A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration

Exploring the decision-making experience of elderly diabetes patients regarding their health-seeking behaviour: a descriptive qualitative study

BACKGROUND

Diabetes has emerged as a critical global public health issue. The burden of diabetes is escalating in developing countries, including China. For individuals with diabetes, making informed and rational decisions regarding health-seeking behaviour is crucial to prevent or delay the occurrence of complications. However, prevalent irrational health-seeking behaviours among Chinese patients with diabetes have led to a low treatment rate of only 32.2%. In this study, we explore the subjective experiences of elderly patients with diabetes related to their decision-making experience for seeking healthcare, providing valuable insights for targeted intervention, and provide theoretical basis for establishing an efficient medical and health service system.

METHODS

A qualitative study using descriptive phenomenology research methodology was adopted to explore the decision-making experience of elderly diabetes patients in seeking healthcare services. A purposive sampling approach, specifically maximum variation sampling, was employed to conduct semistructured in-depth interviews with 11 eligible participants between January and February 2023. Data analysis was carried out using QSR Nvivo 12.0 software and Colaizzi's seven-step analysis method.

RESULTS

Four themes emerged: 'lack of disease risk perception and negative coping styles', ' huge medical and economic burden', 'lack of family and social support' and 'Dissatisfaction with medical services'.

CONCLUSION

The health-seeking behavioural decision-making level of elderly diabetic patients is relatively low. Medical and healthcare professionals should formulate targeted intervention measures aimed at improving their disease cognition level, changing their coping styles and enhancing their health-seeking behavioural decision-making level to improve their health outcomes. Meanwhile, policymakers should plan and allocate medical resources in a targeted manner based on the needs and expectations of patients.

Effect of Treatment of Neuropathic and Ischemic Diabetic Foot Ulcers with the Use of Local Ozone Therapy Procedures-An Observational Single Center Study

Background: Diabetes ranks high among worldwide global health problems, and diabetic foot ulcer syndrome (DFU) is considered as one of its most serious complications. The purpose of this study was to evaluate the impact of local ozone therapy procedures on the wound healing process in patients with two DFU types: neuropathic and ischemic. Material and Methods: In the retrospective study reported here, the treatment outcomes of 90 patients were analyzed: 44 males (48.8%) and 46 females (51.2%), in the age range between 38 and 87 years of age, with neuropathic (group 1) and ischemic (group 2) diabetic foot ulcers treated by means of local ozone therapy. The assessment of therapeutic effects in both groups of patients included an analysis of the rate of ulcer healing using planimetry and an analysis of the intensity of pain associated with ulcers performed using the VAS scale. Results: After the application of ozone therapy procedures, a statistically significant decrease in the surface area of the ulcers was obtained in both groups of patients, respectively: in group 1 from 7 (6-7.5) cm2 to 3 (2-3.5) cm2 and in group 2 from 7.5 (6.5-8) cm2 to 5 (4.5-5.5) cm2 (p < 0.001), with a complete healing of ulcers not observed in any patients from groups 1 and 2. After treatment, the surface area of the assessed ulcers was smaller in the neuropathic group. The intensity of pain experienced after treatment also decreased with statistical significance in both groups (p < 0.001). Conclusions: Short-term local ozone therapy was effective in promoting wound healing and alleviating pain in patients with DFUs of both neuropathic and ischemic etiology. The effectiveness of therapy in the neuropathic type of DFUs was significantly higher than in the ischemic type, in which patients had a higher incidence of risk factors and more advanced lesions, characterized by a larger initial ulcer area and greater intensity of pain.

The application and uses of telemedicine in vascular surgery: A narrative review

Technological advances over the past century have accelerated the pace and breadth of medical and surgical care. From the initial delivery of "telemedicine" over the radio in the 1920s, the delivery of medicine and surgery in the 21st century is no longer limited by connectivity. The COVID-19 pandemic hastened the uptake of telemedicine to ensure that health care can be maintained despite limited face-to-face contact. Like other areas of medicine, vascular surgery has adopted telemedicine, although its role is not well described in the literature. This narrative review explores how telemedicine has been delivered in vascular surgery. Specific themes of telemedicine are outlined with real-world examples, including consultation, triaging, collaboration, mentoring, monitoring and surveillance, mobile health, and education. This review also explores possible future advances in telemedicine and issues around equity of care. Finally, important ethical considerations and limitations related to the applications of telemedicine are outlined.

Patient experience of the process to diagnosis of chronic limb-threatening ischaemia: A qualitative study

INTRODUCTION

Delays exist at each stage of the chronic limb-threatening ischaemia (CLTI) care pathway, but there is little known about patient factors influencing delay to diagnosis of CLTI. This study explores the experiences and perceptions of patients recently diagnosed with CLTI.

METHODS

A qualitative interview study was conducted. Sixteen participants underwent semi-structured interviews. Reflexive thematic analysis was performed on the data, aiming to understand factors which can influence delay in the CLTI care pathway.

RESULTS

Five interrelated themes were developed: CLTI is a devastating condition; Reluctance to ask for help; When we are empowered we get better care; Luck plays a role in the process to diagnosis; and Vascular units can do better, comprising sub-themes of information transfer-consider communication and arterial versus non-arterial centres-proximity isn't everything.

CONCLUSIONS

The five themes generated from the interview data describe factors relevant to delay given meaning by participants who have lived experience of CLTI. Theme content should be noted by clinicians, commissioners and providers looking to improve care pathways for patients with CLTI. The importance of awareness for the public, patients and clinicians linked ideas in some themes and interventions to raise awareness should be considered.

Research hotspots and trends in nursing for diabetic foot ulcers: A bibliometric analysis from 2013 to 2023

Background

Nursing can effectively prevent and ameliorate diabetic foot ulcers (DFU). However, there is a lack of literature on the bibliometric analysis of DFU nursing. This study aimed to analyze the research hotspots and development trends in DFU nursing over the past 10 years to provide references for future related research.

Methods

The Web of Science Core Collection was used to retrieve literature related to DFU nursing from 2013 to 2023. Analyses included the annual publication trends; author, institution, and country collaborations; journal and literature co-citation; and keyword co-occurrence, clustering, and bursting, performed using CiteSpace 5.8 R3.

Results

A total of 229 papers were included, showing an upward trend in annual publications. American scholar David G Armstrong (n = 3) and King's College Hospital London (n = 4) were the most productive authors and institutions, respectively. The United States ranked first (n = 45) in national contributions, followed by China and Brazil. The overall research strength between authors and institutions was relatively scattered, and intensive cooperation has not yet been formed. National collaborations resulted in a core team dominated by Europe and North America with concentrated research strengths. The most frequently co-cited journal and co-cited reference were Diabetes Care (111 citations) and Armstrong DG (2017) (131 citations), separately. Research hotspots mainly focused on risk assessment, classification systems, protective measures, and clinical management of DFU. "Primary care" and "intervention efficacy" were identified as the research trends in the coming years.

Conclusion

The field of DFU nursing requires more attention. Academic exchange and cooperation between authors, institutions, and countries should be strengthened. Our future research will focus on the latest hotspots and trends, conducting more in-depth and comprehensive studies on DFU management.

