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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024; 45:3538-3700. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Ruyssen-Witrand A, Caillet-Portillo D, Najm A, Fogel O, Baillet A, Claudepierre P, Conort O, Dernis E, Fayet F, Gossec L, Goupille P, Hudry C, Letarouilly JG, Lukas C, Marotte H, Molto A, Pouplin S, Senbel E, Sordet C, Tournadre A, Truchetet ME, Wendling D, Dougados M. Standardized reporting for systematic global evaluation of axial spondyloarthritis: An evidence-based and consensus-driven initiative. Joint Bone Spine 2024; 91:105733. [PMID: 38604594 DOI: 10.1016/j.jbspin.2024.105733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION National and international scientific societies advocate for a regular, systematic, and standardized global evaluation of axial spondyloarthritis (axSpA) patients. However, there are no recommendations specifying the content of this global evaluation. This initiative aimed to propose a standardized reporting framework, using evidence-based and consensus approaches, to collect data on all domains of axSpA. METHODS A literature review and consensus process involved a steering committee and an expert panel of 37 rheumatologists and health professionals. The first steering committee took place in March 2022 and identified the main domains for inclusion in the standardized report. A hierarchical literature review was conducted to identify items within these domains and tools for assessment. The items and tools for assessment were discussed and consensus was reached through a vote session during an expert meeting that took place in March 2023. RESULTS The steering committee identified four main domains to include in the standardized reporting framework: disease assessment, comorbidities, lifestyle, and quality of life. Items and tools for assessment were adopted after the expert meeting. Additionally, recommendations regarding digital tools (websites, apps, social media) were provided. CONCLUSION This initiative led to a consensus, based on evidence and expertise, on a reporting framework for use during periodic systematic global evaluations of axSpa in daily practice.
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Affiliation(s)
- Adeline Ruyssen-Witrand
- Rheumatology Centre, Toulouse University Hospital, Centre d'Investigation Clinique de Toulouse (CIC1436), Inserm, Team PEPSS "Pharmacologie En Population cohorteS et biobanqueS", University of Toulouse 3, Toulouse, France.
| | - Damien Caillet-Portillo
- Rheumatology Centre, Toulouse University Hospital, University of Toulouse 3, Toulouse, France
| | - Aurélie Najm
- Institute of Infection and Immunity, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Olivier Fogel
- Department of Rheumatology, Hôpital Cochin, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Athan Baillet
- Université Grenoble-Alpes, TIMC, CNRS UMR5525, Grenoble, France
| | - Pascal Claudepierre
- AP-HP, Service de Rhumatologie, Hôpital Henri-Mondor, Université Paris Est Créteil, EA 7379, EpiDermE, Paris, France
| | - Orenella Conort
- Department Clinical Pharmacy, Hôpital Cochin, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Emmanuelle Dernis
- Department of Rheumatology and Clinical Immunology, General hospital Le Mans, Le Mans, France
| | - Françoise Fayet
- Rheumatology Centre, Clermont University Hospital, Clermont-Ferrand, France
| | - Laure Gossec
- Sorbonne Université, Inserm, Institut Pierre-Louis d'Épidémiologie et de Santé Publique, AP-HP, Pitié-Salpêtrière Hospital, Rheumatology Department, Paris, France
| | - Philippe Goupille
- Université de Tours, EA 6295, Department of Rheumatology, University Hospital of Tours, Tours, France
| | | | | | - Cédric Lukas
- Department of Rheumatology, University Hospital of Montpellier, Inserm UA11 (IDESP), University of Montpellier, Montpellier, France
| | - Hubert Marotte
- Université Jean-Monnet Saint-Étienne, CHU de Saint-Étienne, Service de Rhumatologie, Mines Saint-Étienne, Inserm, SAINBIOSE U1059, 42023 Saint-Étienne, France
| | - Anna Molto
- ECAMO team (Inserm U1153), Center of Research in Epidemiology and Statistics (CRESS), Université Paris-Cité, Paris, France
| | - Sophie Pouplin
- Rheumatology Centre, Rouen University Hospital, Rouen, France
| | - Eric Senbel
- Centre de Rhumatologie de l'Eldorado, Marseille, France
| | - Christelle Sordet
- Rheumatology Center, Strasbourg University Hospital, University of Strasbourg, Strasbourg, France
| | - Anne Tournadre
- Rheumatology Centre, Clermont University Hospital, UNH INRAe University Clermont Auvergne, Clermont-Ferrand, France
| | - Marie-Elise Truchetet
- Department of Rheumatology, Hôpital Pellegrin, Bordeaux, France; Bordeaux University, CNRS, ImmunoConcept, UMR 5164, 33000 Bordeaux, France
| | - Daniel Wendling
- Rheumatology Centre, CHU de Besançon, University Hospital, EA4266, Université de Franche-Comté, Besançon, France
| | - Maxime Dougados
- University of Paris-Cité, Department of Rheumatology, Hôpital Cochin, Assistance publique-Hôpitaux de Paris, Inserm (U1153): Clinical epidemiology and biostatistics, PRES Sorbonne Paris-Cité, Paris, France.
