Reevaluating the way we classify the diabetic foot: restructuring the diabetic foot risk classification system of the International Working Group on the Diabetic Foot

Outcomes Following Advanced Wound Care for Diabetic Foot Ulcers: A Canadian Study

OBJECTIVES

Data concerning outcomes of Canadian patients with diabetic foot ulcers (DFUs) are limited. The objectives of this study were to evaluate the healing rates and identify the predictors of poor outcomes following advanced wound care in patients presenting with DFUs.

METHODS

We conducted retrospective cohort study of adult patients who had DFUs and were referred to a single Canadian advanced diabetic foot and wound care centre between January 1, 2010, and December 31, 2010. The primary outcome was the healing rate at 52 weeks. The generalized estimating equation model was used to identify potential risk factors associated with delayed healing of DFUs.

RESULTS

Of the 40 patients for whom there were complete follow ups, 35 (87.5%) had healing of all DFUs by 52 weeks. Predictors of poor healing were the presence of chronic ulcers, ulcer sizes >1 cm², peripheral vascular disease and multiple ulcers at first presentation. Of the patients, 7.1% required amputation, and 8.9% of patients receiving our treatment died before 52 weeks. At 52 weeks of follow up, 16 of 17 recurrent ulcers and 68 of 108 pre-existing ulcers had healed. Compared to the unadjusted healing rate of preexisting ulcers (63.0%), the unadjusted healing rate of recurrent ulcers (94.1%) was significantly higher (p=0.01).

CONCLUSIONS

Our findings demonstrate that patients with DFUs in Canada who receive early and continued care from specialized, outpatient, advanced wound care centres experience significantly improved rates of healing of recurrent DFUs compared to pre-existing DFUs.

Type 2 Diabetes and Metformin Influence on Fracture Healing in an Experimental Rat Model

Persons with diabetes have a greater incidence of fractures compared with persons without diabetes. However, very little published information is available concerning the deleterious effect of late-stage diabetes on osseous structure and bone healing. The purpose of the present study was to evaluate the role of diabetes on fracture healing in a rat femur repair model. Thirty-six lean and diabetic Zucker rats were subdivided into 3 groups: (1) 12 lean rats as the control group; (2) 12 diabetic rats without blood glucose control (DM group); and (3) 12 diabetic rats treated with 300 mg/kg metformin to reduce the blood glucose levels (DM + Met group). Radiographs were taken every week to determine the incidence of bone repair and delayed union. All the rats were killed at 6 weeks after surgery. In both the sham-operated and the fractured and repaired femurs, significant decreases in the fracture-load/weight and marginal decreases in the fracture-load between the lean and DM groups were found. Metformin treatment significantly reduced the blood glucose and body weight 12 days postoperatively. Furthermore, a decrease in the fracture-load and fracture-load/weight in the repaired femurs was found in the DM + Met group. Diabetes impairs bone fracture healing. Metformin treatment reduces the blood glucose and body weight but had an adverse effect on fracture repair in diabetic rats. Further investigations are needed to reveal the mechanisms responsible for the effects of type 2 diabetes mellitus on bone and bone quality and the effect of medications such as metformin might have in diabetic bone in the presence of neuropathy and vascular disease.

The impact of comorbidities on inpatient Charcot neuroarthropathy cost and utilization

AIMS

The purpose of this study was to portray the impact of comorbidities on inpatient cost and utilization in Charcot neuroarthropathy (CN) patients.

METHODS

Two cohorts, CN and diabetic peripheral neuropathy (DPN), were identified by ICD-9 codes in the California Office for Statewide Health Planning and Development 2009-2012 public patient discharge files. DPN and CN costs and length of stay (LOS) were compared adjusting for the number of chronic conditions. The impact of the Elixhauser comorbidity measures and other comorbidities on costs and LOS in CN subjects was evaluated.

RESULTS

CN was associated with 17.2% higher costs and 1.4 days longer LOS compared to DPN alone. Adjusting for 0.71 additional chronic conditions in CN patients accounted for 79.8% of variance and estimated a 13.9% cost difference between cohorts. Subjects averaged 4.5 Elixhauser comorbidities with higher scores corresponding to increased cost, LOS, and inpatient mortality. Other diabetic foot risk factors demonstrated that foot ulcers, foot infections, and osteomyelitis had significantly higher costs. Patients with foot ulcers, osteomyelitis, and depression had significantly increased LOS.

CONCLUSIONS

Systemic and local comorbidities significantly impact the cost, utilization, and inpatient mortality in inpatient management of Charcot foot.

A shift in priority in diabetic foot care and research: 75% of foot ulcers are preventable

Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system, but prevention thereof receives little attention. For every euro spent on ulcer prevention, ten are spent on ulcer healing, and for every randomized controlled trial conducted on prevention, ten are conducted on healing. In this article, we argue that a shift in priorities is needed. For the prevention of a first foot ulcer, we need more insight into the effect of interventions and practices already applied globally in many settings. This requires systematic recording of interventions and outcomes, and well-designed randomized controlled trials that include analysis of cost-effectiveness. After healing of a foot ulcer, the risk of recurrence is high. For the prevention of a recurrent foot ulcer, home monitoring of foot temperature, pressure-relieving therapeutic footwear, and certain surgical interventions prove to be effective. The median effect size found in a total of 23 studies on these interventions is large, over 60%, and further increases when patients are adherent to treatment. These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach, where attempts are made to assure treatment adherence. Effect sizes of 75-80% may be expected. If such state-of-the-art integrated foot care is implemented, the majority of problems with foot ulcer recurrence in diabetes can be resolved. It is therefore time to act and to set a new target in diabetic foot care. This target is to reduce foot ulcer incidence with at least 75%.

Current and emerging therapies in the management of diabetic foot ulcers

BACKGROUND

Diabetic foot ulcers are one of the major causes of mortality in diabetic patients. Very few drugs and therapies have regulatory approval for this indication and several agents from diverse pharmacological classes are currently in various phases of clinical trials for the management of diabetic foot ulcers.