Surveillance of Enterobacteriaceae from Diabetic Foot Infections in a Tunisian Hospital: Detection of E. coli-ST131-blaCTX-M-15 and K. pneumoniae-ST1-blaNDM-1 Strains

The study determined the prevalence, antimicrobial resistant (AMR) determinants, and genetic characteristics of Escherichia coli and Klebsiella pneumoniae isolates from patients with diabetic foot infection (DFI) in a Tunisian hospital. A total of 26 Escherichia spp. and Klebsiella spp. isolates were recovered and identified by MALDI-TOF-MS. Antimicrobial susceptibility testing, the detection of AMR determinants and Shiga-like toxin genes, phylogenetic grouping, and molecular typing were performed. Twelve E. coli, 10 K. pneumoniae, 3 K. oxytoca, and 1 E. hermanii were isolated. A multidrug-resistant phenotype was detected in 65.4% of the isolates. About 30.8% of isolates were extended-spectrum β-lactamase (ESBL) producers and mainly carried blaCTX-M-15 and blaCTX-M-14 genes. One blaNDM-1-producing K. pneumoniae-ST1 strain was identified. Class 1 integrons were detected in 11 isolates and 5 gene cassette arrangements were noted: dfrA1+aadA1 (n = 1), dfrA12+aadA2 (n = 3), and dfrA17+aadA5 (n = 1). Other non-β-lactam resistance genes detected were as follows (number of isolates): aac(3')-II (3), aac(6')-Ib-cr(8), qnrB (2), qnrS (4), cmlA (2), floR (4), sul1 (11), sul2 (11), and sul3 (2). The phylogroup B1 was the most frequent (41.7%) among E. coli, and two ESBL-producing isolates corresponded to the ST131-B2 lineage. The ESBL- and carbapenemase-producing Enterobacteriaceae in DFIs are described for the first time in Tunisia.

Multimodal imaging device to comprehensively assess infection, oxygenation, and wound analytics-A pilot study

Wound analytics, infection detection, and oxygenation measurement are the three critical prerequisites for appropriate wound care. Although devices that rapidly detect the above-mentioned parameters independently exist, there is no single point-of-care device that is enabled with all the three functionalities. Through this study, we are introducing and evaluating the performance of Illuminate Pro Max-a novel, rapid, hand-held non-contact, point-of-care multimodal imaging device that is equipped to measure the three wound assessment parameters. Here, a total of 60 diabetic foot ulcer patients were imaged using Illuminate Pro Max to detect bioburden and measure StO2 levels and wound dimensions (size and depth). The results were further evaluated against the current gold standard technique for each parameter, that is, culture test to detect bioburden, a transcutaneous oxygen pressure (TcPO2) measuring device-Perimed Periflux 5000 to measure oxygenation, and paper ruler to measure wound size. Culture tests reported 42 samples as infection-positive and 18 samples as infection-negative. On comparing with the culture report, the device showed 88% sensitivity and 86% PPV in detecting the bioburden. Wound dimensions (length and width) were comparable with the paper scale measurements. Wound depth was also reported by the device. The StO2 map generated by the device depicted the tissue oxygenation levels in various regions of the wound. In conclusion, this novel, comprehensive point-of-care multispectral imaging device can be an effective tool for rapid wound assessment which can help in prompt treatment.

New Horizons in Peripheral Artery Disease

Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.

Understanding delays in chronic limb-threatening ischaemia care: Application of the theoretical domains framework to identify factors affecting primary care clinicians' referral behaviours

INTRODUCTION

Patients in the community with suspected Chronic limb-threatening ischaemia (CLTI) should be urgently referred to vascular services for investigation and management. The Theoretical Domains Framework (TDF) allows identification of influences on health professional behaviour in order to inform future interventions. Here, the TDF is used to explore primary care clinicians' behaviours with regards to recognition and referral of CLTI.

METHODS

Semi-structured interviews were conducted with 20 podiatrists, nurses and general practitioners in primary care. Directed content analysis was performed according to the framework method. Utterances were coded to TDF domains, and belief statements were defined by grouping similar utterances. Relevance of domains was confirmed according to belief frequency, presence of conflicting beliefs and the content of the beliefs indicating relevance.

RESULTS

Nine TDF domains were identified as relevant to primary care clinicians: Knowledge, Environmental context and resources, Memory, Decision and attention processes, Beliefs about capabilities, Skills, Emotions, Reinforcement and Behavioural regulation. Relationships across domains were identified, including how primary care clinician confidence and working in a highly pressurized environment can affect behaviour.

CONCLUSION

We have identified key barriers and enablers to timely recognition and referral behaviour. These beliefs identify targets for theory-driven behaviour change interventions to reduce delays in CLTI pathways.

Documentary analysis of national and international guidance for community clinicians referring patients with suspected chronic limb-threatening ischaemia

BACKGROUND

Delayed referral of patients with chronic limb-threatening ischaemia (CLTI) from the community to vascular services may increase risk of amputation due to delayed revascularisation. Lack of appropriate guidance for clinicians in the community may contribute to this problem. This documentary analysis investigated referral guidance available to primary care clinicians.

METHODS

National and international documents providing guidance on CLTI management were identified by searching sources including Medline, Embase, Guidelines International Network and College/Society websites. Data were extracted on referral recommendations, target audience and author groups. Recommendations were coded according to the Behaviour Change Technique Taxonomy. Clinical practice guideline quality and ease of implementation were assessed independently by two reviewers using the Appraisal of Guidelines Research and Evaluation (AGREE) II and Guideline Implementability Appraisal (GLIA) tools, respectively.

RESULTS

12 documents containing guidance on CLTI referrals were included. Five were clinical practice guidelines. Nine targeted clinicians in the community among their audience, yet only one included a primary care clinician in their author group. Recommendations on identification and referral of CLTI were often in non-specific language and frequently assumed specialist knowledge of vascular disease. Just 4 of the 93 behaviour change techniques were identified in the guidance documents. Three relevant domains of the AGREE II tool were scored for five clinical practice guidelines: stakeholder involvement (range 21.4%-52.4%, mean 42.9%), clarity of presentation (range 71.4%-92.9%, mean 82.9%) and applicability (25.0%-57.1%, mean 36.8%). The GLIA tool identified barriers to ease of implementation for all five clinical practice guidelines.

CONCLUSIONS

Most guidance for clinicians in the community on the management of CLTI has been written without their input and assumes knowledge of vascular disease, which may be lacking. Future guidance development should involve community clinicians, consider using additional behaviour change techniques, and improve the applicability and ease of implementation of recommendations.

Identification, influencing factors and outcomes of time delays in the management pathway of diabetic foot: A systematic review

OBJECTIVE

A systematic review was conducted to evaluate the time delays in the management of diabetic foot and explore influencing factors of these delays and potential outcomes.

METHODS

The researchers searched several electronic databases (Pubmed, Web of Science, Cochrane Library, EMbase, CNKI, WanFang, CBM and VIP) for English and Chinese studies that examined time delays in the management pathway of diabetic foot. Two authors independently screened and extracted data, and assessed the quality of the included studies using the Newcastle-Ottawa Scale and the Agency for Health Research and Quality checklist. Due to heterogeneity among the studies, descriptive analysis was performed.

RESULTS

The review included 28 articles, comprising 20 cohort studies and 8 cross-sectional studies, that met the inclusion criteria. Among these, 14 were deemed of high quality. The median times from symptom onset to primary health care or specialist care varied from 3 to 46.69 days. The median delay in referral by primary care specialists ranged from 7 to 31 days, and subsequent median times to definitive treatment ranged from 6.2 to 56 days. Multiple complex factors were found to contribute to these delays, including patient demographics (older age, lower education level and income level) and poor patient health-seeking behaviors (inaccurate self-treatment, incorrect recognition and interpretation of symptoms), inaccurate assessment or initial treatment by health primary professionals, complex referral pathways and clinical characteristics of diabetic foot (number of foot ulcers, Wagner grade scale, and hemoglobin A1c index). Negative outcomes associated with these delays included increased risk of major amputation and mortality, decreased wound healing rate, prolonged hospital stay, and increased hospital costs.

CONCLUSIONS

Time delays in the diabetic foot management pathway were both common and serious, contributing to negative health outcomes for patients with diabetic foot. Many complex factors related to patient's poor patient health-seeking behaviors, health system, and clinical characteristics of diabetic foot are responsible for these delays. Therefore, it is necessary to develop new strategies for standard referral practices and strengthen patient awareness of seeking care.