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Pérez-Montes de Oca A, Ricou Ríos L, López Seguí F, Alonso N. Economic impact of introducing a multidisciplinary diabetic foot clinic in a tertiary hospital. Med Clin (Barc) 2024; 163:40-45. [PMID: 38653617 DOI: 10.1016/j.medcli.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Alejandra Pérez-Montes de Oca
- Department of Endocrinology and Nutrition, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laura Ricou Ríos
- Direcció d'Estratègia Assistencial, Gerència Territorial Metropolitana Nord, Institut Català de la Salut, Barcelona, Spain; CRES (Centre de Recerca en Economia i Salut) - Pompeu Fabra University, Barcelona, Spain; Research Group on Innovation, Health Economics and Digital Transformation - Institut Germans Trias i Pujol, Spain
| | - Francesc López Seguí
- CRES (Centre de Recerca en Economia i Salut) - Pompeu Fabra University, Barcelona, Spain
| | - Núria Alonso
- Department of Endocrinology and Nutrition, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Meloni M, Giurato L, Monge L, Miranda C, Scatena A, Ragghianti B, Silverii GA, Vermigli C, De Cassai A, Volpe A, Tramonta R, Medea G, Bordieri C, Falcone M, Stefanon L, Bernetti A, Cappella C, Gargiulo M, Lorenzoni V, Scevola G, Stabile E, Da Ros R, Murdolo G, Bianchini E, Gaggia F, Gauna C, Romeo F, Apicella M, Mantuano M, Monami M, Uccioli L. Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome. Acta Diabetol 2024; 61:543-553. [PMID: 38461443 DOI: 10.1007/s00592-024-02246-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/24/2024] [Indexed: 03/12/2024]
Abstract
The treatment of patients with diabetic foot ulcers (DFUs) is extremely complex, requiring a comprehensive approach that involves a variety of different healthcare professionals. Several studies have shown that a multidisciplinary team (MDT) approach is useful to achieve good clinical outcomes, reducing major and minor amputation and increasing the chance of healing. Despite this, the multidisciplinary approach is not always a recognized treatment strategy. The aim of this meta-analysis was to assess the effects of an MDT approach on major adverse limb events, healing, time-to-heal, all-cause mortality, and other clinical outcomes in patients with active DFUs. The present meta-analysis was performed for the purpose of developing Italian guidelines for the treatment of diabetic foot with the support of the Italian Society of Diabetology (Società Italiana di Diabetologia, SID) and the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD). The study was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. All randomized clinical trials and observational studies, with a duration of at least 26 weeks, which compared the MDT approach with any other organizational strategy in the management of patients with DFUs were considered. Animal studies were excluded. A search of Medline and Embase databases was performed up until the May 1st, 2023. Patients managed by an MDT were reported to have better outcomes in terms of healing, minor and major amputation, and survival in comparison with those managed using other approaches. No data were found on quality of life, returning-to-walking, and emergency admission. Authors concluded that the MDT may be effective in improving outcomes in patients with DFUs.
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Affiliation(s)
- Marco Meloni
- Department of Systems of Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
| | - Laura Giurato
- Department of Endocrinology and Diabetology, CTO Hospital, 00145, Rome, Italy
| | - Luca Monge
- AMD-Italian Association of Clinical Diabetologists, Milan, Italy
| | | | | | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy
| | | | - Cristiana Vermigli
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | | | | | | | - Gerardo Medea
- SIMG- Italian Society of General Medicine, Florence, Italy
| | | | - Marco Falcone
- Cisanello Hospital and University of Pisa, Pisa, Italy
| | | | | | - Cristina Cappella
- Associazione Di Volontariato Piede Diabetico Umbria ODV, Perugia, Italy
| | - Mauro Gargiulo
- University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | | | | | - Roberto Da Ros
- Azienda Sanitaria Universitaria Giuliana Isontina, Monfalcone, Italy
| | - Giuseppe Murdolo
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | - Eleonora Bianchini
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | - Francesco Gaggia
- Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy
| | | | | | | | | | - Matteo Monami
- Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy
| | - Luigi Uccioli
- Department of Systems of Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
- Department of Endocrinology and Diabetology, CTO Hospital, 00145, Rome, Italy
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Alkhalfan Y, Lewis TL, Kavarthapu V, Hester T. Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon. J Clin Orthop Trauma 2024; 48:102330. [PMID: 38274641 PMCID: PMC10806189 DOI: 10.1016/j.jcot.2023.102330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.
