Staff Publication

High mortality following major amputation in diabetes: An analysis of risk factors and causes of death (2024)

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Type of publication:

Conference abstract

Author(s):

*Cane C.; *Beard N.; *Al-Samaraaie E.; *Basavaraju N.; *Moulik P.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024.

Abstract:

Aims: Mortality following major diabetic amputation is high. We analysed data on factors leading to mortality following major amputation. Method(s): Data on all 48 major non-traumatic diabetic lower-limb amputation between April 2022 and March 2023 were analysed in September 2023. 33 (69%) were alive and 15 (31%) had died. Result(s): 90% patients had type 2 diabetes and 67% had diabetes duration>10 years. 17 (35%) were female. 38 (80%) were between 50 and 80, 9 (18%) over 80 years old. 21 (42%) were overweight or obese. 26 (54%) had below knee amputation (BKA) and 22 (46%) above knee amputation (AKA). Half were current or ex-smokers, 58% hypertensive, 79% hyperlipidaemic or on statins, 83% on antiplatelet/anticoagulants. 27 (57%) had eGFR >60 mL/min, 17 (35%) eGFR 30-60 mL/min, 4 (8%) eGFR 15-30 mL/min and none with eGFR <15 mL/min. 37% had pre-proliferative/proliferative retinopathy or maculopathy, 28 (58%) previous foot ulcers and 19 (40%) previous amputation. 80% had neuropathy and 80% peripheral arterial disease. Cause of amputation was critical ischaemia in 27 (56%), sepsis/spreading gangrene in 17 (36%). 10 patients died in hospital and 5 in the community. Cause of death was cardiorespiratory in 6 (40%), sepsis related to DFU in 2 (13%), sepsis unrelated to DFU in 3 (20%), old age/dementia in 2 (13%) and unknown in 2 (13%). Mortality was similar in BKA and AKA. Mann-Whitney test with Monte Carlo correction suggested age >40 at diagnosis of diabetes, advanced nephropathy and retinopathy additionally predicted mortality. Conclusion(s): A third of patients had died within a year following major amputation. Majority were older patients with multiple risk factors contributing both to amputation and mortality, but additional predictors of mortality were nephropathy and retinopathy.

DOI: 10.1111/dme.15296

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Root cause analysis of non-traumatic major amputation in diabetes in a district general hospital: Are we missing opportunities to improve care? (2024)

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Type of publication:

Conference abstract

Author(s):

*Beard N.B.; *Basavaraju N.B.; *Al-Samaraaie E.A.; *Cane C.C.; *Moulik P.M.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024.

Abstract:

Background: There is concern that Shropshire and Telford have significantly higher minor and major diabetic foot amputations. Method(s): Data on all 48 major non-traumatic lower limb amputation in diabetes were collected between April 2022 and March 2023. Indicators of care and pathways to amputation were studied. Result(s): 38 (80%) patients were between 50 and 80, 9 (18%) over 80 and 1 (2%) was less than 50 years age. 26 (54%) had below knee and 22 (46%) above knee amputation. 22 (45%) had documented diabetes foot check in the preceding year, 39 (80%) had high risk feet, 28 (58%) previous foot ulcers and 19 (40%) previous minor amputation. 23 (48%) had been seen by the foot protection team in the 8 weeks prior to amputation and 26 (54%) did not have an urgent referral to the muldisciplinary (MDT) foot clinic. 39 (80%) had neuropathy, 38 (80%) had peripheral arterial disease and 10% had Charcot's. SINBAD score was unavailable for 19 (40%) as not seen in MDT clinic, the score was 1, 2, 3, 4, 5 and 6 in 2%, 10%, 8%, 33%, 4% and 2%, respectively, in the rest. Pre-amputation x-rays were available in 54%, antibiotics given in 69%, debridement done in 33% and offloading provided in 60%. 23% had lower limb arterial bypass, 21% had angioplasty and 8% theatre-based debridement. Conclusion(s): Opportunities for improving foot care exist and could prevent or reduce major amputations as majority were in known high risk feet but did not receive NICE recommended care. A significant number of patients were admitted directly for amputation without having the benefit of amputation prevention interventions.

DOI: 10.1111/dme.15296

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Lessons from a teacher: Managing diabetic foot sepsis in the NHS under critical pressure (2024)

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Type of publication:

Conference abstract

Author(s):

*Cane C.L.; *Beard N.; *Breeze S.; *Moulik P.K.

Citation:

Diabetic Medicine. Conference: Diabetes UK Professional Conference 2024. London . 41(Supplement 1) (no pagination), 2024. Date of Publication: 01 Apr 2024.

Abstract:

A 49-year-old schoolteacher with insulin treated type 2 diabetes attended the diabetic foot clinic. Four days prior he tripped causing a left big toe superficial abrasion. He felt unwell the next day with chills. In MDT clinic, he had normal blood pressure and glucose, temperature 37.2degreeC, left hallux superficial ulcer, SINBAD score 3, cellulitis on left forefoot, neuropathy, biphasic foot pulses on doppler. The hospital was in critical incident, the patient was compliant but reluctant to come in and a decision for supervised outpatient treatment made with daily phone contact, alternate day attendance with safety netting advice to attend A&E. He was started on CGM (Freestyle Libre), oral co-amoxiclav and ciprofloxacin. Initial abnormal blood tests (WBC 18.7 x 109/L, CRP 210 mg/L, Lactate 2.4 mmol/L, Glucose 10.8 mmol/L) results improved on retesting. Sepsis symptoms were settling. After 4 days, foot doppler signals became monophasic and with tissue necrosis on the hallux though his cellulitis was settling. He was admitted briefly for intravenous antibiotics and urgent MRI angiogram (showed good anterior tibial inflow into foot). The foot is slowly healing, his foot pulse doppler signal has returned to biphasic, but there is an eschar on the left hallux and the toenail has fallen off. The case highlights the risk of capillaritis in diabetic foot sepsis which can lead to rapid tissue hypoperfusion and necrosis. Doppler signals are unreliable in presence of sepsis and tissue oedema. A virtual ward setup with intravenous antibiotics and rapid diagnostic test access is being developed before the winter bed crisis.