An Endovascular- Versus a Surgery-First Revascularization Strategy for Chronic Limb-Threatening Ischemia: A Meta-Analysis of Randomized Controlled Trials

Timely revascularization is essential for limb salvage and to reduce mortality in patients with chronic limb-threatening ischemia (CLTI). In patients who are candidates for endovascular therapy and surgical bypass, the optimal revascularization strategy remains uncertain. Recently published randomized controlled trials (RCTs) have presented conflicting results. We conducted a trial-level meta-analysis to compare the outcomes between endovascular-first and surgery-first strategies for revascularization. PubMed, Web of Science, and the Cochrane Library were searched to identify RCTs comparing the outcomes of endovascular-first versus surgery-first strategies for revascularization in patients with CLTI. Data were pooled for major outcomes and their aggregate risk ratios (RRs) with 95% confidence intervals were calculated using a random-effects model. Kaplan-Meier curves for amputation-free survival and overall survival time were plotted using the pooled aggregated data from published curves, with their corresponding hazard ratios (HRs) and 95% confidence intervals reported for up to 5 years of follow-up. A total of 3 RCTs with 2,627 patients (1,312 endovascular-first and 1,315 surgery-first) were included in the meta-analysis. Of these, 1,864 patients (70.9%) were men and 347 (13.2%) were older than 80 years. Comparing the endovascular-first and surgery-first approaches, there was no significant difference in the overall (HR 0.92 [0.83 to 1.01], p = 0.09) or amputation-free survival (HR 0.98 [0.92 to 1.03], p = 0.42), reintervention (RR 1.24 [0.74 to 2.07], p = 0.41), major amputation, (RR 1.16 [0.87 to 1.54], p = 0.31), or therapeutic crossover (RR 0.92 [0.37 to 2.26], p = 0.85). In conclusion, data from available RCTs suggest that there is no difference in clinical outcomes between endovascular-first and surgery-first revascularization strategies for CLTI. A planned patient-level meta-analysis may provide further insight.

The symptom to assessment pathway for suspected chronic limb-threatening ischaemia (CLTI) affects quality of care: a process mapping exercise

BACKGROUND

Delays in the pathway from first symptom to treatment of chronic limb-threatening ischaemia (CLTI) are associated with worse mortality and limb loss outcomes. This study examined the processes used by vascular services to provide urgent care to patients with suspected CLTI referred from the community.

METHODS

Vascular surgery units from various regions in England were invited to participate in a process mapping exercise. Clinical and non-clinical staff at participating units were interviewed, and process maps were created that captured key staff and structures used to create processes for referral receipt, triage and assessment at the units.

RESULTS

Twelve vascular units participated, and process maps were created after interviews with 45 participants. The units offered multiple points of access for urgent referrals from general practitioners and other community clinicians. Triage processes were varied, with units using different mixes of staff (including medical staff, podiatrists and s) and this led to processes of varying speed. The organisation of clinics to provide slots for 'urgent' patients was also varied, with some adopting hot clinics, while others used dedicated slots in routine clinics. Service organisation could be further complicated by separate processes for patients with and without diabetes, and because of the organisation of services regionally into vascular networks that had arterial and non-arterial centres.

CONCLUSIONS

For referred patients with symptoms of CLTI, the points of access, triage and assessment processes used by vascular units are diverse. This reflects the local context and ingenuity of vascular units but can lead to complex processes. It is likely that benefits might be gained from simplification.

Undercover Peripheral Arterial Disease

Peripheral arterial disease is a frequently underdiagnosed disease that can severely affect the quality of life. We present a clinical case of a 62-year-old smoker post-menopause woman with a mild stroke. Further investigation revealed a severe disseminated arterial disease. Due to multidisciplinary and timely interventions, peripheral ischemia was prevented successfully. In fact, this patient had polyvascular disease. Despite its worst prognosis than either coronary artery disease, cerebrovascular disease, or peripheral arterial disease alone, polyvascular disease is still underdiagnosed. Atherosclerosis and cardiovascular risk should be regarded as multisystemic and managed as such in multidisciplinary teams. A proper and timely intervention is essential to diminish its morbidity and mortality.

Psychosocial markers of pre-hospital delay in patients with diabetic foot: A cross-sectional survey

AIM

This study aimed to determine the psychosocial markers associated with pre-hospital delay among patients with diabetic foot (DF).

DESIGN

This study has a cross-sectional design.

METHODS

The participants completed a questionnaire including pre-hospital time, demographic characteristics, Social Support Rate Scale, Brief Illness Perception Questionnaire and Type D Personality Scale-14. Bivariate and multivariate analyses were conducted to explore independent associations with pre-hospital delay.

RESULTS

Only 1.8% (3/164) of participants arrived at the hospital for medical care in 24 h of symptom onset. Patients with low utilization of social support (p = 0.029), low negative illness perceptions (p = 0.014) and high levels of negative affectivity (p = 0.009) are likely to arrive late at the clinic. Medical staff should pay attention to identifying diabetic patients' Type D personalities and take actions to improve their social support as well as illness perception, so as to reduce the occurrence of hospital delay.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Psychosocial factors play a vital role in the delay in seeking medical treatment for patients with DF. Medical staff need to improve patients' illness perception as well as self-management ability through health education. Importantly, key family members provide an emotional and psychological support system for diabetic patients. Therefore, nurses need to work with family members together to give information and psychological support during family visits. Additionally, building and maintaining trust with patients is crucial to encouraging individuals to express their concerns and worries. In this case, nurses may identify patients' negative emotions and conduct timely intervention, so as to achieve favourable outcomes.

PATIENT OR PUBLIC CONTRIBUTION

This study used a convenience sample of 164 participants with DF recruited from the wound clinic of Northern Jiangsu People's Hospital and Yangzhou Hospital of TCM in China.

Limb Salvage and Survival in Chronic Limb-Threatening Ischemia: The Need for a Fast-Track Team-Based Approach

Chronic limb-threatening ischemia (CLTI) represents the end-stage form of peripheral arterial disease (PAD) and is associated with a very poor prognosis and high risk of limb loss and mortality. It can be considered very similar to a terminal cancer disease, reflecting a large impact on quality of life and healthcare costs. The aim of this study is to offer an overview of the relationship between CLTI, limb salvage, and mortality, with a focus on the need of a fast-track team-based management that is a driver to achieve better survival results. This review can be useful to improve management of this growing impact disease, and to promote the standardisation of care and communication between specialist and non-specialist healthcare professionals.

Hospital clinicians' perceptions and experiences of care pathways for chronic limb-threatening ischaemia: a qualitative study

BACKGROUND

Chronic limb-threatening ischaemia (CLTI) is a condition associated with significant risks of lower limb loss and mortality, which increase with delays in management. Guidance recommends urgent referral and assessment, but delays are evident at every stage of the CLTI patient pathway. This study uses qualitative methods to explore hospital clinicians' experiences and perceptions of the existing CLTI pathway.

METHODS

A qualitative interview study was conducted. Semi-structured interviews were undertaken with 13 clinicians involved in the assessment of patients referred to hospital with suspected CLTI, identified via purposive sampling from English vascular surgery units. Clinicians included podiatrists, vascular specialist nurses and doctors. Reflexive thematic analysis was performed on the data from a critical realist position.

RESULTS

The need for speed was the single overarching theme identified. Four linked underlying themes were also identified; 1. Vascular surgery as the poor relation (compared to cancer and other specialties), with a sub-theme of CLTI being a challenging diagnosis. 2. Some patients are more equal than others, with sub-themes of diabetes vs. non-diabetes, hub vs. spoke and frailty vs. non-frail. 3. Life in the National Health Service (NHS) is tough, with sub-themes of lack of resource and we're all under pressure. 4. Non-surgeons can help.

CONCLUSIONS

The underlying themes generated from the rich interview data describe barriers to timely referral, assessment and management of CLTI, as well as the utility of non-surgical roles such as podiatrists and vascular specialist nurses as a potential solution for delays. The overarching theme of the need for speed highlights the meaning given to adverse consequences of delays in management of CLTI by clinicians involved in its assessment. Future improvement projects aimed at the CLTI pathway should take these findings into account.

