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Liew H, Bates M, Vas P, Rashid H, Kavarthapu V, Edmonds M, Manu C. Resource use within a multidisciplinary foot team clinic. J Wound Care 2022; 31:154-161. [PMID: 35148630 DOI: 10.12968/jowc.2022.31.2.154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The establishment of multidisciplinary foot team clinics reduces the risk of amputation, but little is known about its resource requirement. This study evaluates the service's resource use for first visit attendees to an established multidisciplinary foot team clinic. METHOD A retrospective evaluation was performed for new referrals to the clinic over six months, including demographics, resource use and clinical outcome. Data were extracted electronically with retrospective review of electronic clinical notes. RESULTS A total of 240 first visit attendees were analysed. Mean age was 64±15years, 63% were male, 72% had type 2 diabetes, 16% had type 1 diabetes, 15% had a previous amputation, and 40% had a previous ulceration. Common presentations were ulcers (62%), osteomyelitis (11%), Charcot foot (19%), foot ischaemia (17%), post-surgical wounds (13%), and osteomyelitis (11%). At first attendance, 79% of patients required specialist services including diabetologist (45%), joint vascular review (23%), joint orthopaedics services (8%), dermatologist (2%), and orthotics services (1%). A total of 4% of patients had complex debridement, 0.4% total nail excision, 0.8% pus drainage, 3% cast-related procedures, and 1% vacuum-assisted dressing. Of the patients, 4% were admitted to hospital, 38% had vascular duplex investigations, 7% had a deep vein thrombosis scan, 16% had magnetic resonance imagine (MRI), and 5% had a bone scan. CONCLUSION A functional multidisciplinary foot team clinic requires significant resources-both clinical and administrative-for prompt investigations and revascularisation to sustain low amputation rates. Regular appraisal of resource use helps with clinic and pathway planning.
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Affiliation(s)
- Huiling Liew
- Diabetic Foot Clinic, King's College Hospital, UK.,Department of Diabetes and Endocrinology, Tan Tock Seng Hospital, Singapore
| | | | | | | | | | | | - Chris Manu
- Diabetic Foot Clinic, King's College Hospital, UK
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Sharma V, Sharma D, Dinar H, Dhatariya KK. Myositis ossificans in the diabetic foot: a review of the literature with an illustrative case series. JRSM Open 2019; 10:2054270419885231. [PMID: 31839972 PMCID: PMC6902400 DOI: 10.1177/2054270419885231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Objective Myositis ossificans is a rare non-neoplastic form of heterotopic ossification most commonly described after trauma or surgery, in the diabetic foot. Design We provide a review of the literature including three illustrative cases. Participants Individuals presenting to the foot clinic. Setting Single centre, tertiary multidisciplinary specialist diabetes foot clinic. Results We review the literature surrounding Myositis ossificans, and describe three cases of Myositis ossificans following foot surgery in people with diabetes. All of the imaging was consistent with the descriptions of Myositis ossificans reported elsewhere in large muscle groups. These are the first reports of Myositis ossificans occurring in the feet of people with diabetes. Conclusions Myositis ossificans has only very rarely been described in the foot and, as far as we are aware, never in people with diabetes. Given that the prevalence of diabetes is increasing, and the foot problems requiring surgery are also rising, we suggest that clinicians should be more aware of this condition because it may occur more frequently.
