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J Apelqvist

Publications and source records attributed to J Apelqvist.

At least 37 records · Page 2Linked to original sources
PubMed1997

Clinical characteristics and outcome in 223 diabetic patients with deep foot infections.

Clinical characteristics and outcome in 223 consecutive diabetic patients with deep foot infections are reported. Patients were treated by a multidisciplinary diabetic foot-care team at the University Hospital, Lund, Sweden, and were prospectively followed until healing or death. About 50% of patients lacked clinical signs of infection, such as a body temperature > 37.8 degrees C, a sedimentation rate > 70 mm/hour, and white blood cell count (WBC) > 10 x 10(9)/liter. Eighty-six percent had surgery before healing or death. Thirty-nine percent healed without amputation; 34% healed after a minor and 8% after a major amputation. Sixteen percent were unhealed at death, and 3% were unhealed at the end of the observation period. Of those unhealed at death or follow-up, 4 patients had had a major and 11 a minor amputation. After correction for age and sex, duration of diabetes < 14 years, palpable popliteal pulse, a toe pressure > 45 mmHg, and an ankle pressure > 80 mm Hg, absence of exposed bone and a white blood cell count < 12 x 10(9)/liter were all related to healing without amputation in a logistic regression analysis. We conclude that although only 1 in 10 had a major amputation, nearly all diabetic patients with a deep foot infection needed surgery and more than one third had a minor amputation before healing or death in spite of a well-functioning diabetic foot-care team responsible for all included patients.

Adult↗
PubMed1997

Cost-effective management of diabetic foot ulcers. A review.

Foot lesions are common and serious complications in patients with diabetes mellitus. In recent years, several authors have, in addition to the medical aspects, focused on the high costs for treatment of this complication. However, few studies have performed a complete health-economic comparison and analysis of different treatments. This is probably related to the complexity of the problem and ethical difficulties in performing randomised clinical trials on these patients. Despite the lack of comparative health-economic studies, most authors conclude that amputations should be avoided if there is any possibility of saving the limb. This is not only because of the economic consequences-high costs for repeated hospitalisations, rehabilitation, home care and social-service support-associated with amputations, but also the quality-of-life aspects. Alternative treatment options might seem costly in the short term, but most cost-effectiveness analyses that also consider the long term perspective have concluded that treatment alternatives in which the limb is saved are more cost effective. Methodological aspects, such as the perspective of a study, may cause difficulties in comparing results between countries and settings. By using the societal perspective in economic studies, incentives to push costs from one sector to another might be avoided.

Amputation, Surgical↗
PubMed1996

The effect of the non-ionic contrast medium iohexol on glomerular and tubular function in diabetic patients.

The effect of the non-ionic contrast medium iohexol (Omnipaque) on renal function was investigated in diabetic patients with signs of peripheral ischaemia. Forty-six patients, 70 +/- 11 years (mean +/- SD) old, age at diabetes diagnosis 53 +/- 17 years, and with varying degrees of diabetic nephropathy were studied before 1, 2, and 30 days after aortobifemoral arteriography. Serum creatinine, creatinine clearance, urinary excretion of immunoglobulin G, albumin collagen IV (NC1), kappa and lambda chains, alpha-1 microglobulin and Tamm-Horsfall protein were evaluated. Within 1 month before and 30 days after arteriography, the glomerular filtration rate was measured by clearance of iohexol. The acute effect of the radiocontrast medium was an increase in the serum creatinine level in 41 (89%) patients, with a more than 25% increase in 12 (26%) patients. The excretion rates of immunoglobulin G and albumin decreased, whereas the proximal and distal tubular function and the excretion of collagen IV did not change. The increment in serum creatinine was associated with the preangiographic renal function (p < 0.05), a history of heart failure (p < 0.01), but not with age, duration and type of diabetes, gender, systolic or diastolic blood pressure, glycated haemoglobin (HbAlc) or blood glucose levels. The increase of serum creatinine was associated with a pre-existing proximal tubular dysfunction and a worsening of distal tubular function. No changes in the parameters measured persisted 30 days after angiography. In summary, a transient increment in serum creatinine level after arteriography occurred in 89% of diabetic patients. It was associated with the preangiographic renal function, a history of heart failure and signs of preexisting proximal tubular dysfunction and worsening of distal tubular function. However, these changes were reversible.

Age of Onset↗
PubMed1996

Foreign- and Swedish-born diabetic patients--a population-based study of prevalence, glycaemic control and social position.