The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration

BACKGROUND

Diabetes-related foot disease (DFD) accounts for up to 75% of lower-extremity amputations globally. Rural and remote communities are disproportionately affected by DFD. Telehealth has been advocated as a strategy to improve equity of access to health care in rural and remote communities. Current literature suggests that successful implementation of telehealth requires access to adequate reliable equipment, staff training, and support. A real-time video-based telehealth foot service (TFS) for delivering DFD management has recently been established in a Vascular Surgery and Podiatry clinic within a large South Australian metropolitan hospital. The purpose of this study was to gain insights into the experiences of rural and remote health professionals utilising the TFS, as this could be invaluable in optimising the uptake of telehealth use in DFD.

METHODS

This exploratory, descriptive qualitative study employed one-on-one, semi-structured interviews with health professionals who utilised the service. Thematic analysis using an essentialist inductive approach was employed.

RESULTS

Participants included 14 rural and remote health professionals; 2 general practitioners, 2 nurses, 1 Aboriginal Health Practitioner, and 9 podiatrists. In addition, 2 metropolitan-based TFS staff were interviewed. Five key themes were identified. 'Patients have reduced travel burden' included that telehealth enabled Indigenous patients to stay on country. 'Patients had increased psychosocial support' covered the benefits of having health professionals who knew the patient present in consults. 'Improved access' incorporated how telehealth improved interprofessional relationship building and communication. 'Technological and equipment challenges' highlighted that poor network connectivity and poor access to equipment to conduct telehealth consults in rural areas were barriers. The last theme,'Lack of service communication to rural health professionals', highlighted the need for communication around service details.

CONCLUSION

Telehealth is a valuable tool that can improve access to treatment for rural and remote Indigenous DFD patients. While this has the potential to improve DFD outcomes, empirical data is required to confirm outcomes. Considering the advantages of telehealth and rural staff shortages, there is an urgent need for investment in improved equipment and processes and an understanding of the training needs of the health care workforce to support the use of telehealth in DFD management.

Insoles to ease plantar pressure in people with diabetes and peripheral neuropathy: a feasibility randomised controlled trial with an embedded qualitative study

BACKGROUND

Therapeutic footwear and insoles are preventative strategies to reduce elevated plantar pressures associated with diabetic foot ulcer risk. An insole intervention appropriate for chairside delivery optimising plantar foot pressure reduction in people with diabetes has been developed.

AIM

To explore the feasibility and acceptability of testing an optimised insole compared with an active control insole to reduce plantar pressures for people with diabetic peripheral neuropathy.

METHODS

A double-blinded multi-centre feasibility RCT with an embedded qualitative study. Participants were randomised to either an optimised insole group (intervention) or a standard cushioned insole group (active control). Participants were assessed at baseline, 3, 6, and 12 months with clinical outcomes of foot ulceration and mean peak plantar pressure (MPPP) reduction. An embedded qualitative study involved semi-structured interviews with 12 study participants and three podiatrists to explore their experiences of the intervention and trial procedures. Data were analysed using descriptive statistics (quantitative data) and thematic analysis (qualitative data).

RESULTS

Screened were142 patients from which 61 were recruited; 30 participants were randomised to the intervention group and 31 to the active control group. Forty-two participants completed the study. At 12 months, 69% of the patient-reported questionnaires were returned and 68% of the clinical outcomes were collected. There were 17 incidences of foot ulceration occurring in 7/31 of the active control group and 10/30 in the intervention group. Mean difference in MPPP between the intervention and active control groups for all regions-of-interest combined favoured the intervention. Thematic analysis revealed three themes; accepting the study, behaviour and support during study procedures, and impact from study participation.

CONCLUSION

The results of the feasibility RCT suggest that the optimised insole holds promise as an intervention, and that a full RCT to evaluate the clinical and cost-effectiveness of this intervention is feasible and warranted for people with diabetic peripheral neuropathy.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number: ISRCTN16011830 . Registered 9th October 2017.

The NIDDK Diabetic Foot Consortium

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Diabetic Foot Consortium (DFC) was established in September 2018 by the NIDDK to build an organization to facilitate the highest quality of clinical research on diabetic foot ulcers (DFUs) that will answer clinically significant questions to improve DFU healing and prevent amputations. The initial focus of the DFC is to develop and validate biomarkers for DFUs that can be used in clinical care and research. The DFC consists of a data coordinating center (DCC) for operational oversight and statistical analysis, clinical sites for participant recruitment and evaluation, and biomarker analysis units (BAUs). The DFC is currently studying biomarkers to predict wound healing and recurrence and is collecting biosamples for future studies through a biorepository. The DFC plans to address the challenges of recruitment and eligibility criteria for DFU clinical trials by taking an approach of "No DFU Patient Goes Unstudied." In this platform approach, clinical history, DFU outcome, wound imaging, and biologic measurements from a large number of patients will be captured and the in-depth longitudinal data set will be analyzed to develop a computational-based DFU risk factor profile to facilitate scientifically sound clinical trial design. The DFC will expand its platform to include studies of the role of social determinants of health, such as food insecurity, housing instability, limited health literacy, and poor social support. The DFC is starting partnerships with the broad group of stakeholders in the wound care community.

The amputation and mortality of inpatients with diabetic foot ulceration in the COVID-19 pandemic and postpandemic era: A machine learning study

This study aimed to explore the clinical characteristic and outcomes of inpatients with diabetic foot ulceration (DFU) in 2019 (prelockdown) and 2020 (postlockdown) due to the COVID-19 pandemic, at an emergency medical service unit. Prediction models for mortality and amputation were developed to describe the risk factors using a machine learning-based approach. Hospitalized DFU patients (N = 23) were recruited after the lockdown in 2020 and matched with corresponding inpatients (N = 23) before lockdown in 2019. Six widely used machine learning models were built and internally validated using 3-fold cross-validation to predict the risk of amputation and death in DFU inpatients under the COVID-19 pandemic. Previous DF ulcers, prehospital delay, and mortality were significantly higher in 2020 compared to 2019. Diabetic foot patients in 2020 had higher hs-CRP levels (P = .037) but lower hemoglobin levels (P = .017). The extreme gradient boosting (XGBoost) performed best in all models for predicting amputation and mortality with the highest area under the curve (0.86 and 0.94), accuracy (0.80 and 0.90), sensitivity (0.67 and 1.00), and negative predictive value (0.86 and 1.00). A long delay in admission and a higher risk of mortality was observed in patients with DFU who attended the emergency center during the COVID-19 post lockdown. The XGBoost model can provide evidence-based risk information for patients with DFU regarding their amputation and mortality. The prediction models would benefit DFU patients during the COVID-19 pandemic.

Patients' Perceptions of Reasons Contributing to Delay in Seeking Help at the Onset of a Diabetic Foot Ulcer: A Grounded Theory Study

PURPOSE

The purpose of this study was to explore patients' perception of reasons contributing to delay in seeking help and referral to a wound care specialist at the onset of a diabetic foot ulcer (DFU).

DESIGN

Constructivist grounded theory study.

SUBJECTS AND SETTING

The sample comprised 30 individuals with active DFU attending a wound care clinic in southeastern Ontario, Canada.

METHODS

Participants were selected through purposive and theoretical sampling. Semistructured interviews were conducted with participants until no new properties of the patterns emerged. All interviews were transcribed, coded, and analyzed using methods informed by constructivist grounded theory.

RESULTS

The reasons contributing to delay to seek help and referral to a wound care specialist were (1) limited knowledge about foot care, (2) unaware of diabetic foot problems, (3) underestimation of ulcer presentation, (4) I thought I could fix it myself, (5) inaccurate diagnosis, and (6) trial and error approach by a nonspecialized wound care provider.

CONCLUSIONS

Study findings suggest that patients and primary healthcare providers need additional education regarding the management of diabetic foot disease and DFU.

Delays to revascularization for patients with chronic limb-threatening ischaemia

BACKGROUND

Vascular services in England are organized into regional hub-and-spoke models, with hubs performing arterial surgery. This study examined time to revascularization for chronic limb-threatening ischaemia (CLTI) within and across different care pathways, and its association with postrevascularization outcomes.

METHODS

Three inpatient and four outpatient care pathways were identified for patients with CLTI undergoing revascularization between April 2015 and March 2019 using Hospital Episode Statistics data. Differences in times from presentation to revascularization across care pathways were analysed using Cox regression. The relationship between postoperative outcomes and time to revascularization was evaluated by logistic regression.