SCOPE

The purpose of this review is to provide concise information of the drugs and therapies which are approved and present in clinical trials.

REVIEW METHODS

This review was carried out by systematic searches of relevant guidelines, patents, published articles, reviews and abstracts in PubMed/Medline, Web of Science, clinicaltrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Google Scholar of all English language articles up to 1 March 2015. The following search terms were used: diabetes, diabetic foot, diabetic foot ulcer, diabetic wound, diabetic foot infections, wound management, randomized controlled trials, approved treatments, new treatments and clinical trials.

CONCLUSIONS

The various drugs and therapies for the management of diabetic foot ulcers comprise antibiotics, neuropathic drugs, wound dressings, skin substitutes, growth factors and inflammatory modulators. The majority of these therapies target the treatment of diabetic foot ulcers to address the altered biochemical composition of the diabetic wound. However, no single treatment can be definitively recommended for the treatment of diabetic foot ulcers.

Clinical decision support software for diabetic foot risk stratification: development and formative evaluation

Background

Identifying people at risk of developing diabetic foot complications is a vital step in prevention programs in primary healthcare settings. Diabetic foot risk stratification systems predict foot ulceration. The aim of this study was to explore the views and experiences of potential end users during development and formative evaluations of an electronic diabetic foot risk stratification tool based on evidence-based guidelines and determine the accuracy of the tool.

Methods

Formative evaluation of the risk tool occurred in five stages over an eight-month period and employed a mixed methods research design consisting of semi-structured interviews, focus group and participant observation, online survey, expert review, comparison to the Australian Guidelines and clinical testing.

Results

A total of 43 healthcare practitioners trialled the computerised clinical decision support system during development, with multiple software changes made as a result of feedback. Individual and focus group participants exposed critical design flaws. Live testing revealed risk stratification errors and functional limitations providing the basis for practical improvements. In the final product, all risk calculations and recommendations made by the clinical decision support system reflect current Australian Guidelines.

Conclusions

Development of the computerised clinical decision support system using evidence-based guidelines can be optimised by a multidisciplinary iterative process of feedback, testing and software adaptation by experts in modern development technologies.

Growth factors for treating diabetic foot ulcers

BACKGROUND

Foot ulcers are a major complication of diabetes mellitus, often leading to amputation. Growth factors derived from blood platelets, endothelium, or macrophages could potentially be an important treatment for these wounds but they may also confer risks.

OBJECTIVES

To assess the benefits and harms of growth factors for foot ulcers in patients with type 1 or type 2 diabetes mellitus.

SEARCH METHODS

In March 2015 we searched the Cochrane Wounds Group Specialised Register, The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations, Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting.

SELECTION CRITERIA

Randomised clinical trials in any setting, recruiting people with type 1 or type 2 diabetes mellitus diagnosed with a foot ulcer. Trials were eligible for inclusion if they compared a growth factor plus standard care (e.g., antibiotic therapy, debridement, wound dressings) versus placebo or no growth factor plus standard care, or compared different growth factors against each other. We considered lower limb amputation (minimum of one toe), complete healing of the foot ulcer, and time to complete healing of the diabetic foot ulcer as the primary outcomes.

DATA COLLECTION AND ANALYSIS

Independently, we selected randomised clinical trials, assessed risk of bias, and extracted data in duplicate. We estimated risk ratios (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We subjected our analyses to both fixed-effect and random-effects model analyses.

MAIN RESULTS

We identified 28 randomised clinical trials involving 2365 participants. The cause of foot ulcer (neurologic, vascular, or combined) was poorly defined in all trials. The trials were conducted in ten countries. The trials assessed 11 growth factors in 30 comparisons: platelet-derived wound healing formula, autologous growth factor, allogeneic platelet-derived growth factor, transforming growth factor β2, arginine-glycine-aspartic acid peptide matrix, recombinant human platelet-derived growth factor (becaplermin), recombinant human epidermal growth factor, recombinant human basic fibroblast growth factor, recombinant human vascular endothelial growth factor, recombinant human lactoferrin, and recombinant human acidic fibroblast growth factor. Topical intervention was the most frequent route of administration. All the trials were underpowered and had a high risk of bias. Pharmaceutical industry sponsored 50% of the trials.Any growth factor compared with placebo or no growth factor increased the number of participants with complete wound healing (345/657 (52.51%) versus 167/482 (34.64%); RR 1.51, 95% CI 1.31 to 1.73; I(2) = 51%, 12 trials; low quality evidence). The result is mainly based on platelet-derived wound healing formula (36/56 (64.28%) versus 7/27 (25.92%); RR 2.45, 95% 1.27 to 4.74; I(2) = 0%, two trials), and recombinant human platelet-derived growth factor (becaplermin) (205/428 (47.89%) versus 109/335 (32.53%); RR 1.47, 95% CI 1.23 to 1.76, I(2)= 74%, five trials).In terms of lower limb amputation (minimum of one toe), there was no clear evidence of a difference between any growth factor and placebo or no growth factor (19/150 (12.66%) versus 12/69 (17.39%); RR 0.74, 95% CI 0.39 to 1.39; I(2) = 0%, two trials; very low quality evidence). One trial involving 55 participants showed no clear evidence of a difference between recombinant human vascular endothelial growth factor and placebo in terms of ulcer-free days following treatment for diabetic foot ulcers (RR 0.64, 95% CI 0.14 to 2.94; P value 0.56, low quality of evidence)Although 11 trials reported time to complete healing of the foot ulcers in people with diabetes , meta-analysis was not possible for this outcome due to the unique comparisons within each trial, failure to report data, and high number of withdrawals. Data on quality of life were not reported. Growth factors showed an increasing risk of overall adverse event rate compared with compared with placebo or no growth factor (255/498 (51.20%) versus 169/332 (50.90%); RR 0.83; 95% CI 0.72 to 0.96; I(2) = 48%; eight trials; low quality evidence). Overall, safety data were poorly reported and adverse events may have been underestimated.