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Affiliation(s)
- Yousif Alkhalfan
- Guy's and St Thomas' NHS Foundation Trust, Maze Pond, London, SE1 9RT, UK
| | | | - Venu Kavarthapu
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
| | - Thomas Hester
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
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Monami M, Scatena A, Miranda C, Monge L, De Cassai A, Volpe A, Tramonta R, Medea G, Bordieri C, Falcone M, Stefanon L, Bernetti A, Cappella C, Gargiulo M, Lorenzoni V, Scevola G, Stabile E, Ragghianti B, Silverii GA, da Ros R, Meloni M, Giurato L, Murdolo G, Bianchini E, Gaggia F, Gauna C, Romeo F, Apicella M, Mantuano M, Uccioli L, Vermigli C. Development of the Italian clinical practice guidelines for the treatment of diabetic foot syndrome: design and methodological aspects. Acta Diabetol 2023; 60:1449-1469. [PMID: 37491605 DOI: 10.1007/s00592-023-02150-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/27/2023] [Indexed: 07/27/2023]
Abstract
AIMS Diabetic foot syndrome (DFS) and its complications are a growing public health concern. The Italian Society of Diabetology (SID) and the Italian Association of Clinical Diabetologists (AMD), in collaboration with other scientific societies, will develop the first Italian guidelines for the treatment of DFS. METHODS The creation of SID/AMD Guidelines is based on an extended work made by 19 panelists and 12 members of the Evidence Review Team. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology has been used to decide aims, reference population, and target health professionals. Clinical questions have been created using PICO (Patient, Intervention, Comparison, Outcome) conceptual framework. The definition of questions has been performed using a two-step web-based Delphi methodology, a structured technique aimed at obtaining by repeated rounds of questionnaires a consensus opinion from a panel of experts in areas wherein evidence is scarce or conflicting, and opinion is important. RESULTS The mean age of panelists (26.3% women) was 53.7 ± 10.6 years. The panel proposed 34 questions. A consensus was immediately reached for all the proposed questions, 32 were approved and 2 were rejected. CONCLUSIONS The areas covered by clinical questions included diagnosis of ischemia and infection, treatment of ischemic, neuropathic, and infected ulcers, prevention of foot ulceration, organization and education issues, and surgical management. The PICO presented in this paper are designed to provide indications for healthcare professionals in charge of diabetic foot treatment and prevention, primarily based on clinical needs of people with diabetic foot syndrome and considering the existing organization of health care.
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Affiliation(s)
- Matteo Monami
- Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy.
- University of Florence, Florence, Italy.
| | | | | | - Luca Monge
- AMD-Italian Association of Clinical Diabetologists, Milan, Italy
| | | | | | | | - Gerardo Medea
- SIMG-Italian Society of General Medicine, Florence, Italy
| | | | - Marco Falcone
- Cisanello Hospital and University of Pisa, Pisa, Italy
| | | | | | - Cristina Cappella
- Associazione di Volontariato Piede Diabetico Umbria ODV, Perugia, Italy
| | - Mauro Gargiulo
- University of Bologna, Policlinico Sant'Orsola-Malpighi, Bologna, Italy
| | | | | | | | - Benedetta Ragghianti
- Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy
| | | | - Roberto da Ros
- Azienda Sanitaria Universitaria Giuliana Isontina, Monfalcone, Italy
| | - Marco Meloni
- Endocrinology Unit CTO/SEU Hospitals - Roma 2 Dept of Biomedicine and Prevention - Tor Vergata University, Rome, Italy
| | - Laura Giurato
- Endocrinology Unit CTO/SEU Hospitals - Roma 2 Dept of Biomedicine and Prevention - Tor Vergata University, Rome, Italy
| | - Giuseppe Murdolo
- Azienda Ospedaliera Santa Maria della Misericordia, Ospedale di Perugia, Perugia, Italy
| | - Eleonora Bianchini
- Azienda Ospedaliera Santa Maria della Misericordia, Ospedale di Perugia, Perugia, Italy
| | - Francesco Gaggia
- Azienda Ospedaliera Santa Maria della Misericordia, Ospedale di Perugia, Perugia, Italy
| | | | | | | | | | - Luigi Uccioli
- Endocrinology Unit CTO/SEU Hospitals - Roma 2 Dept of Biomedicine and Prevention - Tor Vergata University, Rome, Italy
| | - Cristiana Vermigli
- Azienda Ospedaliera Santa Maria della Misericordia, Ospedale di Perugia, Perugia, Italy
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Sadler S, Gerrard J, Searle A, Lanting S, West M, Wilson R, Ginige A, Fang KY, Chuter V. The Use of mHealth Apps for the Assessment and Management of Diabetes-Related Foot Health Outcomes: Systematic Review. J Med Internet Res 2023; 25:e47608. [PMID: 37792467 PMCID: PMC10585435 DOI: 10.2196/47608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 07/19/2023] [Accepted: 08/04/2023] [Indexed: 10/05/2023] Open
Abstract