RESULTS

Among 16 483 patients with CLTI, 9470 had pathways starting with admission to a hub or spoke hospital, whereas 7013 (42.5 per cent) were first seen at outpatient visits. Among the inpatient pathways, patients admitted to arterial hubs had shorter times to revascularization than those admitted to spoke hospitals (median 5 (i.q.r. 2-10) versus 12 (7-19) days; P < 0.001). Shorter times to revascularization were also observed for patients presenting to outpatient clinics at arterial hubs compared with spoke hospitals (13 (6-25) versus 26 (15-35) days; P < 0.001). Within most care pathways, longer delays to revascularizsation were associated with increased risks of postoperative major amputation and in-hospital death, but the effect of delay differed across pathways.

CONCLUSION

For patients with CLTI, time to revascularization was influenced by presentation to an arterial hub or spoke hospital. Generally, longer delays to revascularization were associated with worse outcomes, but the impact of delay differed across pathways.

Multidisciplinary extremity preservation program improves quality of life for patients with advanced limb threat

INTRODUCTION

The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution.

METHODS

Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions.

RESULTS

From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P<0.044) and emotional role limitation (OR:8.1; P=0.042), while patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P<0.049). Conversely, patients with a smoking history had less improvement in energy level (OR:0.4; P=0.044) and patients with dialysis-dependence had less improvement in social function (OR:0.2; P=0.034).

CONCLUSION

Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Further study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.

Increased Expression of miR-155 in Peripheral Blood and Wound Margin Tissue of Type 2 Diabetes Mellitus Patients Associated with Diabetic Foot Ulcer

PURPOSE

To investigate the correlations of miR-155 expression in the peripheral blood and wound margin tissue of patients with diabetic foot ulcer (DFU) and explore the clinical value of miR-155 as a potential biomarker for the diagnosis and treatment outcomes of DFU.

METHODS

Sixty newly diagnosed T2DM patients without DFU (T2DM group), 112 T2DM patients with DFU (DFU group), and 60 healthy controls (NC group) were included. MiR-155 levels in the peripheral blood and wound margin tissue were determined by quantitative real-time PCR, while clinical features and risk factors of DFU were explored. Multiple stepwise logistic regression analysis was used to determine whether miR-155 expression was an independent risk factor for DFU. The diagnostic effectiveness of miR-155 level on DFU was evaluated using ROC curve analysis.

RESULTS

A significant decrease in the expression level of miR-155 was observed in T2DM group compared with NC group (P < 0.05), while a markedly increased miR-155 expression level was noted in DFU group compared with T2DM group (P < 0.01). Moreover, there was a negative correlation between the expression levels of miR-155 with healing rate of DFU. Kaplan-Meier survival curve analysis showed that the cumulative rate of unhealed DFU in miR-155 high expression group is higher than that in miR-155 low expression group, both in peripheral blood and wound margin tissue (log rank, P = 0.004, P < 0.001, respectively). The multivariate logistic regression analysis confirmed that a high expression of miR-155 was an independent risk factor for DFU. The ROC curve analysis indicated that the AUC of miR-155 for the diagnosis of DFU was 0.794, with the optimum sensitivity being 96.82% and the optimum specificity of 95.93%.

CONCLUSION

The increased expression of miR-155 in peripheral blood of T2DM patients is closely related to the occurrence of DFU. MiR-155 is a potentially valuable biomarker for diagnosis and prognosis of DFU.

Diabetic foot ulcers: Retrospective comparative analysis from Sicily between two eras

Aim

The aim of this study was to analyze changes in the incidence, management and mortality of DFU in Sicilian Type 2 diabetic patients hospitalized between two eras, i.e. 2008–2013 and 2014–2019.

Methods

We compared the two eras, era1: 2008–13, era2: 2014–19. In era 1, n = 149, and in era 2, n = 181 patients were retrospectively enrolled.

Results

In the population hospitalized for DFU in 2008–2013, 59.1% of males and 40.9% of females died, whilst in 2014–2019 65.9% of males and 34.1% of females died. Moderate chronic kidney disease (CKD) was significantly higher in patients that had died than in ones that were alive (33% vs. 43%, p < 0.001), just as CKD was severe (14.5% vs. 4%, p < 0.001). Considering all together the risk factors associated with mortality, at Cox regression multivariate analysis only moderate-severe CKD (OR 1.61, 95% CI 1.07–2.42, p 0.021), age of onset greater than 69 years (OR 2.01, 95% CI 1.37–2.95, p <0.001) and eGFR less than 92 ml/min (OR 2.84, 95% CI 1.51–5.34, p 0.001) were independently associated with risk of death.

Conclusions

Patients with DFU have high mortality and reduced life expectancy. Age at onset of diabetic foot ulcer, eGFR values and CKD are the principal risk factors for mortality.

Impact of nutritional and inflammatory status in patients with critical limb-threatening ischemia

BACKGROUND

A pro-inflammatory state and a poor nutritional status have been associated with severity and prognosis of patients with peripheral arterial disease (PAD). The clinical applicability of the different pre-operative nutritional and inflammatory biomarkers in patients with critical limb-threatening ischemia (CLTI) was analyzed.

METHODS

A retrospective observational study was performed, that included all patients with CLTI revascularized from January 2016 to July 2019. The inflammatory state was calculated using neutrophil/lymphocyte (NLR), lymphocyte/monocyte (LMR) and platelet/lymphocyte ratios (PLR). For nutritional status, the Prognostic Nutritional Index (PNI) was calculated. Mortality and number of major amputations at 6 months and hospital length-of stay were studied.

RESULTS

310 patients were included. Higher levels of NLR and lower levels of PNI were associated with mortality (6.61±5.6 vs. 3.98±3.27, P=0.034; 40.33±7.89 vs. 45.73±7.48, P=0.05, respectively). Lower levels of PNI and LMR (42.57±7.82 vs. 45.44±7.65, P=0.036; 2.77±1.61 vs. 3.22±1.75, P=0.013, respectively) and higher levels of NLR (6.91±7.85 vs. 3.94±2.57, P=0.023) were associated with major amputations. The mean hospital length-of-stay was higher in patients with lower levels of PNI and LMR (P=0.000 and P=0.003) and higher levels of NLR and PLR (P=0.001 and P=0.002). A PNI<42.87 predicted short-term mortality with a 66.7% of sensitivity and a 66.8% of specificity (P=0.000).

CONCLUSIONS

Our experience suggests that these inflammatory and nutritional biomarkers are independent predictors of short-term mortality and major amputations. In addition, our results suggest that PNI could be used to predict the short-term mortality with high sensitivity and specificity.

What is the current practice for managing patients with chronic limb-threatening ischaemia in vascular surgery services? A survey of UK vascular surgeons

INTRODUCTION

The Vascular Society of Great Britain and Ireland (VSGBI) Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) stipulates targets for managing patients with chronic limb-threatening ischaemia (CLTI); however, it is unknown whether these are achievable. This survey aims to evaluate contemporary practice for managing CLTI in the UK.

METHODS

A questionnaire was developed in conjunction with the VSGBI to survey the management of CLTI and canvass opinions on the PAD QIF. The survey was distributed to all consultant members of the VSGBI and through a targeted social media campaign.

RESULTS

Forty-seven consultant vascular surgeons based at 36 arterial centres across the UK responded (response rate from arterial centres = 46%). Only 14.3% of centres provided outpatient consultation within the target of seven days from referral, with only one centre providing revascularisation within the target of seven days from consultation. For inpatient management, 31.6% provided surgical and 23.8% endovascular revascularisation within the target of three days from assessment. While 60% of participants believe the PAD QIF's 5-day 'admitted care' pathway is achievable, only 28.6% thought the 14-day 'non-admitted care' pathway was feasible. Challenges to meeting these targets include the availability of theatre space and angiography lists, and availability of outpatient appointments for patient assessment.

