Diabetic foot disease carries an intrinsic high risk of mortality and other severe outcomes in type 2 diabetes: a propensity score-matched retrospective population-based study.

BACKGROUND: To evaluate the association between diabetic foot disease (DFD) and the incidence of fatal and non-fatal events in individuals with type 2 diabetes (T2DM) from primary-care settings. METHODS: We built a cohort of people with a first DFD episode during 2010-2015, followed up until 2018. These subjects were 1 to 1 propensity score matched to subjects with T2DM without DFD. The incidence of all-cause mortality, the occurrence of new DFD, amputations, cardiovascular diseases, or composite outcome, including all-cause mortality and/or cardiovascular events during the follow-up period, were calculated. A Cox proportional hazard analysis was conducted to evaluate the hazard ratios (HR) for different events. RESULTS: Overall, 11,117 subjects with T2DM with a first episode of DFD were compared with subjects without DFD. We observed higher incidence rates (IRs) for composite outcome (33.9 vs. 14.5 IR per 100 person-years) and a new DFD episode event (22.2 vs. 1.1 IR per 100 person-years) in the DFD group. Compared to those without DFD, those with a first episode of DFD had a higher HR for all events, with excess rates particularly for amputation and new DFD occurrence (HR: 19.4, 95% CI: 16.7-22.6, HR: 15.1, 95% CI: 13.8-16.5, respectively) was found. CONCLUSIONS: Although DFD often coexists with other risk factors, it carries an intrinsic high risk of morbidity and mortality in individuals with T2DM. DFD should be regarded as a severe complication already at its onset, as it carries a poor clinical prognosis.

Clinical characteristics and degree of cardiovascular risk factor control in patients with newly-diagnosed type 2 diabetes in Catalonia.

Introduction: Women with type 2 diabetes mellitus (T2DM) face a greater risk of cardiovascular disease (CVD) and encounter challenges in managing cardiovascular risk factors (CVRF); however, limited data are available in individuals with newlydiagnosed T2DM. Methods: This study aimed to examine differences between women and men at the onset of T2DM in terms of clinical characteristics, glycaemic status, and CVRF management. This was a retrospective cohort study including subjects with newly-diagnosed T2DM from the System for the Development of Research in Primary Care (SIDIAP) database in Catalonia (Spain). Sex differences (Dif) were assessed at baseline and 1-year post-diagnosis, by calculating the absolute difference of means or proportions. Results: A total of 13,629 subjects with newly-diagnosed T2DM were analyzed. Women were older and had a higher BMI than men. At baseline, women had higher total cholesterol [Dif (95%CI) 10 mg/dL (9.1/10.8)] and low-density lipoprotein cholesterol (LDL-c) [Dif (95%CI) 7 mg/dL (6.3/7.7)], while men had higher rates of smoking and alcohol intake. Lipid target achievement was lower in women, in both primary prevention (LDL-c < 100 mg/dL) [Dif (95%CI) -7.3 mg/dL (-10.5/-4.1)] and secondary prevention (LDL-c < 70 mg/dL) [Dif (95%CI) -8.3 mg/dL (-17.3/0.7)], along with lower statin and antiplatelet prescriptions, especially one year after diagnosis. Changes in clinical and laboratory data one year post-diagnosis revealed that, in the primary prevention group, men experienced greater improvements in total cholesterol, LDL-c and triglycerides, while women had less success in achieving CVRF control targets compared to men. Additionally, cardiovascular events, such as coronary artery disease and peripheral artery disease increased more in men than in women within the first year of diagnosis, especially in primary prevention subjects. Conclusion: Differences between men and women CVRF are already apparent at the onset of T2DM, particularly in primary prevention, with notable differences in lipid profile and target level attainment.

Measurement of the ankle brachial index with a non-mercury sphygmomanometer in diabetic patients: a concordance study.

BACKGROUND: The removal of mercury sphygmomanometers from health centers requires the validation of other instruments to measure blood pressure in the limbs to calculate the ankle-brachial index (ABI). METHODS: Descriptive cross-sectional study of agreement between two measurement methods in type 2 diabetes patients from three urban primary healthcare centres in the Barcelonès Nord i Maresme area (Catalonia, Spain). RESULTS: 211 patients were included, from these, 421 limbs were available for study. The mean age of the participants was 67 years (SD = 10), 51.7% were women. CONCLUSION: The combination of a Doppler device with the hybrid sphygmomanometer is a simple and reliable method to measure ABI showing that hybrid sphygmomanometer is a good alternative to the use of mercury sphygmomanometers.

A novel assessment, diagnostic and treatment system for diabetic foot.