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Affiliation(s)
- Vivek Sharma
- University College London Medical School, London WC1E 6BT, UK
| | - Dhiraj Sharma
- North Manchester General Hospital, Pennine Acute Hospitals NHS Trust, Manchester M8 5RB, UK
| | - Heather Dinar
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK
| | - Ketan K Dhatariya
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, UK.,Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
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Fry W, McCafferty S, Gooday C, Nunney I, Dhatariya KK. Assessing the Effect of Piperacillin/Tazobactam on Hematological Parameters in Patients Admitted with Moderate or Severe Foot Infections. Diabetes Ther 2018; 9:219-228. [PMID: 29302933 PMCID: PMC5801243 DOI: 10.1007/s13300-017-0357-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Piperacillin/tazobactam is a commonly used antibiotic for the empirical treatment of severe diabetic foot infections. One of the most feared complications of this drug is the development of pancytopenia. The aim of this study was to determine whether the use of piperacillin/tazobactam caused any hematological changes in patients admitted with severe diabetes-related foot infections from a specialist multidisciplinary foot clinic. Specifically, looking at whether it caused anemia, leukopenia, neutropenia, or thrombocytopenia. METHODS A 1-year retrospective analysis of patients admitted to a tertiary care center for treatment of diabetes-related foot infection using piperacillin/tazobactam. Hematological indices, urea and electrolytes, and C-reactive protein (CRP) were recorded pretreatment, during treatment, and posttreatment. HbA1c, vitamin B12, folate, thyroid-stimulating hormone, and free thyroxin were also analyzed to exclude any potential confounders as a cause of pancytopenia. RESULTS A total of 154 patients were admitted between 1 January 2016 and 31 December 2016 who received piperacillin/tazobactam for severe diabetes-related foot infection. On admission, white cell count and CRP were raised and fell significantly within the first 48 h. Other hematological factors did not change. Five patients developed a mild pancytopenia, of which three were unexplained. CONCLUSION In this relatively small cohort, pancytopenia did not occur. As such, piperacillin/tazobactam appeared to have a low risk of adverse hematological outcomes and remains the treatment of choice for severe diabetes-related foot infections.
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Affiliation(s)
- Will Fry
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Sean McCafferty
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Catherine Gooday
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
| | - Ian Nunney
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Ketan K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK.
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
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Petrakis I, Kyriopoulos IJ, Ginis A, Athanasakis K. Losing a foot versus losing a dollar; a systematic review of cost studies in diabetic foot complications. Expert Rev Pharmacoecon Outcomes Res 2017; 17:165-180. [DOI: 10.1080/14737167.2017.1305891] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Ioannis Petrakis
- National School of Public Health, Health Economics Department, Athens, Greece
| | - Ilias J Kyriopoulos
- National School of Public Health, Health Economics Department, Athens, Greece
| | | | - Kostas Athanasakis
- National School of Public Health, Health Economics Department, Athens, Greece
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Gu Y, Kokar C, Gooday C, Morrow D, Dhatariya K. A 5-Year Follow-up Study to Assess Clinical Outcomes of Patients with Diabetes Undergoing Lower Limb Angiography for Significant Peripheral Artery Disease. Diabetes Ther 2015; 6:481-493. [PMID: 26386883 PMCID: PMC4674466 DOI: 10.1007/s13300-015-0131-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION The optimal management for patients with diabetes and peripheral vascular disease-intermittent claudication or critical limb ischemia (CLI)-remains undetermined. METHODS In a single-center retrospective analysis, we compared 1- and 5-year amputation-free survival rates in patients undergoing angiography subsequently treated with medical therapy or revascularization. RESULTS 78 patients were included, 56 with CLI (mean age 77 years); 22 with claudication (mean age 75 years). Of the CLI cohort, 30 patients were medically treated. Their 1-year amputation-free survival rate was similar to those treated with revascularization (46.7% versus 50.0%, respectively). 8 patients in the claudicant cohort were treated conservatively. The 1-year amputation-free survival rate was 75.0% for conservative treatment versus 78.6% in those revascularized. Within the CLI cohort, in those conservatively treated 20% underwent major, and 16.7% minor amputations, compared to 15.4% and 23.1% in those revascularized. At 5 years in the claudicant cohort, the amputation-free survival rate was 37.5% with medical treatment, versus 71.4% for those treated with revascularization. For CLI, the 5-year amputation-free survival rate was 10% for conservative treatment, versus 26.9% for revascularization. CONCLUSION We found similar rates of amputation at 1 year for patients treated medically or revascularized. However, at 5 years, the amputation-free survival rate was markedly higher in revascularized patients compared to those medically managed. Our study highlights the potential role of predicting life expectancy when considering treatment, with the option of surgical treatment offered to those in whom survival is predicted to be longer than 5 years. However, larger studies with matched cohorts are now needed to confirm these findings.
