Journal of Diabetes and Its Complications 22 (2008) 77 82

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
a

Department of Orthopaedic Surgery, National University Hospital, Singapore

Division of Endocrinology, Department of Medicine, National University Hospital, Singapore
c
Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
b

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 problems (DFP) are very common in Singapore, accounting for
approximately one fifth of all emergency admissions in
National University Hospital (NUH). Every year, almost
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: dosnathe@nus.edu.sg (A. Nather).
1056-8727/08/$ see front matter D 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jdiacomp.2007.04.004

700 lower limb amputations resulting from diabetic foot

complications are performed (Ministry of Health Singapore,
1993). According to Ministry of Health, Singapore, guidelines (Ministry of Health Singapore, 1999), the comprehensive 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,

78

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

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 limb
amputations 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 osteoarthropathy. 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 SemmesWeinstein
Monofilament 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 belowknee 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 at Pb.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 to
females 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 earlier
study performed by Bose (Bose, 1979), who found
monomicrobial infections in 53.3% and polymicrobial
infections in 46.7%. The commonest pathogens encountered 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 aureus (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 infections, and the commonest pathogens encountered were

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

79

Table 1
Results of evaluation of factors as predictive factors of limb loss
Limb loss
Risk factor

Positive

Age
V60 years
N60 years

19 (18.4)
36 (36.4)

Gender
Male
Female
Race
Chinese
Malay
Indian
Others

Unadjusted

Stepwise analysis

OR (95% CI)

P value

84 (81.6)
63 (63.6)

1.0
2.5 (1.34.8)

26 (25.2)
29 (29.3)

77 (74.8)
70 (70.7)

1.0
1.2 (0.72.3)

25
15
12
3

(27.2)
(22.7)
(33.3)
(37.5)

67
51
24
5

(72.8)
(77.3)
(66.7)
(62.5)

1.0
0.8 (0.41.6)
1.3 (0.63.1)
1.6 (0.47.2)

Yes
No
Yes
No
Yes
No

43
12
28
27
9
46

(28.5)
(23.5)
(38.4)
(20.9)
(50.0)
(25.0)

108
39
45
102
9
138

(71.5)
(76.5)
(61.6)
(79.1)
(50.0)
(75.0)

1.3 (0.62.7)
1.0
2.4 (1.24.4)
1.0
3.0 (1.18.0)
1.0

.493

Yes
No
Yes
No
Yes
No
Yes
No

3
52
3
52
12
43
33
22

(15.8)
(28.4)
(17.6)
(28.1)
(30.8)
(26.4)
(32.0)
(22.2)

16
131
14
133
27
120
70
77

(84.2)
(71.6)
(82.4)
(71.9)
(69.2)
(73.6)
(68.0)
(77.8)

0.5
1.0
0.5
1.0
1.2
1.0
1.7
1.0

(0.11.7)

.249

(0.22.0)

.360

(0.62.7)

.581

(0.93.1)

.119

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

24
31
40
15
45
10
30
25
40
15

(27.0)
(27.4)
(38.5)
(15.3)
(48.4)
(9.2)
(35.3)
(21.4)
(36.7)
(16.1)

65
82
64
83
48
99
55
92
69
78

(73.0)
(72.6)
(61.5)
(84.7)
(51.6)
(90.8)
(64.7)
(78.6)
(63.3)
(83.9)

1.0
1.0
3.5
1.0
9.3
1.0
2.0
1.0
3.0
1.0

(0.51.8)

.941

(1.86.8)

b.001

(4.320.0)

b.001

(1.13.8)

.029

(1.55.9)

.001

Type of DFP
Gangrene
Infection
Ulcer
Cellulitis
Necrotizing fasciitis
Charcots osteoarthropathy

30
6
15
0
4
0

(46.9)
(10.3)
(26.8)
(0.0)
(57.1)
(0.0)

34
52
41
13
3
4

(53.1)
(89.7)
(73.2)
(100.0)
(42.9)
(100.0)

4.0 (2.17.7)
0.2 (0.10.6)
1.0 (0.51.9)
N.A
3.8 (0.817.4)
N.A

b.001
.001
.930
.999
.090
.999

Diabetes mellitus type

Type 1
Type 2

2 (20.0)
53 (27.6)

8 (80.0)
139 (72.4)

1.0
1.5 (0.37.4)

