Diabetes foot disease: the Cinderella of Australian diabetes management?

Definitive single-stage surgery for treating diabetic foot osteomyelitis: a protocolized pathway including antibiotic bone graft substitute use

BACKGROUND

Diabetic foot ulcers (DFUs) are a challenging complication of diabetes mellitus, often leading to poor clinical outcomes and significant socioeconomic burdens. We evaluated the effectiveness of a definitive single-stage protocolized surgical management pathway, including the use of local antibiotic bone graft substitute, for the treatment of infected DFUs with associated osteomyelitis.

METHODS

A retrospective cohort study was conducted. Medical records were extracted (from January 2017 to December 2020) to establish a database consisting of patients who underwent surgical intervention for the treatment of an infected DFU with osteomyelitis. Patients were divided into conventional (control) and protocolized (intervention) surgical groups depending on the treatment received. Clinical outcomes were assessed over a 12-month follow-up period.

RESULTS

A total of 136 consecutive patients were included (conventional = 33, protocolized = 103). The protocolized group demonstrated a statistically significant reduction in the mean number of operations performed per patient (1.2 vs. 3.5) (P < 0.001) and a shorter accumulative hospital length of stay (12.6 vs. 25.1 days) (P < 0.001) compared to the conventional group. Major amputation rates were significantly lower in the protocolized group (2% vs. 18%) (P < 0.001). Within 12 months of surgical intervention, the protocolized group exhibited an ulcer healing rate of 89%, with a low rate of recurrence (3%).

CONCLUSION

The protocolized surgical pathway, including local antibiotic bone graft substitute use, demonstrated superior outcomes compared to conventional management for the treatment of infected DFUs with osteomyelitis. Further research is needed to evaluate the cost-effectiveness and generalizability of this approach.

Experiences and impact of a rural Australian high-risk foot service: A multiple-methods study

OBJECTIVE

Most podiatry-led high-risk foot services (HRFS) in Australia are located in metropolitan areas or large regional centres. In rural areas, where there are limited specialist services, individuals with diabetes-related foot ulceration are more likely to undergo amputation. This study aimed to explore clinicians' perceptions of a recently implemented HRFS in rural New South Wales, Australia, and compare trends of amputation and hospitalisation prior to and post-implementation of the service.

SETTING

Rural HRFS in Tamworth, New South Wales, Australia.

PARTICIPANTS

Health professionals working within the HRFS were recruited to participate.

DESIGN

This was a multiple-methods study. For the qualitative arm, semi-structured interviews were conducted, which were analysed using a reflexive thematic approach. The quantitative arm of the study utilised a retrospective analytic design which applied an interrupted time series to compare amputation and hospitalisation trends pre- and post-implementation of the HRFS utilising diagnostic and procedural ICD codes.

RESULTS

The qualitative arm of the study derived three themes: (1) navigating the divide, (2) rural community and rural challenges and (3) professional identity. Results of the interrupted time series indicate that there was a downward trend in major amputations following implementation of the HRFS; however, this was not statistically significant.

CONCLUSION

Clinicians were aware of the inequity in DFD outcomes between rural and metropolitan areas and were committed to improving outcomes, particularly with respect to First Nations peoples. Future research will explore service use and amputation rates in the longer term to further evaluate this specialised multidisciplinary care in a rural community.

The financial burden of diabetes-related foot disease in Australia: a systematic review

BACKGROUND

Diabetes-related foot disease (DFD) is a common, costly, and severe complication of diabetes mellitus. DFD is associated with high rates of morbidity and mortality and poses a significant burden on patients, healthcare systems and society. While the detrimental impact of DFD is widely recognised, the precise financial implications of its management in Australia remain unclear due to inconsistent and inconclusive contemporary data. Therefore, the aim of this review was to identify, summarise and synthesise existing evidence to estimate the costs associated with DFD management in Australia.