CONCLUSIONS

The opinion of UK vascular surgeons indicates that achieving the targets of the PAD QIF represents a major challenge based upon current services. Adapting existing services with a greater focus on providing an 'urgent' model of care may help to potentially overcome these challenges.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

BACKGROUND

People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.

AIM

To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.

DESIGN & SETTING

Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).

METHOD

Factors precipitating admissions were examined using framework analysis.

RESULTS

Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services - in time and proximity - and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.

CONCLUSION

Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

Innovations in drug delivery for chronic wound healing

Wound healing is a varied and complex process designed to promptly restore standard skin structure, function, and appearance. To achieve this goal, different immune and biological systems participate in coordination through four separate steps, including homeostasis, inflammation, proliferation, and regeneration. Each step involves the function of other cells, cytokines, and growth factors. However, chronic ulcers, which are classified into three types of ulcers, namely vascular ulcers, diabetic ulcers, and pressure ulcers, cannot heal through the mentioned natural stages. It causes mental and physical problems for these people and, as a result, imposes high economic and social costs on society. In this regard, using a system that can accelerate the healing process of such chronic wounds, as an urgent need in the community, should be considered. Therefore, in this study, the innovations of drug delivery systems for the healing of chronic wounds using hydrogels, nanomaterial, and membranes are discussed and reviewed.

Nationwide prevalence and clinical characteristics of inpatient diabetic foot complications: A Peruvian multicenter study

OBJECTIVE

To evaluate the burden of diabetic foot complications amongst inpatients in Peru.

MATERIALS AND METHODS

Cross-sectional multicenter study, performed in public hospitals, in one-day enrollment between October and December 2018.

RESULTS

We included 8346 patients from 39 national hospitals. Diabetic foot (DF) inpatient point prevalence was 2.8% (CI 95% 2.4-3.1), and DF point prevalence among Diabetes Mellitus (DM) inpatients was 18.9% (CI 95% 16.7-21.1). DF prevalence was higher in jungle and coastal hospitals than highlands ones, and there was no difference according to its care complexity level. Of the 234 patients with DF, 73% were males, age average was 62 ± 12 years, with DM mean time duration of 15 ± 9.9 years. Regarding to DF etiology, 91% and 68% had some degree of peripheral neuropathy and peripheral artery disease, respectively. According to the Infectious Diseases Society of America criteria, 61% presented moderate to severe infections, and 40% had bone involvement. Debridement within 48 h was performed in 36% of sepsis cases.

CONCLUSION

Peru has a substantial burden of DF disease, with a greater share of that burden falling on less equipped hospitals in the country's jungle and coastal regions. Interdisciplinary teams and pathways may improve the time of surgical debridement in the highest risk patients.

Associations of Clinical Frailty with Severity of Limb Threat and Outcomes in Chronic Limb-threatening Ischaemia

OBJECTIVE

Investigate the relationship of frailty and severity of chronic limb-threatening ischaemia (CLTI), and their comparative associations with one-year outcomes, in patients presenting to a vascular limb salvage (VaLS) clinic.

METHODS

This retrospective cohort study utilised data collected from a prospectively maintained VaLS clinic database. Patients aged ≥50 presenting to the VaLS clinic with CLTI between February 2018 and April 2019 were included. Frailty was measured using the Clinical Frailty Scale (CFS) and limb threat severity by the Wound, Ischaemia, and foot Infection (WIfI) score. Excessive polypharmacy was defined as ≥10 medications. Anticholinergic burden (ACB) score and Charlson comorbidity index (CCI) were calculated for all patients. The primary outcome measure was a composite endpoint of death or amputation at one-year. Associations with outcome were assessed using Cox regression and reported as hazards ratios (HR) with 95% confidence intervals (CI).

RESULTS

A total of 198 patients were included, with CFS scores available for 190 patients. 98 patients (52%) were frail (CFS ≥5). 127 patients (67%) initially underwent endovascular revascularisation. Excessive polypharmacy was common (55 patients; 28%). Frailty was associated with increased WIfI stage (P = 0.025) as well as age, female sex, CCI score, number of medications, excessive polypharmacy but not ACB score. Frail patients were more frequently managed non-operatively (P = 0.017). Frailty (HR 1.91; 95% CI 1.09, 3.34; P = 0.024) and WIfI stage 4 (HR 3.29; 95%CI 1.23, 8.80; P = 0.018) were associated with death or amputation on univariable analysis. WIfI stage 4 (HR 2.80; 95%CI 1.04, 7.57; P = 0.042) and CCI score (HR 1.21; 95%CI 1.03, 1.41; P = 0.015), but not frailty (HR 1.25; 95%CI 0.67, 2.33; P = 0.474), were independently associated with death or amputation on multivariable analysis.

CONCLUSIONS

Frailty is highly prevalent among CLTI patients and related to severity of limb threat. The CFS may be a useful adjunct to patient risk assessment in CLTI.

Exploring the barriers of patients with diabetic foot complications in China: a qualitative interview study

Background

Patients with diabetic foot complications are associated with high rates of morbidity, disability, and mortality. Through findings of qualitative interviews with patients with this disease, we aimed to explore the barriers they encountered, provide evidence to improve the efficacy of medical services, discuss prevention and treatment strategies for future policymakers, and attract widespread attention from the Chinese society.

Methods

Patients with diabetic foot complications were recruited from three tertiary hospitals in China between July to September 2020. Patients were included who had a clinical diagnosis of diabetic foot complications, were 18 years or older, spoke Chinese as their first language, and were willing to share treatment experiences. An interview guide was used during the in-person semi-structured interviews that lasted 20 to 50 minutes and were audio-recorded. Transcripts were analyzed for qualitative themes.

Results

Forty-one patients (range, 38-79 years; 12 men, 29 women) were recruited. Data analysis indicated five thematic dimensions on barriers encountered by patients with diabetic foot complications: hospital visits, doctor-patient communication, mental burden, economic burden, and social support.

Conclusions

Patients with diabetic foot complications face serious financial, mental, and social burdens in China. Future studies can use the five dimensions to help solve the existing problems and improve treatment outcomes of this patient population.

Factors associated with delays in revascularization in patients with chronic limb-threatening ischaemia: population-based cohort study

BACKGROUND

Prompt revascularization in patients with chronic limb-threatening ischaemia (CLTI) is important, and recent guidance has suggested that patients should undergo revascularization within 5 days of an emergency admission to hospital. The aim of this cohort study was to identify factors associated with the ability of UK vascular services to meet this standard of care.

METHODS

Data on all patients admitted non-electively with CLTI who underwent open or endovascular revascularization between 2016 and 2019 were extracted from the National Vascular Registry. The primary outcome was interval between admission and procedure, analysed as a binary variable (5 days or less, over 5 days). Multivariable Poisson regression was used to examine the relationship between time to revascularization and patient and admission characteristics.

RESULTS

The study analysed information on 11 398 patients (5973 open, 5425 endovascular), 50.6 per of whom underwent revascularization within 5 days. The median interval between admission and intervention was 5 (i.q.r. 2-9) days. Patient factors associated with increased risk of delayed revascularization were older age, greater burden of co-morbidity, non-smoking status, presentation with infection and tissue loss, and a Fontaine score of IV. Patients admitted later in the week were less likely undergo revascularization within 5 days than those admitted on Sundays and Mondays (P < 0.001). Delays were slightly worse among patients having open compared with endovascular procedures (P = 0.005) and in hospitals with lower procedure volumes (P < 0.001).

CONCLUSION

Several factors were associated with delays in time to revascularization for patients with CLTI in the UK, most notably the weekday of admission, which reflects how services are organized. The results support arguments for vascular units providing revascularization to have the resources for a 7-day service.

[Randomized study of tolerability, safety and efficacy of Pletax in intermittent claudication]

AIM

This study was aimed at assessing tolerability, safety and therapeutic efficacy of Pletax® (cilostazol) compared with Trental® (pentoxifylline) in patients with moderate-to-severe intermittent claudication.