AUTHORS' CONCLUSIONS

This Cochrane systematic review analysed a heterogeneous group of trials that assessed 11 different growth factors for diabetic foot ulcers. We found evidence suggesting that growth factors may increase the likelihood that people will have complete healing of foot ulcers in people with diabetes. However, this conclusion is based on randomised clinical trials with high risk of systematic errors (bias). Assessment of the quality of the available evidence (GRADE) showed that further trials investigating the effect of growth factors are needed before firm conclusions can be drawn. The safety profiles of the growth factors are unclear. Future trials should be conducted according to SPIRIT statement and reported according to the CONSORT statement by independent investigators and using the Foundation of Patient-Centered Outcomes Research recommendations.

Identifying type 2 diabetes risk classification systems and recommendations for review of podiatric care in an Australian Aboriginal health clinic

Background

There are several risk classification systems developed to facilitate diabetic foot assessments and prioritise diabetes patients for foot prevention services according to risk factors. Utilisation of both The University of Texas Diabetic Foot Risk Classification System (UTDFRCS) and The National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes), allows guidance for the podiatrist in terms of review timeframes for future assessments and treatment. The aim of this clinical audit was to classify Aboriginal type 2 diabetes subjects’ risk status according to UTDFRCS and identify if evidence based standards are being met for podiatry services at the Albury-Wodonga Aboriginal Health Service in New South Wales, Australia.

Methods

A retrospective clinical audit over a twenty six month period was undertaken at the Albury-Wodonga Aboriginal Health Service, New South Wales. This is a primary health care facility that started podiatry services in August 2011. The primary variables of interest were the UTDFRCS for each subject and whether those participants met or did not meet the National Evidence-Based Guideline for review appointment timeframes. Other variables of interest include age, gender, duration of diabetes, occasions of visits and cancelled and failure to attend appointments to the podiatry service over the data collection period.

Results

There was excellent overall adherence (94 %) of this sample population (n = 729) to the National Evidence-Based Guideline for podiatric review timeframes according to their risk status. Males were reported to be less likely to comply with the review timeframes compared to women. There was no association between risk status and age (OR = 1.04, p = 0.11), duration of diabetes (OR = 1.03, p = 0.71) or gender (OR = 0.77, p = 0.67).

Conclusions

Regular foot examinations aid in stratifying patients according to risk status, guiding podiatry interventions to reduce the likelihood of ulceration and amputation. This primary health care setting has achieved podiatric evidence based standards for Aboriginal people with type 2 diabetes, demonstrated by acceptable timeframes for review appointments.

The role of surgical off-loading to prevent recurrent ulcerations

Foot ulcerations in patients with diabetes are common. Most ulcers heal with conservative treatment, but recurrence is common. The pathway of ulcer development includes neuropathy, deformity, and trauma. The first attempt to avoid recurrence is by the use of shoes and insoles. When shoes and insoles fail, surgical correction of deformity leading to the ulcer can be attempted. This article reviews the most common procedures performed to heal ulcers or avoid recurrence.

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration

The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current $6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of $1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of $1.296 billion (year 3) to $1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly $1 billion the annual cost of DFU treatment in the United States.

Tool for Rapid & Easy Identification of High Risk Diabetic Foot: Validation & Clinical Pilot of the Simplified 60 Second Diabetic Foot Screening Tool

Background

Most diabetic foot amputations are caused by ulcers on the skin of the foot i.e. diabetic foot ulcers. Early identification of patients at high risk for diabetic foot ulcers is crucial. The ‘Simplified 60-Second Diabetic Foot Screening Tool’ has been designed to rapidly detect high risk diabetic feet, allowing for timely identification and referral of patients needing treatment. This study aimed to determine the clinical performance and inter-rater reliability of ‘Simplified 60 Second Diabetic Foot Screening Tool’ in order to evaluate its applicability for routine screening.

Methods and Findings

The tool was independently tested by n=12 assessors with n=18 Guyanese patients with diabetes. Inter-rater reliability was assessed by calculating Cronbach’s alpha for each of the assessment items. A minimum value of 0.60 was considered acceptable. Reliability scores of the screening tool assessment items were: ‘monofilament test’ 0.98; ‘active ulcer’ 0.97; ‘previous amputation’ 0.97; ‘previous ulcer’ 0.97; ‘fixed ankle’ 0.91; ‘deformity’ 0.87; ‘callus’ 0.87; ‘absent pulses’ 0.87; ‘fixed toe’ 0.80; ‘blisters’ 0.77; ‘ingrown nail’ 0.72; and ‘fissures’ 0.55. The item ‘stiffness in the toe or ankle’ was removed as it was observed in only 1.3% of patients. The item ‘fissures’ was also removed due to low inter-rater reliability. Clinical performance was assessed via a pilot study utilizing the screening tool on n=1,266 patients in an acute care setting in Georgetown, Guyana. In total, 48% of patients either had existing diabetic foot ulcers or were found to be at high risk for developing ulcers.

Conclusions

Clinicians in low and middle income countries such as Guyana can use the Simplified 60-Second Diabetic Screening Tool to facilitate early detection and appropriate treatment of diabetic foot ulcers. Implementation of this screening tool has the potential to decrease diabetes related disability and mortality.

Does physical therapy and rehabilitation improve outcomes for diabetic foot ulcers?

One of the most common and serious complications of diabetes mellitus is ulceration of the foot. Among persons with diabetes, 12%-25% will present to a healthcare institution for a foot disorder during their lifespan. Despite currently available medical and surgical treatments, these are still the most common diabetes-related cause of hospitalization and of lower extremity amputations. Thus, many adjunctive and complementary treatments have been developed in an attempt to improve outcomes. We herein review the available literature on the effectiveness of several treatments, including superficial and deep heaters, electro-therapy procedures, prophylactic methods, exercise and shoe modifications, on diabetic foot wounds. Overall, although physical therapy modalities seem to be useful in the treatment of diabetic foot wounds, further randomized clinical studies are required.