BACKGROUND Globally, diabetes affects approximately 500 million people and is predicted to affect up to 700 million people by 2045. In Australia, the ongoing impact of colonization produces inequity in health care delivery and inequality in health care outcomes for First Nations Peoples, with diabetes rates 4 times those of non-Indigenous Australians. Evidence-based clinical practice has been shown to reduce complications of diabetes-related foot disease, including ulceration and amputation, by 50%. However, factors such as a lack of access to culturally safe care, geographical remoteness, and high costs associated with in-person care are key barriers for First Nations Peoples in accessing evidence-based care, leading to the development of innovative mobile health (mHealth) apps as a way to increase access to health services and improve knowledge and self-care management for people with diabetes. OBJECTIVE This study aims to evaluate studies investigating the use of mHealth apps for the assessment and management of diabetes-related foot health in First Nations Peoples in Australia and non-Indigenous populations globally. METHODS PubMed, Informit's Indigenous Collection database, Ovid MEDLINE, Embase, CINAHL Complete, and Scopus were searched from inception to September 8, 2022. Hand searches of gray literature and reference lists of included studies were conducted. Studies describing mHealth apps developed for the assessment and management of diabetes-related foot health were eligible. Studies must include an evaluation (qualitative or quantitative) of the mHealth app. No language, publication date, or publication status restrictions were used. Quality appraisal was performed using the revised Cochrane risk-of-bias tool for randomized trials and the Health Evidence Bulletins Wales checklists for observational, cohort, and qualitative studies. RESULTS No studies specifically including First Nations Peoples in Australia were identified. Six studies in non-Indigenous populations with 361 participants were included. Foot care education was the main component of all mHealth apps. Of the 6 mHealth apps, 2 (33%) provided functionality for participants to enter health-related data; 1 (17%) included a messaging interface. The length of follow-up ranged from 1-6 months. Of the 6 studies, 1 (17%) reported high levels of acceptability of the mHealth app content for self-care by people with diabetes and diabetes specialists; the remaining 5 (83%) reported that participants had improved diabetes-related knowledge and self-management skills after using their mHealth app. CONCLUSIONS The findings from this systematic review provide an overview of the features deployed in mHealth apps and indicate that this type of intervention can improve knowledge and self-care management skills in non-Indigenous people with diabetes. Future research needs to focus on mHealth apps for populations where there is inadequate or ineffective service delivery, including for First Nations Peoples and those living in geographically remote areas, as well as evaluate direct effects on diabetes-related foot disease outcomes. TRIAL REGISTRATION PROSPERO CRD42022349087; https://tinyurl.com/35u6mmzd.
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Affiliation(s)
- Sean Sadler
- Western Sydney University, Campbelltown, Australia
- University of Newcastle, Ourimbah, Australia
| | - James Gerrard
- Western Sydney University, Campbelltown, Australia
- University of Newcastle, Ourimbah, Australia
- Central Australian Aboriginal Congress, Mparntwe (Alice Springs), Australia
| | | | - Sean Lanting
- Western Sydney University, Campbelltown, Australia
- University of Newcastle, Ourimbah, Australia
| | - Matthew West
- Western Sydney University, Campbelltown, Australia
| | - Rhonda Wilson
- University of Newcastle, Gosford, Australia
- Massey University, Auckland, New Zealand
| | | | - Kerry Y Fang
- Western Sydney University, Campbelltown, Australia
| | - Vivienne Chuter
- Western Sydney University, Campbelltown, Australia
- University of Newcastle, Ourimbah, Australia
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Troisi N, Bertagna G, Juszczak M, Canovaro F, Torri L, Adami D, Berchiolli R. Emergent management of diabetic foot problems in the modern era: Improving outcomes. Semin Vasc Surg 2023; 36:224-233. [PMID: 37330236 DOI: 10.1053/j.semvascsurg.2023.04.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 06/19/2023]
Abstract
Limb amputation is a consequence, and the leading complication, of diabetic foot ulcers. Prevention depends on prompt diagnosis and management. Patients should be managed by multidisciplinary teams and efforts should be focused on limb salvage ("time is tissue"). The diabetic foot service should be organized in a way to meet the patient's clinical needs, with the diabetic foot centers at the highest level of this structure. Surgical management should be multimodal and include not only revascularization, but also surgical and biological debridement, minor amputations, and advanced wound therapy. Medical treatment, including an adequate antimicrobial therapy, has a key role in the eradication of infection and should be guided by microbiologists and infection disease physicians with special interest in bone infection. Input from diabetologists, radiologists, orthopedic teams (foot and ankle), orthotists, podiatrists, physiotherapists, and prosthetics, as well as psychological counseling, is required to make the service comprehensive. After the acute phase, a well-structured, pragmatic follow-up program is necessary to adequately manage the patients with the aim to detect earlier potential failures of the revascularization or antimicrobial therapy. Considering the cost and societal impact of diabetic foot problems, health care providers should provide resources to manage the burden of diabetic foot problems in the modern era.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy.
