epidemiology of diabetic foot problems and predictive factors for.pdf

7/24/2019 Epidemiology of diabetic foot problems and predictive factors for.pdf

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Epidemiology of diabetic foot problems and predictive factors for

limb loss

Aziz Nathera,4, Chionh Siok Beeb, Chan Yiong Huakc, Jocelyn L.L. Chewa, Clarabelle B. Lina,Shuhui Neoa, Eileen Y. Sima

aDepartment of Orthopaedic Surgery, National University Hospital, Singapore

bDivision of Endocrinology, Department of Medicine, National University Hospital, Singapore

cBiostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore

Received 8 August 2006; received in revised form 28 March 2007; accepted 23 April 2007

Abstract

Objectives: The aim of this study was to evaluate the epidemiology of diabetic foot problems (DFP) and predictive factors for major

amputations (below- and above-knee). Methods: This is a prospective study of 202 patients treated in National University Hospital (NUH)

during the period of January 2005 to May 2006. A protocol was designed for documentation including patient profile, type of DFP, presence

of risk factors, comorbidities and complications, clinical presentation, investigations, treatment given, and final outcome. The predictors for

limb loss were determined using univariate and stepwise logistic regression analysis. Results: One hundred ninety-two patients had Type 2

diabetes. Mean age of cohort was 60 years, with male to female ratio of 1:1. Incidence of DFP was significantly higher in Malays ( P=.0015)

and Indians (P=.036) and significantly lower in Chinese (Pb.05). Of patients, 72.8% had poor endocrine control (GHb level N7%), and

42.1% of patients had sensory neuropathy based on 5.07 SemmesWeinstein Monofilament test. Common DFP included gangrene (31.7%),

infection (abscess, osteomyelitis) (28.7%), ulcer (27.7%), cellulitis (6.4%), necrotizing fasciitis (3.5%) and Charcots osteoarthropathy

(2.0%). Surgery was performed in 74.8% of patients and major amputation in 27.2% of patients (below-knee in 20.3% and above-knee in

6.9%). Conclusions: This is the first detailed prospective study evaluating predictive factors for major amputations in patients with DFP.

Significant univariate predictive factors for limb loss were age above 60 years, stroke, ischaemic heart disease, nephropathy, peripheral

vascular disease (PVD), sensory neuropathy, glycosylated haemoglobin level, Ankle Brachial Index (ABI) b0.8, gangrene, infection, and

pathogens such as methicillin-resistant Streptococcus aureus (MRSA) and Staphylococcus aereus. Upon stepwise logistic regression

analysis, only PVD and infection were significant.

D 2008 Elsevier Inc. All rights reserved.

Keywords:Diabetes; Amputation; Risk factors; Epidemiology

1. Introduction

The prevalence of diabetes in Singapore is 8.2% in 2004(Ministry of Health Singapore, 2004). Diabetic foot prob-

lems (DFP) are very common in Singapore, accounting for

approximately one fifth of all emergency admissions in

National University Hospital (NUH). Every year, almost

700 lower limb amputations resulting from diabetic foot

complications are performed (Ministry of Health Singapore,

1993). According to Ministry of Health, Singapore, guide-lines (Ministry of Health Singapore, 1999), the comprehen-

sive care of a patient with diabetes mellitus included good

endocrine control, education on endocrine control, quarterly

monitoring of glycosylated haemoglobin (GHb) levels,

yearly eye checkups, and yearly foot screening. With better

knowledge of the various predictive factors that determine

limb loss (Fejfarova, Jirkovska, Skibova, & Petkov, 2002;

Gurlek, Bayraktar, Savas, & Gedik, 1998; Hamalainen,

Ronnemaa, Halonen, & Toikka, 1999; Hennis, Fraser,

1056-8727/08/$ see front matterD 2008 Elsevier Inc. All rights reserved.

doi:10.1016/j.jdiacomp.2007.04.004

4 Corresponding author. Department of Orthopaedic Surgery, Yong

Loo Lin School of Medicine, National University of Singapore, Singapore.