PATIENTS AND METHODS

The study included a total of one hundred 40-to-65-year-old patients presenting with confirmed diagnosis of moderate-to-severe intermittent claudication. Depending on the therapeutic regimen, the patients were divided into two groups. Group 1: 50 patients orally took Pletax® (cilostazol) at a dose of 100 mg twice daily 30 minutes before meals or 2 hours after meals together with conventional therapy. Group 2: 50 patients took oral Trental® (pentoxifylline) in a dose of 400 mg 3 times daily 30 minutes before meals or 2 hours after meals along with conventional therapy. The duration of the follow up period amounted to 24 weeks for both groups. The treadmill test was carried out at room temperature, with the running track tilt angle of 0° at a speed of 3 km/h. The primary parameters of efficacy were as follows: the dynamics of the minimal walking distance (a distance walked by the patient until the appearance of pain in the extremity) and dynamics of the maximal walking distance (a distance walked by the patients until full stop due to pain in the extremity).

RESULTS

Analysing efficacy demonstrated higher results of Pletax® compared with Trental®. The obtained findings suggested that Pletax® showed a significant clinical effect as soon as at 2 weeks, followed by advantage during the whole period of follow up. Analysing the parameters of the minimal and maximal walking distances in the group of patients taking Pletax® demonstrated clear superiority over the Trental® group as soon as by week 2 of administration, which preserved during the whole follow-up period. The minimal pain-free walking distance in the Pletax group at baseline amounted to 92.9±83.4 m (Trental group - 92.3±78.4; p=0.3), followed by an increase at week 8 to 126±115 m (Trental group - 116±96.3; p=0.51), at week 16 to 136±116 m (Trental group - 118±95.5; p=0.04), at week 24 to 149±126 b (Trental group - 127±98.9; p=0.01). At the same time, the effect of Pletax® and Trental® on the secondary parameter of efficacy, i.e., the ankle-brachial index was comparable: at baseline - 0.472 and 0.482 (p=0.28), at 2 weeks - 0.48 and 0.483 (p=031), at 8 weeks - 0.49 and 0.485 (p=0.74), at 16 weeks - 0.494 and 0.492 (p=0.2), at 24 weeks - 0.501 and 0.496 (p=0.45).

CONCLUSION

The obtained findings demonstrated advantages of Pletax® over Trental®, manifesting themselves in the achievement of the highest parameters by such criteria as the minimal and maximal walking distance. High safety and efficacy of Pletax® were confirmed by low frequency of unfavourable events during therapy.

[Resuscitative endovascular balloon occlusion of the aorta in haemodynamically unstable patients with bleeding (webinar review)]

This article reviews a webinar of the European Society for Vascular Surgery and the Endovascular Trauma and Resuscitation Management Society, dedicated to using endovascular balloon occlusion of the aorta in haemodynamically unstable patients, briefly covering the main conclusions of the reports and underlining prospects of this method. Possibilities of using aortic balloon occlusion arise interest of various-specialty medical experts, and the number of scientific works in this field has increasingly been growing, thus explaining the need for measures and studies on the subject concerned.

Does the Introduction of a Vascular Limb Salvage Service Improve One Year Amputation Outcomes for Patients with Chronic Limb-Threatening Ischaemia?

OBJECTIVE

Vascular limb salvage services are recommended by the Global Vascular Guidelines to help improve outcomes for patients with chronic limb-threatening ischaemia (CLTI), although their description within the literature is limited. This study reports the 12 month outcomes for an outpatient based vascular limb salvage (VaLS) clinic.

METHODS

An analysis of a prospectively maintained database, involving all consecutive patients diagnosed with CLTI within the VaLS clinic from February 2018-February 2019, was undertaken. Data were compared with two comparator cohorts, identified from coding data: 1) patients managed prior to the clinic, between May 2017 and February 2018 (Pre-Clinic [PC]); and 2) patients managed outside of clinic, between February 2018 and February 2019 (Alternative Pathways [AP]). Freedom from major amputation at 12 months was the primary outcome. Kaplan-Meier plots and adjusted Cox's proportional hazard models (aHR) were used to compare outcomes.

RESULTS

Five hundred and sixty-six patients (VaLS 158, AP 173, PC 235) were included (median age 74 years). Patients managed within the VaLS cohort were statistically significantly more likely to be free from major amputation (90.5%) compared with both the AP (82.1%, aHR 0.52, 95% confidence interval [CI] 0.28 - 0.98, p = .041) and the PC (80.0%; aHR 0.50, 95% CI 0.28 - 0.91, p = .022) cohorts at 12 months, after adjustment for age, disease severity, and presence of diabetes.

CONCLUSION

This study supports the recommendations of the Global Vascular Guidelines that vascular limb salvage clinics may improve the rate of major amputation. Furthermore, the study provides a reproducible service model that delivers timely vascular assessment in an ambulatory setting. Further evaluation is required to assess longer term outcomes.

Association of peripheral artery disease and chronic limb-threatening ischemia with socioeconomic deprivation in people with diabetes: A population data-linkage and geospatial analysis

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation.

Barriers and enablers to providing preventative and early intervention diabetes-related foot care: a qualitative study of primary care healthcare professionals' perceptions

This study explored the perceived healthcare system and process barriers and enablers experienced by GPs and Credentialled Diabetes Educators (CDEs) in Australian primary care, in the delivery of preventative and early intervention foot care to people with diabetes. A qualitative design with inductive analysis approach was utilised and reported according to the Consolidated Criteria for Reporting Qualitative Studies (COREQ). Semi-structured interviews were conducted with two GPs and 14 CDEs from rural, urban and metropolitan areas of Australia. Participants were from New South Wales, South Australia, Victoria, Western Australia, the Northern Territory and Queensland. Barriers to providing foot care constituted five broad themes: (1) lack of access to footcare specialists and services; (2) education and training insufficiencies; (3) human and physical resource limitations related to funding inadequacies; (4) poor care integration such as inadequate communication and feedback across services and disciplines, and ineffectual multidisciplinary care; and (5) deficient footcare processes and guidelines including ambiguous referral pathways. Enablers to foot care were found at opposing ends of the same spectra as the identified barriers or were related to engaging in mentorship programs and utilising standardised assessment tools. This is the first Australian study to obtain information from GPs and CDEs about the perceived barriers and enablers influencing preventative and early intervention diabetes-related foot care. Findings offer an opportunity for the development and translation of effective intervention strategies across health systems, policy, funding, curriculum and clinical practice, in order to improve outcomes for people with diabetes.

Chronic limb-threatening ischaemia and reframing the meaning of 'end'

INTRODUCTION

The possibility of amputation and/or death from chronic limb-threatening ischaemia (CLTI) is real, and deeper understandings of the person and family's capacity and preparedness for limb loss and clinical interventions (active or palliative) are required.

BACKGROUND

The lead-in period to the surgeon's recommendation for amputation for CLTI may be sudden or protracted; the number/invasiveness of previous revascularisation interventions varies, and limb loss and end-of-life considerations frame the experience.

METHOD

This prospective, longitudinal, interpretative phenomenological study in three vascular surgical units involved 19 CLTI journeys. Participants were interviewed when making decisions about amputation (15 patients, 12 family members) and, where applicable, 6-months postamputation (8 patients, 7 family members). Hermeneutic interpretation using Heidegger's philosophical construct of Being-towards-death guided the analysis. The COREQ checklist ensured rigour in research reporting.

FINDINGS

Some participants were unable to face the possibility of death and metaphorically 'fled', either through productive optimism or through hoping for more time (Heidegger's inauthentic positioning towards death). For others, authentic positionings of Being-towards-death were understood as: the confrontation of the certainty of their death by making choices about how to die; the indefiniteness of death where treatment choices influenced timing, yet the time for death remained unknown; the nonrelational nature of death, as the journey could only be lived by the person; and death as not to be outstripped, where for some, there was a freeing of oneself for amputation and/or death.

DISCUSSION

The term 'end of limb' to denote the futility of the limb is a useful marker that emphasises the noncurative nature of CLTI. This may help to instigate and support discussions about end of life to support palliation care planning and the person and family's existential preparation for death.