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Maciej Juszczak
- Department of Vascular Surgery, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Roma 67, 56126, Pisa, Italy
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Hamilton EJ, Davis WA, Baba M, Davis TME. Temporal trends in minor and major lower extremity amputation in people with type 2 diabetes: The Fremantle Diabetes Study. Diab Vasc Dis Res 2023; 20:14791641231154162. [PMID: 36715218 PMCID: PMC9903017 DOI: 10.1177/14791641231154162] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
AIMS To determine whether incident minor and major lower extremity amputations (LEAs) have declined in recent decades in type 2 diabetes. METHODS Participants with type 2 diabetes from the community-based Fremantle Diabetes Study Phases I (FDS1; n = 1,296, mean age 64.0 years, recruited 1993-1996) and II (FDS2; n = 1,509, mean age 65.4 years, recruited 2008-2011) were followed from entry to incident minor/major LEA, death or five years. Cox regression determined hazard ratios (HRs) for each outcome for FDS2 versus FDS1 and independent predictors of incident minor and major LEA in the combined cohort. RESULTS Age- and sex-adjusted HRs (95% CIs) in FDS2 versus FDS1 for incident minor and major LEA were, respectively, 0.60 (0.27, 1.35) and 0.59 (0.22, 1.59). Higher glycated haemoglobin, urine albumin: creatinine (uACR) ratio and peripheral sensory neuropathy (PSN) were independent predictors of incident minor LEA. Higher fasting serum glucose, peripheral arterial disease (PAD), end-stage kidney disease and prior diabetes-related minor LEA were associated with incident major LEA. CONCLUSIONS There were non-significant reductions of approximately 40% in incident minor and major LEA in community-based people with type 2 diabetes during the 15 years between FDS Phases. Predictors of minor/major LEA confirm distinct high-risk patient groups with implications for clinical management.
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Affiliation(s)
- Emma J Hamilton
- Medical School, University of Western Australia, Fremantle, WA, Australia
- Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Wendy A Davis
- Medical School, University of Western Australia, Fremantle, WA, Australia
| | - Mendel Baba
- Podiatry Department, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Timothy ME Davis
- Medical School, University of Western Australia, Fremantle, WA, Australia
- Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, WA, Australia
- Timothy ME Davis, University of Western Australia Medical School, Fremantle Hospital, PO Box 480, Fremantle, WA 6959, Australia.
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Vuorlaakso M, Kiiski J, Majava M, Helminen M, Kaartinen I. Retrospective cohort study of long-term outcomes and prognostic factors for survival after lower extremity amputation in patients with diabetes. J Diabetes Complications 2023; 37:108377. [PMID: 36525903 DOI: 10.1016/j.jdiacomp.2022.108377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
AIMS Lower extremity amputation (LEA) is a pivotal event for patients with diabetes. This study aimed to provide updated data on the outcomes and prognostic factors after LEA for patients with diabetes. METHODS This retrospective cohort study included all LEAs (n = 1081) performed at Tampere University Hospital between February 2007 and September 2020. Overall survival (OS) and major amputation-free survival were evaluated. RESULTS Index amputation level was below ankle in 65 % (n = 704) of patients, below knee in 14 % (n = 154) of patients, and above knee in 21 % (n = 223) of patients. In the whole population, OS was 75.8 % (CI 95 %: 73.3-78.3) at one year and 38.3 % (CI 95 %: 34.7-41.7) at five years. Higher age, peripheral artery disease (PAD), more proximal amputation level, and lower glomerular filtration rate (GFR) reduced OS. Multiple amputations and diagnosed dyslipidemia or hypertension associated with improved OS. Further, age, PAD, and GFR were identified as significant factors for major amputation free survival. CONCLUSIONS OS after LEA is poor. After major amputation, the risk for death is higher compared to minor amputation. Recurrent amputation is associated with improved OS. Further, ischemia and renal disease are significant factors for inferior OS.