Effectiveness of Platelet-Rich Plasma to Enhance Healing of Diabetic Foot Ulcers in Patients With Concomitant Peripheral Arterial Disease and Critical Limb Ischemia

We sought to investigate the effect of autologous platelet-rich plasma (PRP) on the healing rate of diabetic foot ulcers in patients with diabetes and concomitant peripheral arterial disease (PAD). Diabetic patients with foot ulceration presenting with PAD who were treated with local growth factors in a single center, during a 24-month period from May 2009 to April 2011, were retrospectively reviewed. Based on the severity of PAD, subjects were divided into groups A (Fontaine classification stages I, IIa, and IIb) and B (Fontaine classification stages III and IV), with those included in the latter being considered to suffer from critical limb ischemia (CLI). End points of the analysis were clinical improvement, limb salvage, and amputation rate. Outcome was compared between groups A and B. Overall, 72 patients were evaluated, 30 with CLI. Ulcer area reduction >50% was observed in 58/72 patients while reduction >90% was achieved in 52/72 patients. There were 14 (19%) major and minor amputations, whereas the limb salvage rate was 89%. This variable was significantly different between groups A and B (100% vs. 73%, P < .001), as is rate of reduction in ulcer area >90% (83% vs. 56%, P = .02). Reduction of ulcer area >50% was observed in the majority of patients in both groups (group A 86% vs. group B 73%, P = .23). In conclusion, PRP could serve as a useful adjunct during management of diabetic foot ulcers even in diabetic patients with unreconstructable arterial disease.

BE SMART: strategies for foot care and prevention of foot complications in patients with diabetes

BACKGROUND

Diabetic foot ulcers and lower extremity amputations are common complications of diabetes mellitus that are associated with substantial morbidity, loss of quality of life, disability, and a high social and economic burden. The implementation of strategies to prevent these complications is a key aspect of diabetes care.

OBJECTIVES

The objective of this article is to provide an overview of the available evidence on preventive diabetic foot care.

STUDY DESIGN

Literature review.

METHODS

Narrative review based on a thorough search of previous relevant studies, systematic reviews, and clinical guidelines on diabetic foot care published in English.

RESULTS

We describe diabetic foot care strategies that can be categorized within defined domains for the purpose of helping clinicians to remember them. We use the mnemonic "BE SMART" (Be aware of the risk factors, Educate patients and health providers, Structured clinical assessment, Metabolic evaluation and management, Assessment of Risk, and Team care) to organize these domains.

CONCLUSION

Diabetic foot ulcers and lower extremity amputations are potentially preventable complications. Clinicians taking care of patients with diabetes should know, understand, and remember the multiple aspects of diabetic foot care.

CLINICAL RELEVANCE

This review can be used as a reference source for those interested in the care of diabetic foot. It highlights the importance of risk factor recognition, education, a structured clinical and metabolic evaluation, and also the importance of assigning patients a risk category that can help guiding multidisciplinary management efforts.

Association of diabetic foot care and amputation rates in Germany

Podologists are nurses who care for the diabetic foot (orthotics, offloading devices, blisters, calluses, treatment of fungus infection and patient education). In contrast to podiatrists, they are not qualified to perform any surgical treatment or wound care. We analysed whether there is an association between the decrease in major amputations and the number of podologic foot care (PFC) visits prescribed in Germany. Detailed list of all major lower limb amputations (OPS 5-864) performed from 2007 to 2011 was provided by the Federal Statistical Office. Data were separated for the 16 federal states in Germany. Detailed lists of the number of PFC treatments for each of the 5 years were derived from the federal report of the statutory health insurance. The total numbers of hospitalised cases per year having diabetes mellitus documented as an additional diagnosis were used to adjust for the different rates of people with diabetes in each federal state. Within a 5-year time period, population-based major amputations per 100 000 people dropped from 21·7 in 2007 to 17·5 in 2011 (-18·5%); whereas the number of PFC treatments per 1000 insured increased from 22 in 2007 to 60 in 2011 (+172·7%). The total number of major amputations divided by the total number of hospitalised cases with the additional diagnosis of diabetes mellitus (DM) shows an inverse correlation with the number of PFC treatments per 1000 insured (Pearson's correlation factor is -0·52049). The five countries with the highest increase in PFC compared with the five countries with the lowest increase (35·6 versus 15·4 per 1000 insured) will have only small differences in the decrease in major amputation rates in this period (-5·1 versus -3·4 per 100.000). There is a strong association between increasing utilisation PFC and decreasing major amputations in Germany. Further study is required to document the cost-effectiveness of this service.

Current concepts in the surgical management of acute diabetic foot infections

Diabetic foot complications are common, costly, and difficult to treat. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common reasons that lead to ulcers, infection, and hospitalization. Individuals with diabetes presenting with foot infection require optimal medical and surgical management to accomplish limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. Multiple classification systems have been recommended to ease the understanding and the management of these infections. Multi-disciplinary approach is the mainstay for a successful management. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article is an overview in how to medically and surgically approach the diabetic foot infection with emphasis in soft tissue infection.

The efficacy and safety of Grafix(®) for the treatment of chronic diabetic foot ulcers: results of a multi-centre, controlled, randomised, blinded, clinical trial

In a randomised, controlled study, we compared the efficacy of Grafix^®, a human viable wound matrix (hVWM) (N = 50), to standard wound care (n = 47) to heal diabetic foot ulcers (DFUs). The primary endpoint was the proportion of patients with complete wound closure by 12 weeks. Secondary endpoints included the time to wound closure, adverse events and wound closure in the crossover phase. The proportion of patients who achieved complete wound closure was significantly higher in patients who received Grafix (62%) compared with controls (21%, P = 0·0001). The median time to healing was 42 days in Grafix patients compared with 69·5 days in controls (P = 0·019). There were fewer Grafix patients with adverse events (44% versus 66%, P = 0·031) and fewer Grafix patients with wound‐related infections (18% versus 36·2%, P = 0·044). Among the study subjects that healed, ulcers remained closed in 82·1% of patients (23 of 28 patients) in the Grafix group versus 70% (7 of 10 patients) in the control group (P = 0·419). Treatment with Grafix significantly improved DFU healing compared with standard wound therapy. Importantly, Grafix also reduced DFU‐related complications. The results of this well‐controlled study showed that Grafix is a safe and more effective therapy for treating DFUs than standard wound therapy.