In this study foreign- and Swedish-born individuals with diabetes mellitus were compared regarding prevalence and characteristics. In a Swedish county 1,568 patients aged 20-64 years were identified, of whom 97.4% were included (143 foreign- and 1,384 Swedish-born) in the study of medical records. There was no difference in prevalence of diabetes (1.4% (95% CI 1.2-1.7%) vs 1.5% (95% CI 1.4-1.6%) but diagnosis at or after the age of 30 years was more common in foreign-born patients (p < 0.001). They were also less often treated with insulin (p < 0.001), had shorter duration of diabetes (p < 0.001), were more often classified as having a low social position in Sweden (p < 0.001) and less often controlled in specialized diabetes care departments (p < 0.001, 18% vs 43%). There was a higher occurrence of albuminuria among foreign-born women (p < 0.05). No differences were found in glycaemic control, but low social position was related to poor glycaemic control independent of being foreign- or Swedish-born, and it seems to be more important than place of birth.

Adult↗
PubMed1996

Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial.

Diabetic foot ulcers with exposure of tendon, muscle, or bone imply a high probability for deep infections and amputations. Delayed healing times are often described. The aim of this study was to compare the clinical effect and economic cost of cadexomer iodine with standard treatment in diabetic feet with cavity ulcers. Patients with deep, exudative foot ulcers were included in a 12-week open, randomised, comparative study. When ulcers stopped exudating, vaseline gauze was used in both groups until the end of the study. Costs were estimated for dressing material, staff and transportation. Clinically relevant improvement was seen in 12 patients treated with cadexomer iodine and in 13 patients treated with standard treatment. The average weekly cost was SEK 903 and SEK 1,421, respectively, of which the major part was costs for staff and transportation related to frequency of dressing changes. Treatment with cadexomer iodine ointment (Iodosorb) showed no clinical difference compared to topical treatment consisting of gentamicin solution, streptodornase/streptokinase, or dry saline gauze but was associated with considerably lower weekly treatment costs.

Adult↗
PubMed1996

Operations, total hospital stay and costs of critical leg ischemia. A population-based longitudinal outcome study of 321 patients.

In a longitudinal analysis of all 321 patients in a defined population having surgery for critical leg ischemia during 1 year in Malmöhus county (0.53 million inhabitants), Sweden, we investigated all vascular procedures and amputations on both legs, total hospital stay and hospital costs from the first procedure in each patient until death or at follow-up at least 6 years postoperatively. The first (key) operation during the inclusion year was a reconstructive vascular procedure in 96 patients, a restorative vascular procedure in 111 and a major amputation in 114 patients. One third of those with a reconstructive and half of those with a restorative key procedure had an ipsilateral major amputation. The mean number of surgical procedures and length of hospital stay among all patients were 3 (1-19) procedures and 117 (1-1097) days, respectively. Of the total number of days in hospital, less than half were in surgical departments, 10% in other acute-care departments and almost half in rehabilitation clinics and nursing homes. The total hospital and surgical costs among all patients were USD 15.1 million (mean USD 47,000/patient), with no significant differences in relation to the key operation. We conclude that patients who have undergone surgery for critical leg ischemia accumulate very high total long-term hospital costs due to the need for repetitive surgery and long hospital stays. Our findings also show that a longitudinal study, including hospital stay in departments other than surgical, is necessary for a correct cost-and-outcome analysis.

Amputation, Surgical↗
PubMed1995

Topical treatment of diabetic foot ulcers: an economic analysis of treatment alternatives and strategies.

In a prospective study, 314 patients with diabetic foot ulcers were followed and 40 patients died before healing occurred. In those patients who healed, a retrospective economic analysis of the costs for topical treatment was performed. The aim of the study was to analyse the costs and discuss how different treatment strategies influence total costs. Data collected for each patient were total time to healing, treatment time for each type of dressing, and the frequency of dressing changes. Material costs for the dressings, labour, and travelling costs were calculated separately. A formula for simulation of economic consequences of different treatment strategies including the introduction of new strategies was designed. The cost for topical treatment was strongly related to the severity of the ulcer and wound healing time. The average weekly cost per patient for topical treatment varied between 40.3 pounds and 385 pounds. The dominating costs for topical treatment were expenses for staff and transportation. The most important factor to reduce costs is the frequency of dressing changes. The study emphasizes the need for prospective comparative studies of cost effectiveness in topical treatment strategies.