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Affiliation(s)
- M Vuorlaakso
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Surgery, Kanta-Häme Central Hospital, Ahvenistontie 20, 13530 Hämeenlinna, Finland.
| | - J Kiiski
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Elämänaukio 2, 33521 Tampere, Finland
| | - M Majava
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Elämänaukio 2, 33521 Tampere, Finland
| | - M Helminen
- Tays Research Services, Tampere University Hospital, Arvo Ylpön katu 6, 33521 Tampere, Finland; Faculty of Social Sciences, Health Sciences, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - I Kaartinen
- Faculty of Medicine and Life Sciences, University of Tampere, Arvo Ylpön katu 34, 33520, Tampere, Finland; Department of Musculoskeletal Surgery and Diseases, Tampere University Hospital, Elämänaukio 2, 33521 Tampere, Finland
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Kumlien C, Acosta S, Björklund S, Lavant E, Lazer V, Engblom J, Ruzgas T, Gershater M. Research priorities to prevent and treat diabetic foot ulcers-A digital James Lind Alliance Priority Setting Partnership. Diabet Med 2022; 39:e14947. [PMID: 36054410 PMCID: PMC9826297 DOI: 10.1111/dme.14947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 08/26/2022] [Indexed: 01/11/2023]
Abstract
AIM To establish outcomes of a priority setting partnership between participants with diabetes mellitus and clinicians to identify the top 10 research priorities for preventing and treating diabetic foot ulcers (DFUs). METHODS Due to the COVID-19 pandemic, the James Lind Alliance Priority Setting Partnership process was adapted into a digital format which involved a pilot survey to identify understandable uncertainties with high relevance for participants tested by calculating the content validity index; a main survey answered by 53 participants living with diabetes and 49 clinicians; and a final digital workshop to process and prioritise the final top 10 research priorities. RESULTS The content validity index was satisfactory for 20 out of 25 uncertainties followed by minor changes and one additional uncertainty. After we processed the 26 uncertainties from the main survey and seven current guidelines, a list of 28 research uncertainties remained for review and discussion in the digital workshop. The final top 10 research priorities included the organisation of diabetes care; screening of diabetes, impaired blood circulation, neuropathy, and skin properties; vascular surgical treatment; importance of self-care; help from significant others; pressure relief; and prevention of infection. CONCLUSION The top 10 research priorities for preventing and treating DFUs represent consensus areas from persons living with diabetes and clinicians to guide future research. These research priorities can justify and inform strategic allocation of research funding. The digitalisation of James Lind Alliance methodology was feasible.
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Affiliation(s)
- Christine Kumlien
- Department of Care ScienceMalmö UniversityMalmöSweden
- Department of Cardiothoracic and Vascular SurgerySkåne University HospitalMalmöSweden
| | - Stefan Acosta
- Department of Cardiothoracic and Vascular SurgerySkåne University HospitalMalmöSweden
- Department of Clinical SciencesMalmö, Lund UniversityMalmöSweden
| | - Sebastian Björklund
- Department of Biomedical ScienceMalmö UniversityMalmöSweden
- Biofilms—Research Center for BiointerfacesMalmö UniversityMalmöSweden
| | - Eva Lavant
- Department of Biomedical ScienceMalmö UniversityMalmöSweden
- Biofilms—Research Center for BiointerfacesMalmö UniversityMalmöSweden
| | | | - Johan Engblom
- Department of Biomedical ScienceMalmö UniversityMalmöSweden
- Biofilms—Research Center for BiointerfacesMalmö UniversityMalmöSweden
| | - Tautgirdas Ruzgas
- Department of Biomedical ScienceMalmö UniversityMalmöSweden
- Biofilms—Research Center for BiointerfacesMalmö UniversityMalmöSweden
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Atinafu BT, Tarekegn FN, Mulu GB, Kebede WM, Abinew Y, Mossie Y. The Magnitude and Associated Factors of Diabetic Foot Ulcer Among Patients with Chronic Diabetic Mellitus in Northeast Ethiopia, 2021. CHRONIC WOUND CARE MANAGEMENT AND RESEARCH 2022. [DOI: 10.2147/cwcmr.s364288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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13
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Meza-Torres B, Cunningham SG, Heiss C, Joy M, Feher M, Leese GP, de Lusignan S, Carinci F. Adherence to General Diabetes and Foot Care Processes, with Prompt Referral, Are Associated with Amputation-Free Survival in People with Type 2 Diabetes and Foot Ulcers: A Scottish National Registry Analysis. J Diabetes Res 2022; 2022:7414258. [PMID: 35746918 PMCID: PMC9213182 DOI: 10.1155/2022/7414258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 05/10/2022] [Accepted: 05/28/2022] [Indexed: 11/17/2022] Open
Abstract
Aims To compare different packages of care across care providers in Scotland on foot-related outcomes. Methods A retrospective cohort study with primary and secondary care electronic health records from the Scottish Diabetes Registry, including 6,845 people with type 2 diabetes and a first foot ulcer occurring between 2013 and 2017. We assessed the association between exposure to care processes and major lower extremity amputation and death. Proportional hazards were used for time-to-event univariate and multivariate analyses, adjusting for case-mix characteristics and care processes. Results were expressed in terms of hazard ratios with 95% confidence intervals. Results 2,243 (32.7%) subjects had a major amputation or death. Exposure to all nine care processes at all ages (HR = 0.63; 95% CI: 0.58-0.69; p < .001) and higher foot care attendance in people aged >70 years (HR = 0.88; 0.78-0.99; p = .03) were associated with longer major amputation-free survival. Waiting time ≥ 12 weeks between ulceration and clinic attendance was associated with worse outcomes (HR = 1.59; 1.37-1.84; p < .001). In people > 70 years, minor amputations were associated with improved major amputation-free survival (HR = 0.69; 0.52-0.92; p = .01). Conclusions Strict adherence to a standardised package of general diabetes care before foot ulceration, timely foot care after ulceration, and specific treatment pathways were associated with longer major amputation-free survival among a large cohort of people with type 2 diabetes in Scotland, with a larger impact on older age groups.