Predictive Value of Soluble CD14, Interleukin-6 and Procalcitonin For Lower Extremity Amputation in People with Diabetes with Foot Ulcers: A Pilot Study

OBJECTIVE

The aim of this pilot study was to determine clinical and laboratory factors that predict amputation surgery and to evaluate the predictive value of soluble CD14 (sCD14), interleukin-6 (IL-6), and procalcitonin (PCT) in patients with diabetic foot ulcers (DFUs).

METHODS

Twenty-seven (20 males, 7 females) Diabetic Foot Ulcers (DFU) patients admitted to our department were consecutively enrolled. The patients' demographics and wound characteristics were noted. IL-6, PCT, and sCD14 were measured at admission.

RESULTS

Six of the 27 patients (22%) eventually underwent lower extremity amputation. Compared to the non-amputation group, a previous history of amputation (p=0.017), the presence of gangrene (p=0.044), the Wagner grade (p=0.011), the IL-6 concentration (p=0.018), the white blood cell count (WBC) (p=0.036), and the erythrocyte sedimentation rate (ESR) (p=0.042) were significantly high in the amputation group. However, the sCD14 and PCT concentration were not significantly different.

CONCLUSION

We have shown for the first time that IL-6 may have predictive value for lower extremity amputation in patients with DFU. Further studies are needed to confirm its predictive value in this patient group.

Diabetic foot ulcers: Part I. Pathophysiology and prevention

Diabetes mellitus is a serious, life-long condition that is the sixth leading cause of death in North America. Dermatologists frequently encounter patients with diabetes mellitus. Up to 25% of patients with diabetes mellitus will develop diabetic foot ulcers. Foot ulcer patients have an increased risk of amputation and increased mortality rate. The high-risk diabetic foot can be identified with a simplified screening, and subsequent foot ulcers can be prevented. Early recognition of the high-risk foot and timely treatment will save legs and improve patients' quality of life. Peripheral arterial disease, neuropathy, deformity, previous amputation, and infection are the main factors contributing to the development of diabetic foot ulcers. Early recognition of the high-risk foot is imperative to decrease the rates of mortality and morbidity. An interprofessional approach (ie, physicians, nurses, and foot care specialists) is often needed to support patients' needs.

Influence of peripheral vascular calcification on efficiency of screening tests for peripheral arterial occlusive disease in diabetes--a cross-sectional study

AIMS

Pulse palpation and ankle brachial index are recommended to screen for peripheral arterial occlusive disease in people with diabetes. However, vascular calcification can be associated with false negative tests (arteriopathy present despite normal screening tests). We therefore studied the impact of peripheral vascular calcification on the performance of these tests.

METHODS

This cross-sectional study included 200 people with diabetes at high risk of cardiovascular disease. The main exclusion factor was an estimated glomerular filtration rate < 30 ml/min. Peripheral arterial occlusive disease was diagnosed by colour duplex ultrasonography and peripheral vascular calcification scored by computed tomography scan. We measured sensitivity, specificity, predictive values, accuracy and likelihood ratios of pulse palpation and ankle brachial index, and looked for the impact of calcification on false negative tests (arteriopathy present despite normal screening tests).

RESULTS

Ankle brachial index alone had poor sensitivity and negative predictive value and high negative likelihood ratio. Pulse palpation had higher sensitivity and negative predictive value. An abnormal pulse palpation, defined by weak or missing pulses, combined with an abnormal ankle brachial index, had the highest sensitivity and negative predictive value (92.3 and 89.8%, respectively). Vascular calcification score was higher in patients with false negative tests, for both pulse palpation and ankle brachial index (P < 0.0001 for all). Ankle systolic blood pressure was higher in patients with false negative tests for pulse palpation (P = 0.004).

CONCLUSIONS

Below-knee vascular calcification gave a high rate of false negative results for ankle brachial index. Refined pulse palpation combined with ankle brachial index remained the best strategy to screen for peripheral arteriopathy.

Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)

AIMS

The objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors.

METHODS

We assessed the period prevalence of foot complications on 6992 patients using ICD-9 diagnosis codes from health plan administrative data. Demographic and biological variables were ascertained from surveys and medical record reviews. We defined four mutually exclusive groups: any Charcot foot, DFU with debridement, amputation±DFU and debridement, and no foot conditions.

RESULTS

Overall, 55 (0.8%) patients had Charcot foot, 205 (2.9%) had DFU with debridement, and 101 (1.4%) had a lower-extremity amputation. There were 6631 patients with no prevalent foot conditions. Racial/ethnic minorities were less likely to have Charcot foot (OR=0.21; 95% CI: 0.10, 0.46) or DFU (OR=0.61; 95% CI: 0.44, 0.84) compared to non-Hispanic Whites, but there were no racial/ethnic differences in amputation. Histories of micro- or macrovascular disease were associated with a two- to four-fold increase in the odds of foot complications.

CONCLUSION

In managed care patients with uniform access to health care, we found a relatively high prevalence of foot complications, but attenuation of the racial/ethnic differences of rates reported in the literature.

The system of care for the diabetic foot: objectives, outcomes, and opportunities

Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.

Amputations and foot-related hospitalisations disproportionately affect dialysis patients

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD-9 250.X), ulceration (ICD-9 707·10, 707·14 and 707·15) and dialysis (CPT 90935-90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow-up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person-years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P < 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P < 0·001); however, there were more foot-related hospital admissions in the dialysis group (32·9% versus 14·0%, P < 0·001) during the 30-month evaluation period. The incidence of ulcers, amputations and all-cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot-related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high-risk group.