Bandages↗
PubMed1995

Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?

The purpose of this retrospective study was to evaluate the changes in diabetes-related lower extremity amputations following the implementation of a multidisciplinary programme for prevention and treatment of diabetic foot ulcers in a 0.2 million population with a 2.4% prevalence of diabetes. All diabetes-related primary amputations from toe to hip from 1 January 1982 to 31 December 1993 were included. In 294 diabetic patients, 387 primary major (above the ankle) or minor (through or below the ankle) amputations were performed, constituting 48% of all lower extremity amputations. The annual number of amputations at all levels decreased from 38 to 21, equalling a decrease of incidence from 19.1 to 9.4/100,000 inhabitants (p = 0.001). The incidence of major amputations decreased by 78% from 16/1 to 3.6/100,000 inhabitants (p < 0.001). The absolute number of amputations with a final level below the ankle showed no increase, but their proportion increased from 28 to 53% (p < 0.001) and the reamputation rate decreased from 36 to 22% (p < 0.05) between the first and last 3-year period. Thus, a substantial long-term decrease in the incidence of major amputations was seen as well as a decrease in the total incidence of amputations in diabetic patients. Seventy-one per cent of the amputations were precipitated by a foot ulcer. These findings indicate that a multidisciplinary approach plays an important role to reduce and maintain a low incidence of major amputations in diabetic patients.

Adult↗
PubMed1995

Clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers: a prospective study of healing below or above the ankle in 187 patients.

The aim of this study was to describe the clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers. In a prospective series, 187 consecutively presenting patients were investigated. From admission until final outcome, the patients were treated by a multidisciplinary team both as in- and out-patients. All the patients had one or more signs of neuropathy and 171 had evidence of peripheral vascular disease. Healing with an amputation below the ankle occurred in 74 patients, 88 patients healed with an amputation above the ankle, and 25 patients died unhealed. Amputation above the ankle was associated with high age, living in an institution, a limited walking capacity, cerebrovascular disease, congestive heart failure, and a low hemoglobin level. Amputation below the ankle was associated with diabetes diagnosis before 30 years of age and diabetes duration. In conclusion, older age, history of cerebrovascular disease and low hemoglobin level are associated with above ankle amputation level in diabetic patients with foot ulcers. However, level selection cannot be based upon these factors only, since some patients at high age, with cerebrovascular disease or with a low hemoglobin value, healed with an amputation below the ankle. None of these factors per se should be taken as a cause to choose a primary amputation above the ankle, unless amputation is supported by the total clinical picture, including local characteristics, such as type and localization of ulcer, and signs of peripheral vascular disease. More attention should be paid to biological than to chronological age.

Adult↗
PubMed1995

Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting.

The purpose of this study was to analyze long-term costs for foot ulcers in diabetic patients. Patients were treated and followed prospectively by a foot care team. A retrospective economic analysis was performed of costs for 274 patients during 3 years from healing of an initial foot ulcer, with or without amputation. Costs were estimated for inpatient care, outpatient care, home care, and social service. The cost calculations include costs due to complications and disability related to the initial ulcer, costs related to recurrence of ulcer, and costs for prevention of new ulcers. Expected total present value cost per patient during 3 years of observation was $26,700 (U.S. dollars) for primary healed patients with critical ischemia and $16,100 for primary healed patients without critical ischemia. For patients who healed with an amputation, the corresponding costs were $43,100 after a minor amputation and $63,100 after a major amputation. When estimating the costs for diabetic foot ulcers, it is not sufficient to calculate short-term costs. Long-term costs are high, mainly due to the need for increased home care and social service, but also due to costs for recurrent ulcers and new amputations.

Activities of Daily Living↗
PubMed1994

Diabetic foot ulcers in a multidisciplinary setting. An economic analysis of primary healing and healing with amputation.