BACKGROUND: This report aims to present a novel system for the management of foot lesions in patients with diabetes. It was developed in the diabetic foot unit (DFU) of the Mutua de Terrassa University Hospital (HUMT) by primary care professionals, the Diabetic Foot Clinic (DFC), and during emergency cases treated by our group based on daily activities in patients with neuropathy or neuroischemia. BODY: This system considers five degrees of action based on two fixed variables: presence of infection and lesion depth. These two variables allowed the user to investigate aspects of the system until the overall action required by the pathology is made clear. These variables establish pathology stages of various severities that require different actions in aspects of care, management and treatment. CONCLUSION: This tool facilitates diagnosis, treatment, and coordination among different members of a multidisciplinary team working in specialized hospital units, primary care centers, and emergency settings.

Prediction of outcomes in subjects with type 2 diabetes and diabetic foot ulcers in Catalonian primary care centers: a multicenter observational study.

BACKGROUND: Diabetic foot and lower limb complications are an important cause of morbidity and mortality among persons with diabetes mellitus. Very few studies have been carried out in the primary care settings. The main objective was to assess the prognosis of diabetic foot ulcer (DFU) in patients from primary care centers in Catalonia, Spain, during a 12-month follow-up period. METHODS: We included participants with type 2 diabetes and a new DFU between February 2018 and July 2019. We estimated the incidence of mortality, amputations, recurrence and healing of DFU during the follow-up period. A multivariable analysis was performed to assess the association of these outcomes and risk factors. RESULTS: During the follow-up period, 9.7% of participants died, 12.1% required amputation, 29.2% had a DFU recurrence, and 73.8% healed. Having a caregiver, ischemia or infection were associated with higher mortality risk (hazard ratio [HR]:3.63, 95% confidence interval [CI]:1.05; 12.61, HR: 6.41, 95%CI: 2.25; 18.30, HR: 3.06, 95%CI: 1.05; 8.94, respectively). Diabetic retinopathy was an independent risk factor for amputation events (HR: 3.39, 95%CI: 1.37; 8.39). Increasing age decreased the risk for a DFU recurrence, while having a caregiver increased the risk for this event (HR: 0.97, 95%CI: 0.94; 0.99). The need for a caregiver and infection decreased the probability of DFU healing (HR: 0.57, 95%CI: 0.39; 0.83, HR: 0.64, 95%CI: 0.42; 0.98, respectively). High scores for PEDIS (≥7) or SINBAD (≥3) were associated with an increased risk for DFU recurrence and a lower probability of DFU healing, respectively. CONCLUSIONS: We observed high morbidity among subjects with a new DFU in our primary healthcare facilities. Peripheral arterial disease, infection, and microvascular complications increased the risk of poor clinical outcomes among subjects with DFU.

Prevalence and risk factors of diabetic foot disease among the people with type 2 diabetes using real-world practice data from Catalonia during 2018.

Background: Our study aimed to assess the prevalence of diabetic foot disease (DFD) and its associated risk factors among subjects attending primary care centers in Catalonia (Spain). Methods: We undertook a cross-sectional analysis of data from the primary health care (SIDIAP) database. The presence of comorbidities and concomitant medication were analyzed for subjects with or without DFD. DFD prevalence was estimated from 1st January 2018 to 31st December 2018. Results: During the 12-month observational period, out of 394,266 people with type 2 diabetes, we identified 3,277 (0.83%) active episodes of DFD in the database. The majority of these episodes were foot ulcers (82%). The mean age of patients with DFD was 70.3 (± 12.5) years and 55% were male. In the multivariable descriptive models, male gender, diabetes duration, hypertension, macrovascular, microvascular complications, and insulin and antiplatelet agents were strongly associated with DFD. A previous history of DFD was the stronger risk factor for DFD occurrence in subjects with T2DM (OR: 13.19, 95%CI: 11.81; 14.72). Conclusions: In this real-world primary care practice database, we found a lower prevalence of DFD compared to similar previous studies. Risk factors such as male sex, duration of diabetes, diabetes complications and previous history of DFD were associated with the presence of DFD.

Trends in the Degree of Control and Treatment of Cardiovascular Risk Factors in People With Type 2 Diabetes in a Primary Care Setting in Catalonia During 2007-2018.