Reconsidering nerve decompression: an overlooked opportunity to limit diabetic foot ulcer recurrence and amputation

Nerve decompression for relief of subjective diabetic sensorimotor polyneuropathy pain and numbness has been labeled of "unknown" benefit. Objective outcomes in treatment and prevention of diabetic foot complications are reviewed. There is growing evidence that plantar foot ulceration and recurrence in high-risk feet are minimized with this operation. Avoiding neuropathic and neuroischemic ulcer wounds should theoretically reduce amputations and perhaps mortality risk. Protective effects are hypothesized to act via relief of neuro-vascular entrapment, thereby improving neurally modulated tissue homeostasis factors. Nerve decompression deserves considerable research attention to understand its role in limiting foot complications. Its apparent benefits challenge the paradigm that diabetic neuropathy is a purely length-dependent axonopathy and may necessitate appreciation of superimposed nerve entrapment as an significant operant factor.

Preventing the first or recurrent ulcers

Prevention is overlooked and underused, even in very high-risk patients. Prevention is best achieved within a multispecialty group of providers that have a common objective. Ideally, the team approach should include educators; physical therapists; nurses; internist; pedorthists; and vascular, orthopedic, and podiatric surgeons. The basic elements involve education, foot examination, risk classification, therapeutic shoes and insoles, and regular foot care. High-risk patients need additional assessment for vascular disease and intensive disease management, and corrective vascular and foot surgery when necessary. Basic interventions can reduce the incidence of foot ulcers by more than 50%.

Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team

A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes-related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty-three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below-knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.

Advanced glycation end products assessed by skin autofluorescence: a new marker of diabetic foot ulceration

BACKGROUND

Accumulation of advanced glycation end products (AGEs) may contribute to diabetic foot ulceration (DFU). Our goal was to determine whether AGEs measurement by skin autofluorescence (SAF) would be an additional marker for DFU management.

PATIENTS AND METHODS

We performed SAF analysis in 66 patients with a history of DFU prospectively included and compared the results with those of 84 control patients with diabetic peripheral neuropathy without DFU. We then assessed the prognostic value of SAF levels on the healing rate in the DFU group.

RESULTS

Mean SAF value was significantly higher in the DFU group in comparison with the control group, even after adjustment for other diabetes complications (3.2±0.6 arbitrary units vs. 2.9±0.6 arbitrary units; P=0.001). In the DFU group, 58 (88%) patients had an active wound at inclusion. The mean DFU duration was 14±13 weeks. The healing rate was 47% after 2 months of appropriate foot care. A trend for a correlation between SAF levels and healing time in DFU subjects was observed but was not statistically significant (P=0.06).

CONCLUSIONS

Increased SAF levels are associated with neuropathic foot complications in diabetes. Use of SAF measurement to assess foot vulnerability and to predict DFU events in high-risk patients appears to be promising.

Factors associated with nonunion, delayed union, and malunion in foot and ankle surgery in diabetic patients

The incidence of bone healing complications in diabetic patients is believed to be high after foot and ankle surgery. Although the association of hyperglycemia with bone healing complications has been well documented, little clinical information is available to show which diabetes-related comorbidities directly affect bone healing. Our goal was to better understand the risk factors associated with poor bone healing in the diabetic population through an exploratory, observational, retrospective, cohort study. To this end, 165 diabetic patients who had undergone arthrodesis, osteotomy, or fracture reduction were enrolled in the study to assess the risk factors associated with nonunion, delayed union, and malunion after elective and nonelective foot and/or ankle surgery. Bivariate analyses showed that a history of foot ulcer, peripheral neuropathy, and surgery duration were statistically significantly associated with bone healing complications. After adjusting for other covariates, only peripheral neuropathy, surgery duration, and hemoglobin A1c levels >7% were significantly associated statistically with bone healing complications. Of the risk factors we considered, peripheral neuropathy had the strongest association with bone healing complications.

A tale of two soles: sociomechanical and biomechanical considerations in diabetic limb salvage and amputation decision-making in the worst of times

Foot ulcerations complicated by infection are the major cause of limb loss in people with diabetes. This is especially true in those patients with severe sepsis. Determining whether to amputate or attempt to salvage a limb often requires in depth evaluation of each individual patient's physical, mental, and socioeconomic status. The current report presents and juxtaposes two similar patients, admitted to the same service at the same time with severe diabetic foot infections complicated by sepsis. We describe in detail the similarities and differences in the clinical presentation, extent of infection, etiology, and socioeconomic concerns that ultimately led to divergent clinical decisions regarding the choices of attempting diabetic limb salvage versus primary amputation and prompt rehabilitation.

Validation and comparison of currently available stratification systems for patients with diabetes by risk of foot ulcer development

AIMS/HYPOTHESIS

There are five systems to stratify the risk for the development of a diabetic foot ulcer (DFU). This study aimed to prospectively validate all of them in the same cohort of participants to allow their direct comparison.

METHODS

A retrospective cohort study was conducted on all patients with diabetes but without an active DFU attending our podiatry section (n=364) from January 2008 to December 2010. Participants' characteristics and all variables composing the stratification systems were assessed at baseline. Follow-up was performed for 1 year or until DFU occurred.

RESULTS

Participants had a mean age of 64 years; 99.7% had type 2 diabetes and 48.6% were male. Median follow-up was 12 months (1-12) during which 33 subjects (9.1%) developed a DFU. Age, diabetes duration, foot deformity, peripheral vascular disease, diabetic peripheral neuropathy, previous DFU, and previous lower extremity amputation were associated with DFU occurrence. All systems presented greater DFU occurrence frequency as the risk group was higher (χ(2), P<0.001) and showed good diagnostic accuracy values, especially negative predictive value (≥ 95%) and area under the receiver operating curve (≥ 0.73). The lowest performance concerned positive predictive value (≤ 29.5%).

CONCLUSIONS/INTERPRETATION

All the currently available stratification systems show high accuracy to detect which patients will develop a DFU with no significant differences among them. Therefore, for diabetic foot screening and resource allocation, it would be desirable to have a single unified system, combining the available systems, prospectively validated in a multicenter context and testing the inclusion of novel predictive variables' pertinence.