CONCLUSION

Death frames the experience of CLTI. Using 'end-of-limb' and 'end-of-life' terminology may facilitate a family/patient-centred approach to possible amputation and other conservative or palliative strategies.

RELEVANCE TO CLINICAL PRACTICE

Understanding of CLTI illness experience. Decisions about revascularisation, amputation or conservative care. End-of-life care for CLTI.

The utilisation of vascular limb salvage services in the assessment and management of chronic limb-threatening ischaemia and diabetic foot ulceration: A systematic review

Specialist vascular limb salvage services have gained prominence as a new model of care to help overcome barriers which exist in the management of patients with chronic limb-threatening ischaemia (CLTI) and/or diabetic foot ulceration (DFU). This systematic review aims to explore the nature of reported services, investigate their outcome in the management of CLTI/DFU, and assess the scope and quality of the evidence base to help make recommendations for future practice and research. A systematic search of MEDLINE, Embase, The Cochrane Library, Scopus and CINAHL, from 1st January 1995 to 18th January 2019, was performed. Specialist vascular limb salvage services were defined as those services conforming to the definition of "centres of excellence" within the 2019 Global Vascular Guidelines. A study protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019123325). In total, 2260 articles were screened, with 12 articles (describing 11 services) included in a narrative synthesis. All services ran akin to the "toe-and-flow" model, with a number of services having additional core input from diabetology, microbiology, allied health professionals and/or internal/vascular medicine. Methodological weaknesses were identified within the design of the included articles and only one was deemed of high quality. The inception of services was associated with improved rates of major amputation; however, no significant changes in minor amputation or mortality rates were identified. Further research should adopt more a standardised study design and outcomes measures in order to improve the quality of evidence within the literature.

Engaging patients and caregivers to establish priorities for the management of diabetic foot ulcers

OBJECTIVE

Effective diabetic foot ulcer (DFU) care has been stymied by a lack of input from patients and caregivers, reducing treatment adherence and overall quality of care. Our objectives were to capture the patient and caregiver perspectives on experiencing a DFU and to improve prioritization of patient-centered outcomes.

METHODS

A DFU-related stakeholder group was formed at an urban tertiary care center. Seven group meetings were held across 4 months, each lasting ∼1 hour. The meeting facilitator used semistructured questions to guide each discussion. The topics assessed the challenges of the current DFU care system and identified the outcomes most important to stakeholders. The meetings were audio recorded and transcribed. Directed and conventional content analyses were used to identify key themes.

RESULTS

Six patients with diabetes (five with an active DFU), 3 family caregivers, and 1 Wound Clinic staff member participated in the stakeholder group meetings. The mean patient age was 61 years, four (67%) were women, five (83%) were either African American or Hispanic, and the mean hemoglobin A1c was 8.3%. Of the five patients with a DFU, three had previously required lower extremity endovascular treatment and four had undergone at least one minor foot amputation. Overall, stakeholders described how poor communication between medical personnel and patients made the DFU experience difficult. They felt overwhelmed by the complexity of DFU care and were persistently frustrated by inconsistent medical recommendations. Limited resources further exacerbated their frustrations and barriers to care. To improve DFU management, the stakeholders suggested a centralized healthcare delivery pathway with timely access to a coordinated, multidisciplinary DFU team. The clinical outcomes most valued by stakeholders were (1) avoiding amputation and (2) maintaining or improving health-related quality of life, which included independent mobility, pain control, and mental health. From these themes, we developed a conceptual model to inform DFU care pathways.

CONCLUSIONS

Current DFU management lacks adequate care coordination. Multidisciplinary approaches tailored to the self-identified needs of patients and caregivers could improve adherence. Future DFU-related comparative effectiveness studies will benefit from direct stakeholder engagement and are required to evaluate the efficacy of incorporating patient-centered goals into the design of a multidisciplinary DFU care delivery system.

Recurrence rates suggest delayed identification of plantar ulceration for patients in diabetic foot remission

INTRODUCTION

Foot ulcers are a common and costly complication of diabetes, and delays in treatment can result in impaired healing, infection, hospitalization, and lower extremity amputation.

RESEARCH DESIGN AND METHODS

We aimed to determine whether patterns in plantar diabetic foot ulcer (DFU) recurrence coincided with typical intervals between routine preventive care appointments, which would suggest that delays exist between ulcer development and identification. We completed an analysis of existing data from two multicenter studies in 300 total participants. We analyzed unadjusted counts of DFU binned in weekly intervals and defined 'exam periods' as intervals from 2 to 4 weeks, from 6 to 8 weeks, within 1 week of 3 months and within 1 week of 6 months. We tested whether recurrence rates during exam periods were equivalent to rates outside exam periods. We estimated the delay between DFU development and DFU identification such that the rate of development would have been constant.

RESULTS

During exam periods, a total of 43 DFUs were identified (43/86=50%) despite the fact that these periods represent only 23.5% of follow-up in aggregate. Accounting for censoring, the annualized incidence during exam periods was 0.68 DFU/year (CI 0.48 to 0.89) in contrast to 0.25 DFU/year (CI 0.18 to 0.32) outside exam periods (incidence ratio=2.8, CI 1.8 to 4.3). We estimated delays between DFU occurrence and identification to average 15.3 days (IQR 7.4-23.7 days).

CONCLUSIONS

These findings have potential implications for practice, particularly related to the value of telehealth and in-home monitoring of patients in diabetic foot remission. Additionally, there are implications for study design, which should consider the impact of interval censoring and attempt to control for confounders related to frequency and timing of exams.

Missed Opportunities for Timely Recognition of Chronic Limb Threatening Ischaemia in Patients Undergoing a Major Amputation: A Population Based Cohort Study Using the UK's Clinical Practice Research Datalink

OBJECTIVE

Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aimed to investigate for potential "missed opportunities" within primary care.

METHODS

This was a population based cohort study, using the UK's Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 1 January 2000 and 31 December 2016 were included. Primary care consultation and patient clinical data within the one year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into "recent" (7-90 days before amputation) and "late" (> 91 days).

RESULTS

In total, 3 260 patients were included. In the year prior to amputation, patients attended a median of 19 (range 9-32) primary care consultations; however, prescription of secondary preventive medications was poor (antiplatelet 49.7%; lipid lowering agent 40.7%). Overall, 2 175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2 073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2 073 patients, 1 230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing "late" assessment were younger (p = .003), with higher systolic (p = .008) and diastolic (p = .001) blood pressures than those undergoing "recent" assessment. Differences were also observed between assessment timings by deprivation (p = .003) and ethnicity (p = .006).

CONCLUSION

Missed opportunities for timely recognition potentially exist and may be related to age, deprivation, and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the "at risk" stereotype, are also required.

Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada

BACKGROUND

Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019.

METHODS

Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher's exact test or Chi-square test.

RESULTS

Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved.

CONCLUSION

Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.

Knowledge of peripheral artery disease: What do the public, healthcare practitioners, and trainees know?

This systematic review evaluated the knowledge and awareness of peripheral artery disease (PAD) within the general public (including patients with peripheral vascular disease), nonspecialist healthcare professionals (nsHCP), and trainees (medical students and trainee doctors). Relevant articles were identified from electronic databases using key search terms: ‘peripheral artery disease’; ‘limb ischaemia’; ‘intermittent claudication’; ‘knowledge’; ‘understanding’; ‘public’; ‘medical professional’. The heterogeneous results were described narratively. A lack of knowledge and understanding of PAD (disease awareness) were identified in all groups. Among nsHCPs, factors which affect knowledge include the level of training, early clinical exposure and the presence of family members with cardiovascular/vascular disease. Within the general public, knowledge and awareness was improved if a family member/friend had a diagnosis, or following a patient-centred consultation with any HCP. Public campaigns are proven effective in improving disease knowledge/awareness in conditions such as stroke alongside sustained patient education. These may provide future avenues to improve PAD knowledge and awareness, in order to effectively manage risk factors and minimise delayed or missed diagnosis of PAD. (PROSPERO registration number: CRD42018117304)