DOI: 10.1111/dme.15296

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Implementing the new BSE methods and reference ranges for the Proximal Ascending Aorta and the impact on downstream testing-experience of a District General Hospital (2023)

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Type of publication:

Conference abstract

Author(s):

*Doherty J.; *Ellis C.; *Lee E.;

Citation:

Echo Research and Practice. Conference: British Society of Echocardiography annual meeting 2023. Newport . 11(Supplement 1) (no pagination), 2024. Date of Publication: 01 Jul 2024.

Abstract:

Background: In 2020 the BSE updated the methods and reference values for assessing the proximal ascending aorta (PAA). It is important to quantify how implementing these methods alter the rate of 'dilated' PAAs identified by echocardiography, and how this will impact the wider service and patient pathway. Purpose(s): To compare the rate of dilated PAAs detected by the current BSE methods, and two other methods of assessing the PAA in our patient population. Method(s): All transthoracic echocardiograms where the PAA was measured between January 2018 and December 2019 were included. Studies with incomplete demographics or bicuspid aortic valves were excluded. The PAA was indexed to height (Method 1), body surface area (BSA) (Method 2) and height2.7 (Method 3), compared to the corresponding normal reference values and classified as 'dilated' or 'nondilated' accordingly. The rate of 'dilated' proximal ascending aortas were compared using Chi-squared test. Result(s): 11,828 studies were identified. 2189 were removed due to incomplete patient demographics and 27 with bicuspid aortic valves. 2710 studies were removed as Method 2 does not provide reference values for patients < 45 and Method 3 > 80 years old. 6902 studies were included in the analysis. Method 1 classified significantly more PAAs as 'dilated' (31%, AUC = 0.930) compared to Method 2 (10%, AUC = 0.841) and 3 (3%, AUC = 0.921) (X2(1, N = 6902) = 2435.8, p < 0.001). Figure 1 (abstract ABS004) A comparison of number of Proximal Ascending Aortas classified as dilated using three different methods of normalising and assessing the proximal ascending aorta to body size; Method 1-height and sex, Method 2-body surface area, age and sex and Method 3-height2.7, age and sex.*Significantly different from Method 1 (p < 0.001).**Significantly different to Method 2 (p < 0.001) Figure 2 (abstract ABS004) Receiver Operating Characteristic (ROC) curves of three methods for assessing the size of the proximal ascending aorta (PAA) on echocardiography; BSE recommended methods using height and sex (Method 1, green), body surface area, age and sex (Method 2, red) and height2.7, age and sex (Method 3, blue). Sensitivity and 1-specificty values for each method at the PAA diameter of 4 cm is plotted. Of the 6902 studies, 306 PAAs were > 4 cm. Method 1 classified all PAAs > 4 cm and 1885 < 4 cm as dilated; Method 2 classified 111 PAAs > 4 cm and 82 < 4 cm as dilated; and Method 3 classified 203 PAAs > 4 cm and 476 < 4 cm as dilated. Conclusion(s): Adopting the 2020 BSE recommended methods significantly increase the detection rate of dilated PAAs in our patient population. This will impact subsequent downstream testing, affecting resource planning and patient journey.

DOI: 10.1186/s44156-024-00053-0

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Medicine Flow Team – Test of Change PRH (2025)

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Type of publication:

Service improvement case study

Author(s):

*Shelbey Fenton-Cook

Citation:

SaTH Improvement Hub, December 2025

SMART Aim:

During a 1-month test of change 22nd Sept – 17th October 2025

  • Increase pre 12:00 discharges to trust target of 35%
  • Increase pre 08:45 transfers to DCL to 10%
  • Increase in DCL utilisation to 50%
  • Reduction in simple LOS to trust target of 4 days

Link to PDF poster

Medicine Flow Team – Test of Change RSH (2025)

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Type of publication:

Service improvement case study

Author(s):

*Shelbey Fenton-Cook

Citation:

SaTH Improvement Hub, December 2025

SMART Aim:

During a 1-month test of change 22nd Sept – 17th October 2025

  • Reduction in simple LOS to trust target of 4 days
  • Increase pre 12:00 discharges to trust target of 35%
  • Increase pre 08:45 transfers to DCL to 10%
  • Increase in DCL utilisation to 50%

Link to PDF poster

SaTH and CTH Therapy Weekend assessment and Discharge Model (2025)

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Type of publication:

Service improvement case study

Author(s):

*Mandy Taylor; *Sharon Huckerby; *Sarah Robinson.

Citation:

SaTH Improvement Hub, December 2025

SMART Aim:

To develop a streamlined therapy approach to support the discharge of the complex patient ensuring the patient is supported to leave the acute setting as soon as medically optimised by 20th November 2025 as
evidenced by complex discharge figures.

Link to PDF poster

Oxygen Prescriptions for Gynaecology Inpatients (2025)

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Type of publication:

Service improvement case study

Author(s):

*William Roberts

Citation:

SaTH Improvement Hub, December 2025

SMART Aim:

Trust policy for all inpatients to have a target oxygen saturation identified on admission. Widespread issue with poor oxygen prescription compliance across the country. 47% (n = 15) of gynae inpatients had no oxygen prescribed. Incorrect/absent prescriptions have the potential to cause harm. Target compliance 80%

Link to PDF poster