The foot-health of people with diabetes in a regional Australian population: a prospective clinical audit

Background

There is limited understanding of the foot-health of people with diabetes in Australian regional areas. The aim of this study was to document the foot-health of people with diabetes who attend publically funded podiatric services in a regional Australian population.

Methods

A three month prospective clinical audit was undertaken by the publically-funded podiatric services of a large regional area of Victoria, Australia. The primary variables of interest were the University of Texas (UT) diabetic foot risk classification of each patient and the incidence of new foot ulceration during the study period. Age, gender, diabetes type, duration of diabetes and the podiatric service the patients attended were the other variables of interest.

Results

Five hundred and seventy six patients were seen during the three month period. Over 49% had a UT risk classification at a level at least peripheral neuropathy or more serious diabetes-related foot morbidity. Higher risk at baseline was associated with longer duration of diabetes (F = 31.7, p < 0.001), male gender (χ² = 40.3, p <0.001) and type 1 diabetes (χ² = 37.3, p <0.001). A prior history of foot pathology was the overwhelming predictor for incident ulceration during the time period (OR 8.1 (95% CI 3.6 to 18.2), p < 0.001).

Conclusions

The publically funded podiatric services of this large regional area of Australia deal with a disproportionally large number of people with diabetes at high risk of future diabetes-related foot complications. These findings may be useful in ensuring appropriate allocation of resources for future public health services involved in diabetic foot health service delivery in regional areas.

Expert opinion on the management of infections in the diabetic foot

This update of the International Working Group on the Diabetic Foot incorporates some information from a related review of diabetic foot osteomyelitis (DFO) and a systematic review of the management of infection of the diabetic foot. The pathophysiology of these infections is now well understood, and there is a validated system for classifying the severity of infections based on their clinical findings. Diagnosing osteomyelitis remains difficult, but several recent publications have clarified the role of clinical, laboratory and imaging tests. Magnetic resonance imaging has emerged as the most accurate means of diagnosing bone infection, but bone biopsy for culture and histopathology remains the criterion standard. Determining the organisms responsible for a diabetic foot infection via culture of appropriately collected tissue specimens enables clinicians to make optimal antibiotic choices based on culture and sensitivity results. In addition to culture-directed antibiotic therapy, most infections require some surgical intervention, ranging from minor debridement to major resection, amputation or revascularization. Clinicians must also provide proper wound care to ensure healing of the wound. Various adjunctive therapies may benefit some patients, but the data supporting them are weak. If properly treated, most diabetic foot infections can be cured. Providers practising in developing countries, and their patients, face especially challenging situations.

Does open access improve the process and outcome of podiatric care?

Background

Open access to clinics is a management strategy to improve healthcare delivery. Providers are sometimes hesitant to adopt open access because of fear of increased visits for potentially trivial complaints. We hypothesized open access clinics would result in decreased wait times, increased number of podiatry visits, fewer “no shows”, higher rates of acute care visits, and lower minor amputation rates over control clinics without open access.

Methods

This study was a national retrospective case-control study of VHA (Veterans Hospital Administration) podiatry clinics in 2008. Eight case facilities reported to have open podiatry clinic access for at least one year were identified from an email survey. Sixteen control facilities with similar structural features (e.g., full time podiatrists, health tech, residency program, reconstructive foot surgery, vascular, and orthopedic surgery) were identified in the same geographic region as the case facilities.

Results

Twenty-two percent of facilities responded to the survey. Fifty-four percent reported open access and 46% did not. There were no differences in facility or podiatry panel size, podiatry visits, or visit frequency between the cases and controls. Podiatry visits trended higher for control facilities but didn’t reach statistical significance. Case facilities had more new consults seen within 30 days (96%, 89%; P = 0.050) and lower minor amputation rates (0.62/1,000, 1.0/1,000; P = 0.041).

Conclusions

The VHA is the world’s largest managed care organization and it relies on clinical efficiencies as one mechanism to improve the quality of care. Open access clinics had more timely access for new patients and lower rates of minor amputations.

Keywords

Health care; Quality; Access; Evaluation; Delivery of health care; Amputation; Amputation prevention

Assessing the risk of lower extremity amputations using an administrative data-based foot risk index in elderly patients with diabetes

BACKGROUND

The aims of the present study were to derive a foot risk index using administrative data similar to the International Working Group on the Diabetic Foot clinical risk classification scheme and to evaluate its association with the risk of initial lower extremity (through foot or above) amputation (ILEA).

METHODS

Merged Veterans Health Administration administrative and Medicare inpatient and outpatient claims data for a historical cohort of Veterans Health Administration users with diabetes were analyzed. Individuals with diabetes, aged ≥67 years in 1999, were classified into seven foot risk categories (where 0=no foot risk conditions; and 6=severe foot conditions). The outcome variable was the incidence of an ILEA over the period 2000-2004. Foot risk was derived from 1998 to 1999, and other independent variables were derived from 1999. The associations between foot risk category and risk of ILEA were evaluated using Cox proportional hazards regression models.

RESULTS

Of 255,534 individuals with diabetes, 54.8% had a documented foot condition in 1999 and 6869 (26.9 per 1000) had an ILEA over the period 2000-2004. We found increased rates of ILEAs as foot risk increased. Based on a Cox regression model containing all independent variables, the hazard ratios for risk of amputation increased progressively from 1.13 (95% CI 1.00-1.28) for the lowest foot risk category to 6.75 (95% CI 6.31-7.23) for the highest foot risk category, compared with individuals without defined foot conditions.

CONCLUSIONS

An administrative data-derived foot risk category was associated with risk of ILEA in a risk level-dependent pattern.