Objective: To assess the trends in cardiovascular risk factor control and drug therapy from 2007 to 2018 in subjects with type 2 diabetes mellitus (T2DM). Materials and Methods: Cross-sectional analysis using yearly clinical data and treatment obtained from the SIDIAP database. Patients aged ≥18 years with a diagnosis of T2DM seen in primary care in Catalonia, Spain. Results: The number of T2DM patients increased from 299,855 in 2007 to 394,266 in 2018. We also found an increasing prevalence of cardiovascular disease, heart failure, and chronic kidney disease (from 18.4 to 24.4%, from 4.5 to 7.3%, and from 20.2 to 31.3%, respectively). The achievement of glycemic targets (HbA1c<7%) scarcely changed (54.9% to 55.9%). Major improvements were seen in blood pressure (≤140/90 mmHg: from 55% to 71.8%), and in lipid control (low-density lipoprotein cholesterol <100 mg/dl: 33.4% to 48.4%), especially in people with established cardiovascular disease (48.8 to 69.7%). Simultaneous achievement of all three targets improved from 12.5% to 20.1% in the overall population and from 24.5% to 32.2% in those with cardiovascular disease but plateaued after 2013. There was an increase in the percentage of patients treated with any antidiabetic drug (70.1% to 81.0%), especially metformin (47.7% to 67.7%), and DPP4i (0 to 22.6%). The use of SGLT-2 and GLP-1ra increased over the years, but remained very low in 2018 (5.5% and 2.1% of subjects, respectively). There were also relevant increases in the use of statins (38.0% to 49.2%), renin-angiotensin system (RAS) drugs (52.5% to 57.2%), and beta-blockers (14.3% to 22.7%). Conclusions: During the 2007-2018 period, relevant improvements in blood pressure and lipid control occurred, especially in people with cardiovascular disease. Despite the increase in the use of antidiabetic and cardiovascular drugs, the proportion of patients in which the three objectives were simultaneously achieved is still insufficient and plateaued after 2013. The use of antidiabetic drugs with demonstrated cardio renal benefits (SGLT-2 and GLP-1ra) increased over the years, but their use remained quite low.

Incidence and characteristics of diabetic foot ulcers in subjects with type 2 diabetes in Catalonian primary care centres: An observational multicentre study.

AIMS: The main objective was to assess the incidence of diabetic foot ulcers in type 2 diabetes individuals from primary care centres in Catalonia, Spain. METHODS: Prospective observational study in 36 Primary Care centres in Catalonia during February 2018 and July 2019 was conducted. We included participants with type 2 diabetes and a new foot ulcer. We estimated the annual foot ulcer incidence and described the characteristics: presence of comorbidities, clinical parameters and the characteristics of the diabetic foot ulcers (DFU) at inclusion in the study. RESULTS: The incidence of a new DFU during the 12-month recruitment period was 0.42%. The mean age of the participants was 72.2 years (± 12.7), the majority of them were males (n = 178; 69.5%). Overall, 43.8% of DFUs were located on the dorsal aspect of toes or interdigital spaces. A percentage of 43.4% of the participants had ulcers of less than 1 cm2 surface. Further, 44.1% of the participants had a neuroischemic, 20.3% a neuropathic, 20.3% an ischemic ulcer. A 25.3% of ulcers with a concomitant peripheral artery disease were infected. CONCLUSIONS: Although the incidence found was low, our study shows the great complexity of patients with foot ulcers treated in primary care.

Asymptomatic peripheral arterial disease in type 2 diabetes patients: a 10-year follow-up study of the utility of the ankle brachial index as a prognostic marker of cardiovascular disease.

BACKGROUND: Our aim was to evaluate the relationship between asymptomatic peripheral arterial disease, diagnosed only by the ankle brachial index (ABI), and cardiovascular disease (CVD) after a 10-year follow-up period in patients with type 2 diabetes. METHODS: In 1996, the ankle brachial index was measured in 262 patients with type 2 diabetes. During the 10-year follow-up period (mean follow-up time, 7.7 years), all nonfatal cardiovascular events and mortality were recorded. RESULTS: A total of 52 patients died during the follow-up time. The mortality of the patients with normal (0.91-1.24) and abnormal ABI (≤0.90) at the beginning of the study was 16.8% and 52.8%, respectively (p < 0.05). The incidence rate of fatal and nonfatal CVD was 26.9 (95% confidence intervals [CI]: 20.7-37.3) for the patients with a normal baseline ABI and 81.9 (95% CI: 50.9-131.8) for those with an abnormal baseline ABI. An abnormal baseline ABI was associated with a greater risk of CVD (hazard ratio = 2.32; 95% CI: 1.27-4.22). CONCLUSION: ABI values ≤0.9 in patients with type 2 diabetes mellitus and no history of intermittent vascular claudication or rest pain were associated with a higher risk of coronary or cerebrovascular morbidity and mortality.

[Correlation between toe-brachial index and ankle-brachial index in patients with diabetes mellitus type 2]. / Correlación entre los índices dedo-brazo y tobillo-brazo en pacientes con diabetes mellitus tipo 2.