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Affiliation(s)
- Yisu Gu
- Department of Medicine, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
| | - Chatchai Kokar
- St. George's University School of Medicine, Grenada, West Indies
| | - Catherine Gooday
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
| | - Darren Morrow
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
- Department of Vascular Surgery, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
| | - Ketan Dhatariya
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
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Zeun P, Gooday C, Nunney I, Dhatariya K. Predictors of Outcomes in Diabetic Foot Osteomyelitis Treated Initially With Conservative (Nonsurgical) Medical Management. INT J LOW EXTR WOUND 2015; 15:19-25. [DOI: 10.1177/1534734615596892] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The optimal way to manage diabetic foot osteomyelitis remains uncertain, with debate in the literature as to whether it should be managed conservatively (ie, nonsurgically) or surgically. We aimed to identify clinical variables that influence outcomes of nonsurgical management in diabetic foot osteomyelitis. We conducted a retrospective study of consecutive patients with diabetes presenting to a tertiary center between 2007 and 2011 with foot osteomyelitis initially treated with nonsurgical management. Remission was defined as wound healing with no clinical or radiological signs of osteomyelitis at the initial or contiguous sites 12 months after clinical and/or radiological resolution. Nine demographic and clinical variables including osteomyelitis site and presence of foot pulses were analyzed. We identified 100 cases, of which 85 fulfilled the criteria for analysis. After a 12-month follow-up period, 54 (63.5%) had achieved remission with nonsurgical management alone with a median (interquartile range) duration of antibiotic treatment of 10.8 (10.1) weeks. Of these, 14 (26%) were admitted for intravenous antibiotics. The absence of pedal pulses in the affected foot (n = 34) was associated with a significantly longer duration of antibiotic therapy to achieve remission, 8.7 (7.1) versus 15.9 (13.3) weeks ( P = .003). Osteomyelitis affecting the metatarsal was more likely to be amputated than other sites of the foot ( P = .016). In line with previous data, we have shown that almost two thirds of patients presenting with osteomyelitis healed without undergoing surgical bone resection.
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Affiliation(s)
- Paul Zeun
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Catherine Gooday
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Crilly J, Keijzers G, Tippett V, O’Dwyer J, Lind J, Bost N, O’Dwyer M, Shiels S, Wallis M. Improved outcomes for emergency department patients whose ambulance off-stretcher time is not delayed. Emerg Med Australas 2015; 27:216-24. [PMID: 25940975 PMCID: PMC4676924 DOI: 10.1111/1742-6723.12399] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe and compare characteristics and outcomes of patients who arrive by ambulance to the ED. We aimed to (i) compare patients with a delayed ambulance offload time (AOT) >30 min with those who were not delayed; and (ii) identify predictors of an ED length of stay (LOS) of >4 h for ambulance-arriving patients. METHODS A retrospective, multi-site cohort study was undertaken in Australia using 12 months of linked health data (September 2007-2008). Outcomes of AOT delayed and non-delayed presentations were compared. Logistic regression analysis was undertaken to identify predictors of an ED LOS of >4 h. RESULTS Of the 40 783 linked, analysable ambulance presentations, AOT delay of >30 min was experienced by 15%, and 63% had an ED LOS of >4 h. Patients with an AOT <30 min had better outcomes for: time to triage; ambulance time at hospital; time to see healthcare professional; proportion seen within recommended triage time frame; and ED LOS for both admitted and non-admitted patients. In-hospital mortality did not differ. Strong predictors of an ED LOS >4 h included: hospital admission, older age, triage category, and offload delay >30 min. CONCLUSION Patients arriving to the ED via ambulance and offloaded within 30 min experience better outcomes than those delayed. Given that offload delay is a modifiable predictor of an ED LOS of >4 h, targeted improvements in the ED arrival process for ambulance patients might be useful.