Tel.: +65 6772 4323; fax: +65 6778 0720.

E-mail address: [email protected] (A. Nather).

Journal of Diabetes and Its Complications 22 (2008) 7782


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Jonnalagadda, Fuller, & Chaturvedi, 2004; Imran, Ali, &

Mahboob, 2006; Lehto, Ronnemaa, Pyorala, & Laakso,

1996; Leung, Ho, Carnett, Lam, & Wong, 2001; Miyajima,

Shirai, Yamamoto, Okada, & Matsushita, 2006; Nelson

et al., 1988; Resnick et al., 2004; Selby & Zhang, 1995;

Sheahan et al., 2005; Tseng, 2006; Young, Maynard, Reiber,

& Boyko, 2003), the number of cases of lower limbamputations could be reduced.

2. Research designs and methods

This is a prospective study of 202 patients treated in

NUH Multi-Disciplinary Team for DFP during the period

January 2005 to May 2006. A special protocol which was

designed for documentation included patient profileage,

sex, and marital status; duration and type of diabetes;

presence of risk factors such as smoking, alcoholism,

obesity, and hyperlipidaemia; presence of complications

including retinopathy, nephropathy, and peripheral vascular

disease (PVD); and presence of comorbidities such as

hypertension, ischaemic heart disease (IHD), and stroke.

Other information documented included the types of DFP,

namely, gangrene, infection (abscess, osteomyelitis), ulcer,

cellulitis, necrotizing fasciitis and Charcots osteoarthrop-

athy. The ulcers were graded according to Wagners

Classification (Pendsey, 2003) (Grade 0: high-risk foot;

Grade 1: superficial ulcer; Grade 2: deep ulcer penetrating

to tendon, bone, or joint; Grade 3: deep ulcer with abscess

or osteomyelitis; Grade 4: localized gangrene; Grade 5:

extensive gangrene requiring a major amputation) as well

as neuropathy as indicated by the 5.07 SemmesWeinsteinMonofilament Test. Investigations recorded also included

full blood count, erythrocyte sedimentation rate, C-reactive

protein, GHb levels, urea and electrolytes, and blood and

wound cultures. In addition, the treatment given (the type

of primary surgery performed or conservative treatment

instituted) and the final outcome of treatment (limb saved

or limb lost) were studied.

All patients were reviewed weekly in the first month

followed by monthly reviews.

Photographs of patients feet with DFP were taken for

better documentation. DFP were classified according to

Kings Classification (Edmonds & Foster, 2005) (Stage 1:normal; Stage 2: high-risk; Stage 3: ulcerated; Stage 4:

cellulitic; Stage 5: necrotic; Stage 6: major amputation).

Patients who underwent distal operations such as ray

amputation, desloughing, incision and drainage (I&D), or

toe disarticulation were said to have their limbs saved, while

patients who underwent major operations such as below-

knee amputation (BKA) or above-knee amputation (AKA)

were said to have their limbs lost.

All statistical analysis were performed using SPSS 14.0

with statistical significance set atPb.05. Predictors for limb

loss were determined using univariate and stepwise logistic

regression analysis.

3. Results

The age of patients ranged from 21 to 91 years, with

mean age being 60.0 years. Majority of patients were in

their fifth and sixth decades. Bose (1978) also found the

average age to be about 60 years. The ratio of males to

females was 1:1, although Bose found the ratio of males tofemales to be 1:1.5. Racial distribution was 45.5% Chinese,

32.7% Malays, 17.8% Indians, and 4.0% other races. When

compared against the racial distribution of Singapores

national population (Singapore Department of Statistics,

2000), incidence of DFP in our cohort was significantly

higher in Malays (P=.0015) and Indians (P=.036) and

significantly lower in Chinese (Pb.05). Previous studies on

diabetic foot lesions in Singapore (Bose, 1979; Bose, 1978;

Cheah et al., 1985; Lee & Bose, 1985) did not study the

incidence of DFP amongst the different races.