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Affiliation(s)
- Bernardo Meza-Torres
- Department of Clinical and Experimental Medicine, University of Surrey, UK
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Scott G. Cunningham
- Division of Population Health and Genomics, University of Dundee, Scotland, UK
| | - Christian Heiss
- Department of Clinical and Experimental Medicine, University of Surrey, UK
- Surrey and Sussex Healthcare NHS Trust, East Surrey Hospital, Redhill, UK
| | - Mark Joy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Michael Feher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Graham P. Leese
- Division of Population Health and Genomics, University of Dundee, Scotland, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Fabrizio Carinci
- Department of Statistical Sciences, University of Bologna, Italy
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Rodrigues ADSDA, Silva APD, Cardoso AR, Araujo Filho ACAD, Arrais KR, Silva JVD, Silva MSGD, Magalhães RDLB. CLINICAL AND EPIDEMIOLOGICAL PROFILE OF PATIENTS SUBMITTED TO LOWER LIMB AMPUTATION. ESTIMA 2022. [DOI: 10.30886/estima.v20.1212_in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective: To characterize the clinical and epidemiological profile of patients undergoing lower limb amputation in a public hospital in southern Piauí state, Brazil. Method: Retrospective and descriptive study, with document analysis and quantitative approach. Data collection took place in July and August 2021, using an instrument developed by the researchers. Data were processed using the statistical software Statistical Package for Social Sciences, version 20.0. Results: The sample consisted of 70 patients with a mean age of 65.59 years, most of them male (61.4%), brown (88.6%), married (48.3%), retired (42.9%), coming from other cities of Piauí (87.1%). Most patients (47.1%) had a comorbidity at the time of amputation, with diabetes mellitus (34.3%) being the most prevalent, followed by systemic arterial hypertension (12.9%). Diabetes was the main cause of amputation (48.6%), being the transfemoral level (42.9%) the most affected. All procedures were performed on an emergency basis, and most hospitalizations (94.3%) progressed to discharge. Conclusion: The findings of this study reveal that people with diabetes, males, and the elderly were the individuals who most underwent amputation, with the transfemoral level being the most performed.
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Rodrigues ADSDA, Silva APD, Cardoso AR, Araujo Filho ACAD, Arrais KR, Silva JVD, Silva MSGD, Magalhães RDLB. PERFIL CLÍNICO E EPIDEMIOLÓGICO DE PACIENTES SUBMETIDOS A AMPUTAÇÃO DE MEMBROS INFERIORES. ESTIMA 2022. [DOI: 10.30886/estima.v20.1212_pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objetivo:Caracterizar o perfil clínico e epidemiológico dos pacientes submetidos à amputação de membros inferiores em um hospital público do sul do Piauí. Métodos: Estudo retrospectivo, descritivo, com análise documental e abordagem quantitativa. A coleta de dados ocorreu nos meses de julho e agosto de 2021, sendo realizada por meio de um instrumento elaborado pelos pesquisadores. Os dados foram processados pelo o software estatístico Statistical Package for Social Sciences, versão 20.0. Resultados: A amostra foi composta por 70 pacientes com média de idade de 65,6 anos, a maioria do sexo masculino (61,4%), de cor parda (88,6%), casada (48,3%), aposentada (42,9%), advinda de outras cidades do Piauí (87,1%). A maioria dos pacientes (47,1%) apresentava uma comorbidade no momento da amputação, sendo o diabetes mellitus (34,3%) a mais prevalente, seguido de hipertensão arterial sistêmica (12,9%). O diabetes mellitus foi a principal causa de amputação (48,6%), sendo a nível transfemoral (42,9%) a mais predominante. Todos os procedimentos foram realizados em caráter de urgência, e grande parte das internações (94,3%) evoluiu para alta. Conclusão: Os achados demonstram que pessoas com diabetes mellitus, do sexo masculino e idosas foram as que mais se submeteram a amputação, sendo o nível transfemoral o mais realizado
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Kolossváry E, Kolossváry M, Ferenci T, Kováts T, Farkas K, Járai Z. Spatial analysis of factors impacting lower limb major amputation rates in Hungary. VASA 2022; 51:158-166. [DOI: 10.1024/0301-1526/a000995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Summary: Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (β=−0.002, 95% CI: −0.05 – 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (β=−7.45, 95% CI: −10.50 – −4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.