Duration of diabetes
N30 years
110 years
1120 years

2 (20.0)
21 (25.0)
21 (26.6)

8 (80.0)
63 (75.0)
58 (73.4)

1.0
1.3 (0.36.8)
1.4 (0.37.4)

Comorbidities
Hypertension
IHD
Stroke

Risk factors
Alcoholism
Obesity
Smoking
Hyperlipidaemia

Complications
Retinopathy
Nephropathy
PVD
Sensory neuropathy
ABI b0.8

Negative

OR (95% CI)

P value

8.4 (3.918.3)

b.001

0.3 (0.10.7)

.011

.005

.518

.527
.490
.536

.008
.028

.601

.729
.656
(continued on next page)

80

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

Table 1 (continued)
Limb loss
Risk factor
Duration of diabetes
2130 years
GHb level N7%

Yes
No

Pathogens
MRSA
B. fragilis
Staphylococcus aureus
P. aeruginosa
Streptococcus agalactiae Group B

Unadjusted

Stepwise analysis

Positive

Negative

OR (95% CI)

P value

11 (37.9)
34 (23.1)
21 (38.2)

18 (62.1)
113 (76.9)
34 (61.8)

2.4 (0.413.7)
0.5 (0.30.9)
1.0

.309
.034

7.0
1.5
0.4
1.3
0.5

.006
.413
.042
.578
.249

7
7
7
10
3

(70.0)
(35.0)
(15.2)
(31.3)
(15.8)

3
13
39
22
16

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 considered 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 neuropathy 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 evaluation 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.

(30.0)
(65.0)
(84.8)
(68.8)
(84.2)

(1.728.1)
(0.64.0)
(0.21.0)
(0.62.9)
(0.11.7)

OR (95% CI)

P value

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), and Hennis 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 by Young
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
by Fejfarova 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 by Gurlek et al. (1998), Lehto
et al. (1996) and Selby & Zhang (1995).
3.1.6. Comorbidities
Both stroke ( P=.028) and IHD ( P=.008) were found to
be predictive factors of limb loss in our cohort while
hypertension was not ( P=.493). Similarly, stroke was found
to be a significant factor by Selby & 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 by Hamalainen et al. (1999), Young et al.
(2003), Nelson et al. (1988), Resnick et al. (2004), Lehto

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

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

nephropathy to be a significant prognostic factor. However,
Sheahan et al. (2005) and Gurlek et al. (1998) did not find
nephropathy to be a significant predictive factor. Studies
conducted by Fejfarova 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 not
found 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), and Selby & Zhang (1995).
3.1.9. Sensory neuropathy
Presence of sensory neuropathy, as measured by 5.07
SemmesWeinstein 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), and Selby & 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), and Selby & 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) found
Staphylococcus 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

81

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), 177 181.
Bose, K. (1978). Infection in diabetic foot. Annals of the Academy of
Medicine, Singapore, 7, 359 365.
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),
240 246.
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), 302 306.
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), 404 409.
Hamalainen, H., Ronnemaa, T., Halonen, J. P., & Toikka, T. (1999). Factors
predicting 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), 97 103.
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, 2636 2641.
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), 124 127.
Lee, E. H., & Bose, K. (1985). Orthopaedic management of diabetic
foot lesions. Annals of the Academy of Medicine, Singapore, 14 (2),
331 333.
Lehto, S., Ronnemaa, T., Pyorala, K., & Laakso, M. (1996). Risk factors
predicting lower extremity amputations in patients with NIDDM.
Diabetes Care, 19, 607 612.
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: Retrospective study. Hong Kong Medical Journal, 7, 350 355.
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),
272 279.

82

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

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, 8 16.
Pendsey, S. (2003). Classification and staging. In S. Pendsey (Ed.),
Diabetic Foot. A Clinical Atlas (pp. 24 26). 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). Incidence
of lower-extremity amputation in American Indians: The Strong Heart
Study. Diabetes Care, 27 (8), 1885 1891.
Selby, J. V., & Zhang, D. (1995). Risk factors for lower extremity
amputation in persons with diabetes. Diabetes Care, 18, 509 516.

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), 476 480.
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: Canadian
Medical Association Journal, 174 (3), 319 323.
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), 495 501.

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: prediabetes2009@kenes.com
Website: www.kenes.com/prediabetes

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