One hundred ninety-two patients had Type 2 diabetes,

and 10 had Type 1. Duration of diabetes ranged from 1 to

48 years. Of patients, 41.6% had diabetes between 1 and

10 years duration, 39.1% between 11 and 20 years, 14.3%

between 21 and 30 years, and 5.0% with more than

30 years duration.

Majority of patients (72.8%) had poor control of

diabetes, as indicated by their GHb levels (N7%).

The most common comorbidities were hypertension

(74.8%), followed by IHD (36.1%) and stroke (8.9%). Risk

factors included smoking (19.3%), alcoholism (9.4%),

obesity (8.4%), and hyperlipidaemia (51.0%). With respect

to the complications of diabetes, 44.1% of patients had

retinopathy, and 51.5% had nephropathy.

The most common DFP were gangrene (31.7%),infection (abscess and osteomyelitis) (28.7%), and ulcer

(27.7%). Others included cellulitis (6.4%), necrotizing

fasciitis (3.5%), and Charcots osteoarthropathy (2.0%).

Ulcers encountered were Grade 1 in 15 patients, Grade 2 in

27, and Grade 3 in 14.

Infections were encountered in 122 patients (60.4%)

63 patients (31.2%) with monomicrobial infections and

59 patients (29.2%) with polymicrobial infections. This is

based on blood cultures performed for all patients and

swabs for culture in patients with ulcer or discharge. In

patients undergoing operation, tissue from the infected area

was sent for culture. This is rather different to an earlierstudy performed by Bose (Bose, 1979), who found

monomicrobial infections in 53.3% and polymicrobial

infections in 46.7%. The commonest pathogens encoun-

tered in the group with monomicrobial infections were

Staphylococcus aureus (34.9%), Pseudomonas aeruginosa

(17.5%), Streptococcus agalactiae Group B (11.1%), and

methicillin-resistant Streptococcus au reu s (MRSA)

