - 1520-7552. ; 32:Suppl S1, s. 128-135
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Tidskriftsartikel (refereegranskat)abstract
- Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/ or major amputation among patients with active diabetic foot ulceration. Two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies (QUIPS) instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥45 mmHg), and TcPO2 ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ABI < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation. This article is protected by copyright. All rights reserved.
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49. |
- Butt, Talha, et al.
(författare)
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Amputation-Free Survival in Patients With Diabetes Mellitus and Peripheral Arterial Disease With Heel Ulcer : Open Versus Endovascular Surgery
- 2019
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Ingår i: Vascular and Endovascular Surgery. - : SAGE Publications. - 1938-9116 .- 1538-5744. ; 53:2, s. 118-125
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND:: Heel ulcers in patients with diabetes mellitus (DM) and peripheral arterial disease (PAD) are hard to heal. The aim of the present study was to evaluate the difference in amputation-free survival (AFS) between open and endovascular revascularization in patients with DM, PAD, and heel ulcers.METHODS:: Retrospective comparative study of results of open versus endovascular surgery in patients with DM, PAD, and heel ulcer presented at the multidisciplinary diabetes foot clinic between 1983 and 2013.RESULTS:: Patients with heel ulcers were treated with endovascular intervention (n = 97) and open vascular surgery (n = 30). Kaplan-Meier analysis showed that the AFS was higher in patients undergoing open vascular surgery compared to the endovascular group ( P = .009). Multivariate analysis showed that open vascular surgery versus endovascular therapy (hazard ratio 2.1, 95% confidence interval 1.1-3.9; P = .025) was an independent factor associated with higher AFS. The proportion of patients undergoing endovascular therapy in the former (1983-2000) time period was 47% compared to 89% in the latter (2001-2013) time period ( P < .001).CONCLUSION:: The AFS was higher after open than endovascular surgery among patients with DM and PAD with heel ulcer. These results suggest that open vascular surgery should be offered more often as opposed to current practice.
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50. |
- Butt, Talha, et al.
(författare)
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Amputation-free survival in patients with diabetic foot ulcer and peripheral arterial disease : Endovascular versus open surgery in a propensity score adjusted analysis
- 2020
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Ingår i: Journal of Diabetes and its Complications. - : Elsevier BV. - 1056-8727. ; 34:5
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Tidskriftsartikel (refereegranskat)abstract
- Aims: The aim of the present study was to compare outcomes of endovascular surgery versus open vascular surgery in patients with diabetic foot ulcer (DFU) and peripheral arterial disease (PAD). Methods: Between 1984 and 2006, 1151 patients with DFU were admitted to the diabetic foot care team. Three hundred seventy-six patients with 408 limbs were consecutively included at a multidisciplinary foot center, 289 limbs were treated with endovascular surgery and 119 limbs with open vascular surgery first strategy. A propensity score adjusted analysis was performed to compare outcomes for type of revascularization. Results: Major amputation rates at 3 years were 17.0% and 16.8% (p = 0.97) and mortality at 3 years were 43.1% and 46.5% (p = 0.55) after endovascular surgery and open vascular surgery, respectively. In the propensity score adjusted analysis, patients undergoing endovascular surgery first had similar outcomes in terms of major amputation, mortality, combined major amputation/mortality compared to those undergoing open vascular surgery. Longer time to intervention (p = 0.003) was associated with increased major amputation rate in the multivariable Cox regression analysis. Conclusion: The endovascular surgery first and open vascular surgery first strategies were associated with similar long-term results in a large cohort of patients with DFU and PAD undergoing revascularization. Rapid revascularization reduces the risk of amputation.
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