BACKGROUND AND OBJECTIVE: We aimed to know the prevalence of abnormal toe-brachial index (TBI) in a group of patients with type 2 diabetes mellitus (DM2). We also aimed to know the correlation between TBI and the ankle-brachial index (ABI) in these patients and determine the abnormal value of TBI. PATIENTS AND METHODS: Descriptive cross-sectional study conducted in primary care. DM2 patients over 50 years were included. Systolic blood pressure at the arm, ankle and toe were determined to calculate the ABI and the TBI. RESULTS: We studied 175 patients (350 limbs) of a mean age of 67 years (SD=9), 53.7% were women and 72.3% had hypertension. The ABI was abnormal (≤ 0.90) in 8.3% of the limbs and 8.6% met criteria of calcification (≥ 1.40). The TBI was abnormal (≤ 0.60) in 18.6% of cases. Of the 291 limbs with a normal ABI, 34 (11.7%) had an abnormal value of TBI and the 30 limbs with a calcified ABI, 6 (20%) had an abnormal value of TBI. There was a positive linear correlation between ABI and TBI (r = 0.395, P < .001). CONCLUSIONS: Determination of TBI provides additional information to ABI determination and exploration can be very useful in cases of arterial calcification. The value ≤ 0.60 is the best one to consider an abnormal TBI.

Correlación entre los índices dedo-brazo y tobillo-brazo en pacientes con diabetes mellitus tipo 2 / Correlation between toe-brachial index and ankle-brachial index in patients with diabetes mellitus type 2

Fundamento y objetivo: Conocer la prevalencia de índice dedo-brazo (IDB) patológico en un grupo de pacientes con diabetes mellitus tipo 2 (DM2). Conocer la correlación entre el IDB y el índice tobillo-brazo (ITB) en estos pacientes y determinar a partir de que valor se debe considerar patológico el IDB. Pacientes y método: Estudio descriptivo transversal realizado en atención primaria. Se incluyeron pacientes mayores de 50 años con DM2. Se determinaron las presiones arteriales sistólicas en el brazo, tobillo y dedo del pie para poder calcular el ITB y el IDB. Resultados: Se estudiaron 175 pacientes (350 extremidades) de edad media (DE) 67 (9) años. El 53,7% eran mujeres y un 72,3% hipertensos. El ITB fue patológico ( 0,90) en 8,3% de las extremidades y un 8,6% cumplía criterios de calcificacio´n ( 1,40). El IDB fue patológico ( 0,60) en el 18,6% de los casos. De las 291 extremidades con un ITB normal, 34 (11,7%) presentaban un valor patológico del IDB, y de las 30 extremidades con un ITB calcificado, 6 ( 0%) presentaban un valor patológico del IDB. Entre el ITB y el IDB se observó una correlacio´n lineal positiva (r = 0,395; p < 0,001), que se mantuvo en presencia de calcificación arterial pero en sentido opuesto (r = -0,452; p = 0,012). La mayor área bajo la curva ROC la presentó el punto de corte de IDB patológico <0,60. Conclusiones: La determinacio´n del IDB aporta información adicional a la determinación del ITB y puede ser una exploración muy útil en caso de calcificación arterial. El valor inferior o igual a 0,60 es el más adecuado para considerar un IDB patológico (AU)

Background and objective: We aimed to know the prevalence of abnormal toe-brachial index (TBI) in a group of patients with type 2 diabetes mellitus (DM2). We also aimed to know the correlation between TBI and the ankle-brachial index (ABI) in these patients and determine the abnormal value of TBI. Patients and methods: Descriptive cross-sectional study conducted in primary care. DM2 patients over 50 years were included. Systolic blood pressure at the arm, ankle and toe were determined to calculate the ABI and the TBI. Results: We studied 175 patients (350 limbs) of a mean age of 67 years (SD = 9), 53.7% were women and 72.3% had hypertension. The ABI was abnormal ( 0.90) in 8.3% of the limbs and 8.6% met criteria of calcification ( 1.40). The TBI was abnormal ( 0.60) in 18.6% of cases. Of the 291 limbs with a normal ABI, 34 (11.7%) had an abnormal value of TBI and the 30 limbs with a calcified ABI, 6 (20%) had an abnormal value of TBI. There was a positive linear correlation between ABI and TBI (r = 0.395, < .001). Conclusions: Determination of TBI provides additional information to ABI determination and exploration can be very useful in cases of arterial calcification. The value <0.60 is the best one to consider an abnormal TBI (AU)

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Formación troncal de las especialidades médicas: un reto del presente para una mejora del sistema sanitario / Nuclear training in medical specialities

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