(11.1%). In comparison,Bose (1979)found monomicrobial

infections to consist of Streptococcus aureus (30%),

P. aeruginosa (30%), Proteus (22.5%) and Klebsiella

(17.5%). Fifty-nine patients had polymicrobial infec-

tions, and the commonest pathogens encountered were

A. Nather et al. / Journal of Diabetes and Its Complications 22 (2008) 778278


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Table 1

Results of evaluation of factors as predictive factors of limb loss

Risk factor

Limb loss Unadjusted Stepwise analysis

Positive Negative OR (95% CI) Pvalue OR (95% CI) Pvalue

Age

V60 years 19 (18.4) 84 (81.6) 1.0

N60 years 36 (36.4) 63 (63.6) 2.5 (1.34.8) .005

Gender

Male 26 (25.2) 77 (74.8) 1.0

Female 29 (29.3) 70 (70.7) 1.2 (0.72.3) .518

Race

Chinese 25 (27.2) 67 (72.8) 1.0

Malay 15 (22.7) 51 (77.3) 0.8 (0.41.6) .527

Indian 12 (33.3) 24 (66.7) 1.3 (0.63.1) .490

Others 3 (37.5) 5 (62.5) 1.6 (0.47.2) .536

Comorbidities

Hypertension Yes 43 (28.5) 108 (71.5) 1.3 (0.62.7) .493

No 12 (23.5) 39 (76.5) 1.0

IHD Yes 28 (38.4) 45 (61.6) 2.4 (1.24.4) .008No 27 (20.9) 102 (79.1) 1.0

Stroke Yes 9 (50.0) 9 (50.0) 3.0 (1.18.0) .028

No 46 (25.0) 138 (75.0) 1.0

Risk factors

Alcoholism Yes 3 (15.8) 16 (84.2) 0.5 (0.11.7) .249

No 52 (28.4) 131 (71.6) 1.0

Obesity Yes 3 (17.6) 14 (82.4) 0.5 (0.22.0) .360

No 52 (28.1) 133 (71.9) 1.0

Smoking Yes 12 (30.8) 27 (69.2) 1.2 (0.62.7) .581

No 43 (26.4) 120 (73.6) 1.0

Hyperlipidaemia Yes 33 (32.0) 70 (68.0) 1.7 (0.93.1) .119

No 22 (22.2) 77 (77.8) 1.0

ComplicationsRetinopathy Yes 24 (27.0) 65 (73.0) 1.0 (0.51.8) .941

No 31 (27.4) 82 (72.6) 1.0

Nephropathy Yes 40 (38.5) 64 (61.5) 3.5 (1.86.8) b.001

No 15 (15.3) 83 (84.7) 1.0

PVD Yes 45 (48.4) 48 (51.6) 9.3 (4.320.0) b.001 8.4 (3.918.3) b.001

No 10 (9.2) 99 (90.8) 1.0

Sensory neuropathy Yes 30 (35.3) 55 (64.7) 2.0 (1.13.8) .029

No 25 (21.4) 92 (78.6) 1.0

ABI b0.8 Yes 40 (36.7) 69 (63.3) 3.0 (1.55.9) .001

No 15 (16.1) 78 (83.9) 1.0

Type of DFP

Gangrene 30 (46.9) 34 (53.1) 4.0 (2.17.7) b.001

Infection 6 (10.3) 52 (89.7) 0.2 (0.10.6) .001 0.3 (0.10.7) .011

Ulcer 15 (26.8) 41 (73.2) 1.0 (0.51.9) .930Cellulitis 0 (0.0) 13 (100.0) N.A .999

Necrotizing fasciitis 4 (57.1) 3 (42.9) 3.8 (0.817.4) .090

Charcots osteoarthropathy 0 (0.0) 4 (100.0) N.A .999

Diabetes mellitus type

Type 1 2 (20.0) 8 (80.0) 1.0

Type 2 53 (27.6) 139 (72.4) 1.5 (0.37.4) .601

Duration of diabetes

N30 years 2 (20.0) 8 (80.0) 1.0

110 years 21 (25.0) 63 (75.0) 1.3 (0.36.8) .729

1120 years 21 (26.6) 58 (73.4) 1.4 (0.37.4) .656

(continued on next page )

A. Nather et al. / Journal of Diabetes and Its Complications 22 (2008) 7782 79


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Staphylococcus aureus (39.0%), P. aeruginosa (35.6%),

Bacteroides fragilis (23.7%), and Streptococcus agalactiae

Group B (20.7%). Bose did not describe the distribution of

flora found with his polymicrobial infections. When both

monomicrobial and polymicrobial infections were consid-

ered together as one entity, the commonest pathogens

encountered were Staphylococcus aureus (22.3%), P.

aeruginosa (15.8%), and B. fragilis (9.9%).

Of patients, 42.1% were found to have sensory neuro-

pathy based on the 5.07 SemmesWeinstein monofilament

test. With regard to the ABI measurements, 54.2% had ABI

b0.8 (indicating ischaemia).

Of patients, 74.8% underwent surgical treatment. The

most common operations performed were desloughing

(29.7%) and ray amputation (18.8%). Other procedures

included I&D (11.9%), toe disarticulation (1.5%), and split

skin grafting (1.5%). Conservative treatment was instituted

in 25.2% of patients.Limb loss occurred in 27.2% of patients20.3% due to

BKA and 6.9% due to AKAsignificantly lower than the

higher amputation rate of 40% found by Bose (1978), with

120 major amputations performed out of a total of 300

diabetic gangrene cases.

3.1. Predictive factors for limb loss

Table 1 shows the results of our study for evaluating

various factors as predictive factors for limb loss. None of

the previous work on DFP performed in Singapore (Bose,

1979; Bose, 1978; Cheah et al., 1985; Lee & Bose, 1985)studied predictive factors for limb salvage in patients with

DFP. This article is a detailed analysis of DFP in our local

population studying not only the epidemiology of DFP, its

clinical presentation, and investigations but also the evalua-

tion of possible predictive factors for limb loss.