Accuracy of the Neuropad test for the diagnosis of distal symmetric polyneuropathy in type 2 diabetes

OBJECTIVE

To estimate the accuracy of Neuropad for the diagnosis and staging of distal symmetric polyneuropathy (DPN) across different stages of neuropathy, using multiple-level likelihood ratios (LRs) to interpret the time necessary to complete the color change of the test.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional, cohort-type diagnostic accuracy study in 251 consecutive adult type 2 diabetic patients with no peripheral arterial disease or other potential causes of neuropathy, who were recruited between January 2005 and December 2008 from the diabetes outpatient clinics in Alexandroupolis Hospital, Greece. Patients were tested for DPN by means of the neuropathy disability score (NDS) and Neuropad. Multiple-level LRs for time to complete color change were calculated across different stages of neuropathy.

RESULTS

The areas under the curve for the diagnosis of any (NDS of ≥3), at least moderate (NDS of ≥6), or severe (NDS of ≥9) DPN were 0.91, 0.96, and 0.97, respectively. The calculation of multiple-level LRs showed that time to complete color change <360 s suggested the absence of neuropathy. Values between 360 and 1,000 s were indicative of mild neuropathy. Finally, values between 1,000 and 1,200 or >1,200 s were strongly suggestive of moderate or severe DPN, respectively.

CONCLUSIONS

Neuropad could be used as a triage test for the diagnosis and staging of DPN in patients with type 2 diabetes, prompting referral to specialized care setting.

Risk stratification systems for diabetic foot ulcers: a systematic review

AIMS/HYPOTHESIS

Several risk stratification systems have been proposed for predicting development of diabetic foot ulcer. However, little has been published that assesses their similarities and disparities, diagnostic accuracy and evidence level. Consequently, we conducted a systematic review of the existing stratification systems.

METHODS

We searched the MEDLINE database for studies (published until April 2010) describing the creation and validation of risk stratification systems for prediction of diabetic foot ulcer development.

RESULTS

We included 13 studies describing or evaluating the following different risk degree stratification systems: University of Texas; International Working Group on Diabetic Foot; Scottish Intercollegiate Guideline Network (SIGN); American Diabetes Association; and Boyko and colleagues. We confirmed that five variables were included in almost all the systems: diabetic neuropathy, peripheral vascular disease, foot deformity, and previous foot ulcer and amputation. The number of variables included ranged from four to eight and the number of risk groups from two to six. Only four studies reported or allowed the calculation of diagnostic accuracy measures. The SIGN system showed some higher diagnostic accuracy values, particularly positive likelihood ratio, while predictive ability was confirmed through external validation only in the system of Boyko et al.

CONCLUSIONS/INTERPRETATION

Foot ulcer risk stratification systems are a much needed tool for screening patients with diabetes. The core variables of various systems are very similar, but the number of included variables in each model and risk groups varied greatly. Overall, the quality of evidence for these systems is low, as little validation of their predictive ability has been done.

Safety and effectiveness of flexor tenotomies to heal toe ulcers in persons with diabetes

AIM

To evaluate the effectiveness and safety of percutaneous tenotomy of the flexor digitorum longus to heal neuropathic ulcers on the tip of the toe.

METHODS

We retrospectively reviewed a cohort of 48 patients with 58 tenotomy procedures with diabetes related neuropathy and ulceration at the tip of the toe. Subjects were treated with tenotomy of the flexor digitorum longus. We then evaluated healing of the ulceration and any adverse events including recurrence, infection, healing failure, and amputation.

RESULTS

98.3% of the ulcerations healed. Mean ulcer healing time was 40+/-52 days. 12.1% had a recurrence of ulceration at the same site. Mean time to recurrence was 13.9 months. Five percent had post-operative soft tissue infection. Two patients had amputation of the digit; both had pre-existing osteomyelitis. Mean follow up was 28 months.

CONCLUSION

Flexor tenotomy is a safe, simple procedure, which can enhance patients' healing potential with very little risk.

External validation and optimisation of a model for predicting foot ulcers in patients with diabetes

AIMS/HYPOTHESIS

In 2006 a risk stratification model was developed by Boyko et al. to predict foot ulceration in patients with diabetes, using seven commonly available clinical variables. We sought to validate and optimise this clinical prediction rule in a different setting.

METHODS

A retrospective cohort study was conducted on all patients with diabetes attending the podiatry section of a diabetic foot clinic at a tertiary hospital in Portugal (n = 360). Assessment at baseline included variables evaluated in the previous study and other relevant variables.

RESULTS

Type 2 diabetes was present in 98% of patients, 45% were men and (at baseline) the median age was 65 years. Median follow-up was 25 months (range 3-86), during which 94 patients (26%) developed a foot ulcer. Boyko's model had an area under the receiver operating curve of 0.83 (95% CI 0.78-0.88). The corresponding value for the optimised model, which included the footwear risk variable, was 0.88 (95% CI 0.84-0.91). Both models had high classification accuracy for prediction of foot ulceration. However, the optimised model tended to produce higher specificity and positive likelihood ratio values at all levels.

CONCLUSIONS/INTERPRETATION

This study confirmed that Boyko's proposed model has a high capacity to predict foot ulceration in diabetes patients of both sexes. Our results suggest that the inclusion of a further footwear variable could improve the model. Nevertheless, prospective validation in a larger population is still necessary.

Diabetic foot prevention: a neglected opportunity in high-risk patients

OBJECTIVE

To evaluate the frequency of foot prevention strategies among high-risk patients with diabetes.

RESEARCH DESIGN AND METHODS

Electronic medical records were used to identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation with 30 months follow-up to determine the frequency with which patients received education, podiatry care, and therapeutic shoes and insoles as prevention services.

RESULTS

Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or preventative podiatric care (30%). The ulcer incidence density was the same in both groups (210 per 1,000 person-years). In contrast, the amputation incidence density was higher in the dialysis group compared with the ulcer group (58.7 vs. 13.1 per 1,000 person-years, P < 0.001). Patients on dialysis were younger and more likely to be of non-Hispanic white descent (P = 0.006) than patients with a previous history of ulcer or amputation.

CONCLUSIONS

Prevention services are infrequently provided to high-risk patients.