OBJECTIVES: To perform an economic analysis of primary healing and healing with amputation in diabetic patients with foot ulcers. DESIGN: A retrospective economic analysis based on a prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer. SETTING: A multidisciplinary foot-care team. SUBJECTS: A total of 314 consecutively presenting diabetic patients with foot ulcers. Forty patients died before healing occurred. In those patients who healed primarily (n = 197) or after amputation (n = 77), a retrospective economic analysis was performed. INTERVENTIONS: All patients were treated by a multidisciplinary foot care team consisting of diabetologist, orthopaedic surgeon, diabetes nurse, podiatrist and orthotist both as in- and out-patients. The patients were followed by the team from admittance until final outcome, i.e. primary healing or healing with amputation or death. MAIN OUTCOME MEASURES: Data from both the prospectively collected patient material and from patient records were used to estimate the cost for hospital care, antibiotics, surgery, out-patient care, staff attendance, drugs and material for ulcer dressings, and orthopaedic appliances. RESULTS: The total costs were SEK 51,000 (3000-808,000) for patients with primary healing and SEK 344,000 (27,000-992,000) for healing with amputation. Costs for in-patient care were 37% of total average costs for primary healing and 82% for patients with amputation. The costs for topical treatment of the ulcers in out-patient care were 45% of the total average cost for primary healed and 13% for patients who healed with amputation. The costs for products used for ulcer dressings were 21% of total costs for topical treatment, i.e. 9% and 3% of total average costs for primary healing and healing with amputation, respectively. Costs for visits to the foot care team, antibiotics and orthopaedic appliances were low in relation to total costs. CONCLUSION: Treatment of diabetic patients with foot ulcers in a multidisciplinary system was associated with relatively low costs. Healing with amputation was associated with high costs mainly due to multiple and extended hospitalization. These findings indicate the potential cost savings of preventive and multidisciplinary foot care.

Aged↗
PubMed1994

Local signs and symptoms in relation to final amputation level in diabetic patients. A prospective study of 187 patients with foot ulcers.

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.

Adult↗
PubMed1993

[Foot ulcers in patients with diabetes. Preventive measures reduce the number of amputations].

Reports of preventive management resulting in reduction, by 50 percent or more, of the incidence of major amputation due to foot ulceration in diabetics have now been published from seven different localities, five in Europe (Umeå, Kisa, Lund, London and Geneva) and two in the USA (Tucson and Louisville). The methods used to achieve the reduction are remarkably similar, being based on systematic check-ups for incipient foot ulceration and its putative risk factors. In all three Swedish reports, the work has entailed close liaison with community health centres in the respective areas, which is considered to be of the utmost importance in reaching all diabetics at risk of foot ulcers. Another important prerequisite is a specialised foot clinic for diabetic patients in each area, where the skills of a chiropodist, a physician specialised in diabetes, an orthopaedic surgeon and an orthopaedic shoemaker are available.

Amputation, Surgical↗
PubMed1993

Long-term prognosis for diabetic patients with foot ulcers.

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.

Aged↗
PubMed1993

Distal blood pressure as a predictor for the level of amputation in diabetic patients with foot ulcer.

The predictive value of distal blood pressure measurements for the level of amputation was studied prospectively in 161 consecutive diabetic patients with foot ulcers. The patients were treated as outpatients except for periods of surgery and when complications requiring hospital care occurred. All patients were treated pre- and postoperatively by the same multidisciplinary foot care team. Either ankle or toe blood pressure measurement was available in 86% of the patients. Incompressible arteries, ulcer or gangrene at the measuring site, previous amputation, poor general condition, and an emergency situation were factors that excluded standardized ankle and toe blood pressure measurements in 24% and 27% of the patients, respectively. An absolute lower ankle pressure level of 50 mm Hg was found, below which a minor amputation was never sufficient to achieve healing. An ankle pressure below 75 mm Hg was seldom sufficient, and at or above that pressure level, the ankle pressure had no predictive value in this respect. At a toe pressure below 15 mm Hg, a minor amputation was seldom sufficient. Ankle and toe pressure indices gave no further information.

Adult↗
PubMed1992

The association between clinical risk factors and outcome of diabetic foot ulcers.

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.

Adult↗
PubMed1990

Topical treatment of necrotic foot ulcers in diabetic patients: a comparative trial of DuoDerm and MeZinc.

An open randomized controlled study was carried out of 44 diabetic patients with necrotic foot ulcers treated with adhesive zinc oxide tape (MeZinc) or with an adhesive occlusive hydrocolloid dressing (DuoDerm). Fourteen of the 21 patients treated with MeZinc had their necrotic ulcers improved by at least 50% compared to six out of 21 with the hydrocolloid dressing (P less than 0.025). Fifteen patients showed an increase in the area of necrosis during the course of the 5-week study and of these, 10 had been treated with the hydrocolloid dressing.

Administration, Topical↗