3.1.1. Age

Patients aged above 60 years was found to be a

significant predictive factor for limb loss in our study

(P=.005), similar to findings by Leung et al. (2001).

However, Gurlek et al. (1998) and Nelson et al. (1988)

found age not to be significant in their studies.

3.1.2. Sex

Sex was not found to be an important predictive factor in

our study (P=.518). This is similar to findings by Gurlek

et al. (1998). In contrast, Hamalainen et al. (1999), Tseng

(2006),Resnick et al. (2004), andHennis et al. (2004)found

sex to be a significant prognostic factorthe male gender

having an increased predisposition to amputation.

3.1.3. Race

Race was not found to be a significant predictive factor

for limb loss in our study. In a study conducted byYoung

et al. (2003), Native Americans, African Americans, and

Hispanics were found to have an increased risk of

amputations compared to the whites.

3.1.4. Type of DFP

Gangrene (Pb.001) and infection (P=.001) were found

to be predictive factors for limb loss in our study. However,osteomyelitis was found to be a significant prognostic factor

byFejfarova et al. (2002)and Gurlek et al. (1998).

3.1.5. Risk factors

Smoking, alcoholism, obesity and hyperlipidaemia were

not found to be predictive factors for limb loss in our study

conducted (PN.05). Smoking was also not found to be a

significant predictive factor byGurlek et al. (1998), Lehto

et al. (1996)andSelby & Zhang (1995).

3.1.6. Comorbidities

Both stroke (P=.028) and IHD (P=.008) were found tobe predictive factors of limb loss in our cohort while

hypertension was not (P=.493). Similarly, stroke was found

to be a significant factor bySelby & Zhang (1995), while

hypertension was not found to be a significant factor by

Gurlek et al. (1998). However, hypertension was found to

be a significant factor by Selby and Zhang.

3.1.7. Complications

PVD (Pb.001) and nephropathy (Pb.001) were found to

be significant predictive factors for limb loss in our cohort.

Studies conducted byHamalainen et al. (1999),Young et al.

(2003), Nelson et al. (1988), Resnick et al. (2004), Lehto

Table 1 (continued)

Risk factor

Limb loss Unadjusted Stepwise analysis

Positive Negative OR (95% CI) Pvalue OR (95% CI) Pvalue

Duration of diabetes

2130 years 11 (37.9) 18 (62.1) 2.4 (0.413.7) .309

GHb level N7% Yes 34 (23.1) 113 (76.9) 0.5 (0.30.9) .034

No 21 (38.2) 34 (61.8) 1.0

Pathogens

MRSA 7 (70.0) 3 (30.0) 7.0 (1.728.1) .006

B. fragilis 7 (35.0) 13 (65.0) 1.5 (0.64.0) .413

Staphylococcus aureus 7 (15.2) 39 (84.8) 0.4 (0.21.0) .042

P. aeruginosa 10 (31.3) 22 (68.8) 1.3 (0.62.9) .578

Streptococcus agalactiae Group B 3 (15.8) 16 (84.2) 0.5 (0.11.7) .249



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et al. (1996), and Selby & Zhang (1995) also found

nephropathy to be a significant prognostic factor. However,

Sheahan et al. (2005)andGurlek et al. (1998) did not find

nephropathy to be a significant predictive factor. Studies

conducted byFejfarova et al. (2002), Gurlek et al, Hennis

et al. (2004), and Lehto et al. also found PVD to be a

significant predictive factor. In contrast, retinopathy was notfound to be a significant factor (PN.05) in our study, similar

to findings by Gurlek et al.

3.1.8. Duration of diabetes

Duration of diabetes was not found to be a predictive

factor for limb loss in our study, similar to findings by

Gurlek et al. (1998). However, duration of diabetes was

found to be a significant factor by Resnick et al. (2004),

Lehto et al. (1996), andSelby & Zhang (1995).