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Affiliation(s)
- Endre Kolossváry
- Department of Angiology, St. Imre University Teaching Hospital, Budapest, Hungary
- Department of Vascular Surgery (Section of Angiology), Heart and Vascular Center, Semmelweis University of Medicine, Budapest, Hungary
| | - Márton Kolossváry
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, USA
| | - Tamás Ferenci
- Óbuda University, Physiological Controls Research Center, Budapest, Hungary
- Corvinus University of Budapest, Department of Statistics, Budapest, Hungary
| | - Tamás Kováts
- Health Services Management Training Centre, Semmelweis University of Medicine, Budapest, Hungary
| | - Katalin Farkas
- Department of Angiology, St. Imre University Teaching Hospital, Budapest, Hungary
- Department of Vascular Surgery (Section of Angiology), Heart and Vascular Center, Semmelweis University of Medicine, Budapest, Hungary
| | - Zoltán Járai
- Department of Vascular Surgery (Section of Angiology), Heart and Vascular Center, Semmelweis University of Medicine, Budapest, Hungary
- Department of Cardiology, St. Imre University Teaching Hospital, Budapest, Hungary
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Perrin BM, Raspovic A, Williams CM, Twigg SM, Golledge J, Hamilton EJ, Crawford A, Hargreaves C, van Netten JJ, Purcell N, Lazzarini PA. Establishing the national top 10 priority research questions to improve diabetes-related foot health and disease: a Delphi study of Australian stakeholders. BMJ Open Diabetes Res Care 2021; 9:e002570. [PMID: 34764140 PMCID: PMC8587617 DOI: 10.1136/bmjdrc-2021-002570] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/15/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Diabetes-related foot disease is a large cause of the global disease burden yet receives very little research funding to address this large burden. To help address this gap, it is recommended to first identify the consensus priority research questions of relevant stakeholders, yet this has not been performed for diabetes-related foot disease. The aim of this study was to determine the national top 10 priority research questions for diabetes-related foot health and disease from relevant Australian stakeholders. RESEARCH DESIGN AND METHODS A modified three-round Delphi online survey design was used to seek opinions from relevant Australian stakeholders including those with diabetes or diabetes-related foot disease or their carers (consumers), health professionals, researchers and industry. Participants were recruited via multiple public invitations and invited to propose three research questions of most importance to them (Round 1), prioritize their 10 most important questions from all proposed questions (Round 2), and then rank questions in order of importance (Round 3). RESULTS After Round 1, a total of 226 unique questions were proposed by 210 participants (including 121 health professionals and 72 consumers). Of those participants, 95 completed Round 2 and 69 completed Round 3. The top 10 priority research questions covered a range of topics, including health economics, peripheral neuropathy, education, infection, technology, exercise, and nutrition. Consumers prioritized peripheral neuropathy and prevention-related questions. Health professionals prioritized management-related questions including Australia's First Peoples foot health, health economics and infection questions. CONCLUSIONS These priority research questions should guide future national research agendas, funding and projects to improve diabetes-related foot disease burdens in Australia and globally. Future research should focus on consumer priority research questions to improve the burden of diabetes-related foot disease on patients and nations. Further research should also investigate reasons for different priorities between consumers and health professionals.
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Affiliation(s)
- Byron M Perrin
- La Trobe Rural Health School, La Trobe University, Bendigo, Victoria, Australia
- Diabetes Feet Australia, Sydney, New South Wales, Australia
| | - Anita Raspovic
- Discipline of Podiatry, La Trobe University, Melbourne, Victoria, Australia
| | - Cylie M Williams
- School of Primary and Allied Health Care, Monash University, Frankston, Victoria, Australia
| | - Stephen M Twigg
- Diabetes Feet Australia, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Jonathan Golledge
- Diabetes Feet Australia, Sydney, New South Wales, Australia
- Queensland Research Centre for Peripheral Vascular Disease, James Cook University, Townsville, Queensland, Australia
- Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia
| | - Emma J Hamilton
- Department of Endocrinology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Anna Crawford
- Diabetes Centre, High Risk Foot Service, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | | | | | | | - Peter A Lazzarini
- Diabetes Feet Australia, Sydney, New South Wales, Australia
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Queensland, Australia
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