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Affiliation(s)
- Julia Crilly
- Department of Emergency Medicine, Gold Coast Hospital and Health ServiceGold Coast, Queensland, Australia
- Menzies Health Institute Queensland, Griffith UniversityGold Coast, Queensland, Australia
| | - Gerben Keijzers
- Department of Emergency Medicine, Gold Coast Hospital and Health ServiceGold Coast, Queensland, Australia
- School of Medicine, Griffith University and Bond UniversityGold Coast, Queensland, Australia
| | - Vivienne Tippett
- School of Clinical Science, Queensland University of TechnologyBrisbane, Queensland, Australia
| | - John O’Dwyer
- Australian eHealth Research Centre, CSIROBrisbane, Queensland, Australia
| | - James Lind
- Department of Emergency Medicine, Gold Coast Hospital and Health ServiceGold Coast, Queensland, Australia
| | - Nerolie Bost
- Department of Emergency Medicine, Gold Coast Hospital and Health ServiceGold Coast, Queensland, Australia
| | - Marilla O’Dwyer
- Australian eHealth Research Centre, CSIROBrisbane, Queensland, Australia
| | - Sue Shiels
- Department of Emergency Medicine, Logan HospitalLoganholme, Queensland, Australia
| | - Marianne Wallis
- Menzies Health Institute Queensland, Griffith UniversityGold Coast, Queensland, Australia
- School of Nursing and Midwifery, University of Sunshine CoastMaroochydore, Queensland, Australia
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Gooday C, Murchison R, Dhatariya K. An analysis of clinical activity, admission rates, length of hospital stay, and economic impact after a temporary loss of 50% of the non-operative podiatrists from a tertiary specialist foot clinic in the United Kingdom. Diabet Foot Ankle 2013; 4:21757. [PMID: 24040488 PMCID: PMC3772317 DOI: 10.3402/dfa.v4i0.21757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/02/2013] [Accepted: 08/03/2013] [Indexed: 11/14/2022]
Abstract
Introduction Podiatrists form an integral part of the multidisciplinary foot team in the treatment of diabetic foot–related complications. A set of unforeseen circumstances within our specialist diabetes foot service in the United Kingdom caused a loss of 50% of our non-operative podiatry team for almost 7 months during 2010. Some of this time was filled by non-specialist community non-operative podiatrists. Methods We assessed the economic impact of this loss by examining data for the 5 years prior to this 7-month interruption, and for the 2 years after ‘normal service’ was resumed. Results Our data show that the loss of the non-operative podiatrists led to a significant rise in the numbers of admissions into hospital, and hospital length of stay also increased. At our institution a single bed day cost is £275. During the time that the numbers of specialist non-operative podiatry staff were depleted, and for up to 6 months after they returned to normal activities, the extra costs increased by just less than £90,000. The number of people admitted directly from specialist vascular and orthopaedic clinics is likely to have increased due to the lack of capacity to manage them in the diabetic foot clinic. Our data were unable to assess these individuals and did not look at the costs saved from avoiding surgery. Thus the actual costs incurred are likely to be higher. Conclusions Our data suggest that specialist non-operative podiatrists involved in the treatment of the diabetic foot may prevent unwarranted hospital admission and increased hospitalisation rates by providing skilled assessment and care in the outpatient clinical settings.
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Affiliation(s)
- Catherine Gooday
- Diabetic Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals National Health Service Foundation Trust, Norwich, Norfolk, UK
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Abstract
Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. Unchecked, infection can spread contiguously to involve underlying tissues, including bone. A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.
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Affiliation(s)
- Edgar J G Peters
- Department of Internal Medicine, VU University Medical Center, Room ZH4A35, PO Box 7057, Amsterdam NL-1007MB, The Netherlands.
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