3.1.9. Sensory neuropathy

Presence of sensory neuropathy, as measured by 5.07SemmesWeinstein monofilament test, was found to be a

predictive factor in our study (P=.029), similar to findings

by Gurlek et al. (1998). However, the findings of

Hamalainen et al. (1999), Nelson et al. (1988), Hennis

et al. (2004),Lehto et al. (1996), andSelby & Zhang (1995)

found neuropathy to be a significant factor for limb loss.

3.1.10. ABI measurements

With regard to ABI measurements, patients with ABI

b0.8 (indicating ischaemia) was found to be a highly

significant factor for limb loss (P=.001). The same result

was also achieved by Hamalainen et al. (1999).

3.1.11. Endocrine control

GHb level was found to be a significant predictive factor

for limb loss in this cohort (P=.034), which is similar to

findings by Imran et al. (2006), Miyajima et al. (2006),

Hennis et al. (2004), Resnick et al. (2004), Lehto et al.

(1996), andSelby & Zhang (1995).

3.1.12. Pathogens

When individual pathogens were assessed as predictive

factors for limb loss, MRSA (P=.006) and Staphylococcus

aureus (P=.042) were found to be predictive factors for

limb loss in our study. Fejfarova et al. (2002) foundStaphylococcus aureus to be a significant predictive factor

for limb loss.

4. Conclusions

This is the first prospective study in detail to evaluate the

predictive factors for limb salvage in patients with DFP in

Singapore. Significant univariate predictive factors for limb

loss were age above 60 years, comorbidities (stroke and

IHD), complications of diabetes (nephropathy), PVD,

sensory neuropathy, GHb level, ABI b0.8, DFP such as

gangrene and infection, and pathogens such as MRSA and

Staphylococcus aureus. Upon stepwise logistic regression,

only PVD and infection were significant.

Acknowledgment

The authors would like to thank all members of the NUH

Multi-Disciplinary Team for DFP, Dr. Vikram David, Dr

V.A. Rajesh, Dr Ajay Nambiar, and the house officers and

medical officers of NUH wards for their commitment in

providing health care to patients with DFP.

References

Bose, K. (1979). A surgical approach for the infected foot. International

Orthopaedics, 3 (3), 177181.

Bose, K. (1978). Infection in diabetic foot. Annals of the Academy of

Medicine, Singapore, 7, 359365.Cheah, J. S., Thai, A. C., Alli, R., Chan, L., Wang, K. W., & Yeo, P. P.

(1985). Infections in diabetes with special reference to diabetics in

Singapore. Annals of the Academy of Medicine, Singapore, 14 (2),

240246.

Edmonds, M. E., & Foster, A. V. M. (2005). Managing the diabetic foot

(2nd ed.). London7 Blackwell.

Fejfarova, V., Jirkovska, A., Skibova, J., & Petkov, V. (2002). Pathogen

resistance and other risk factors in the frequency of lower limb

amputations in patients with the diabetic foot syndrome. Vnitrni

Lekarstvi, 48 (4), 302306.

Gurlek, A., Bayraktar, M., Savas, C., & Gedik, O. (1998). Amputation rate

in 147 Turkish patients with diabetic foot: The Hacettepe University

Hospital Experience. Experimental and Clinical Endocrinology &

Diabetes, 106(5), 404409.

Hamalainen, H., Ronnemaa, T., Halonen, J. P., & Toikka, T. (1999). Factorspredicting lower extremity amputations in patients with Type 1 or

Type 2 diabetes mellitus: A population-based 7-year follow-up study.

Journal of Internal Medicine, 246 (1), 97103.

Hennis, A. J. M., Fraser, H. S., Jonnalagadda, R., Fuller, J., & Chaturvedi,

N. (2004). Explanations for the high risk of diabetes-related amputation

in a Caribbean population of Black African descent and potential for

prevention.Diabetes Care, 27, 26362641.

Imran, S., Ali, R., & Mahboob, G. (2006). Frequency of lower extremity

amputation in diabetics with reference to glycemic control and Wagner

S grades.Journal of the College of Physicians and SurgeonsPakistan,

16(2), 124127.

Lee, E. H., & Bose, K. (1985). Orthopaedic management of diabetic

foot lesions. Annals of the Academy of Medicine, Singapore, 14 (2),

331333.

Lehto, S., Ronnemaa, T., Pyorala, K., & Laakso, M. (1996). Risk factorspredicting lower extremity amputations in patients with NIDDM.

Diabetes Care, 19, 607612.

Leung, H. B., Ho, Y. C., Carnett, J., Lam, P. K. W., & Wong, W. C. (2001).

Diabetic foot ulcers in the Hong Kong Chinese population: Retro-

spective study. Hong Kong Medical Journal, 7, 350355.

Ministry of Health Singapore. (1993). Central Claims Processing System.

Ministry of Health Singapore. (1999). Clinical Practice Guidelines for

Managing Diabetes Mellitus.

Ministry of Health Singapore. (2004). Details of National Health Survey

2004 Findings.

Miyajima, S., Shirai, A., Yamamoto, S., Okada, N., & Matsushita, T.

(2006). Risk factors for major limb amputations in diabetic foot

gangrene patients. Diabetes Research and Clinical Practice, 71 (3),

272279.

A. Nather et al. / Journal of Diabetes and Its Complications 22 (2008) 7782 81


6/7

Nelson, R. G., Gohdes, D. M., Everhart, J. E., Hartner, J. A., Zwemer, F.

L., Pettitt, D. J., & Knowler, W. C. (1988). Lower-extremity

amputations in NIDDM: 12-yr follow-up study in Pima Indians.

Diabetes Care, 11, 816.

Pendsey, S. (2003). Classification and staging. In S. Pendsey (Ed.),

Diabetic Foot. A Clinical Atlas(pp. 2426). London7 Martin Dunitz.

Resnick, H. E., Carter, E. A., Sosenko, J. M., Henley, S. J., Fabsitz, R. R.,

Ness, F. K., Welty, T. K., Lee, E. T., & Howard, B. V. (2004). Incidenceof lower-extremity amputation in American Indians: The Strong Heart

Study.Diabetes Care, 27(8), 18851891.

Selby, J. V., & Zhang, D. (1995). Risk factors for lower extremity

amputation in persons with diabetes. Diabetes Care, 18, 509516.

Sheahan, M. G., Hamdan, A. D., Veraldi, J. R., McArthur, C. S., Skillman,

J. J., Cambell, D. R., Scovell, S. D., Logerfo, F. W., & Pomposelli, F.

B., Jr. (2005). Lower extremity minor amputations: The roles of

diabetes mellitus and timing of revascularization. Journal of Vascular

Surgery, 42 (3), 476480.

Singapore Department of Statistics. (2000). Singapore Census 2000.

Tseng, C. H. (2006). Prevalence of lower-extremity amputation among

patients with diabetes mellitus: is height a factor? CMAJ: CanadianMedical Association Journal, 174 (3), 319323.

Young, B. A., Maynard, C., Reiber, G., & Boyko, E. J. (2003). Effects of

ethnicity and nephropathy on lower-extremity amputation risk among

diabetic veterans. Diabetes Care, 26(2), 495501.

3rd International Congress on Pediatrics

and the Metabolic Syndrome

3rd International Congress on Prediabetes and the Metabolic Syndrome Epidemiology,

Management and Prevention of Diabetes and Cardiovascular Disease

Venue: Nice, France

Date: April 14, 2009

For further information, please contact:

Secretariat

3rd International Congress on Prediabetes and the Metabolic Syndrome

Tel: +41 22 908 0488

Fax: +41 22 732 2850

E-mail: [email protected]

Website: www.kenes.com/prediabetes



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