METHODS

Searches were conducted in MEDLINE, Embase, AMED, CINAHL, Joanna Briggs Institute EBP, and the Cochrane Library from November 2011 to July 2023. Australian studies investigating costs associated with DFD management were eligible for inclusion. Two independent reviewers performed the study selection, data extraction and quality assessment steps. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) checklist was used to assess study quality. A descriptive analysis was performed due to limited existing evidence and large heterogeneity between study populations to conduct meta-analyses.

RESULTS

Three economic evaluations were included in the review. One study was rated as 'poor', one as 'very good' and one as 'excellent' when assessed against the CHEERS checklist. The estimated cost of DFD management varied between studies and comparisons were not possible due to the different methodological approaches and data sources. The studies were unable to provide an overall cost of DFD with respect to all aspects of care as they did not capture the multi-faceted level of care throughout the entire patient journey between sectors and over time.

CONCLUSION

There is limited contemporary evidence for the costs associated with DFD management within Australia, particularly related to direct costs and resource utilisation. Further research into the economic impact of DFD management is needed to inform optimisation of national service delivery and improve health outcomes for individuals with DFD in Australia. Integrating real-world data on impact of clinical interventions with parallel economic evaluation could be a valuable approach for future research, which would offer a more comprehensive understanding of the clinical and economic outcomes beyond solely model-based evaluations.

TRIAL REGISTRATION

PROSPERO Registration No. CRD42022290910.

A Scientometric Analysis and Visualization of Prosthetic Foot Research Work: 2000 to 2022

This study aims to highlight recent research work on topics around prosthetic feet through a scientometric analysis and historical review. The most cited publications from the Clarivate Analytics Web of Science Core Collection database were identified and analyzed from 1 January 2000 to 31 October 2022. Original articles, reviews with full manuscripts, conference proceedings, early access documents, and meeting abstracts were included. A scientometric visualization analysis of the bibliometric information related to the publications, including the countries, institutions, journals, references, and keywords, was conducted. A total of 1827 publications met the search criteria in this study. The related publications grouped by year show an overall trend of increase during the two decades from 2000 to 2022. The United States is ranked first in terms of overall influence in this field (n = 774). The Northwestern University has published the most papers on prosthetic feet (n = 84). Prosthetics and Orthotics International has published the largest number of studies on prosthetic feet (n = 151). During recent years, a number of studies with citation bursts and burst keywords (e.g., diabetes, gait, pain, and sensor) have provided clues on the hotspots of prosthetic feet and prosthetic foot trends. The findings of this study are based on a comprehensive analysis of the literature and highlight the research topics on prosthetic feet that have been primarily explored. The data provide guidance to clinicians and researchers to further studies in this field.

How does the clinical practice of Aotearoa New Zealand podiatrists align with international guidelines for the prevention of diabetes-related foot disease? A cross-sectional survey

BACKGROUND

Given the importance of preventive care for the lower limb in people with diabetes, and the absence of local guidelines in Aotearoa New Zealand (NZ), the aim of this study was to determine the alignment of assessment and management used in the prevention of diabetes-related foot disease by NZ podiatrists to the international prevention guideline recommendations.

METHODS

A 37-item web-based survey was developed using a 5-point Likert scale (0 = always; 5 = never) based on the International Working Group of the Diabetic Foot (IWGDF) 2019 prevention guidelines and included domains on participant demographics, sector, caseloads, guidelines, screening, management, education, and referral. The survey was distributed to NZ podiatrists through the NZ podiatry association and social media. Participants completing > 50% of items were included. The Mann-Whitney U test was used to examine differences between sector subgroups.

RESULTS

Seventy-seven responses (16.3% of the NZ podiatry workforce) were received, of which 52 completed > 50% of items and were included. Of those 52 podiatrists, 73% were from the private sector. Public sector podiatrists reported higher weekly caseloads of patients with diabetes (p = 0.03) and foot ulcers (p < 0.001). The New Zealand Society for the Study of Diabetes (NZSSD) risk stratification pathway and IWGDF guidelines were the two most frequently utilised guidance documents. Participants reported median scores of at least "often" (< 2) for all items in the assessment and management, inspection, examination, and education provision domains for people with a high-risk foot. More than 50% of respondents reported screening more frequently than guideline recommendations for people with a very low to moderate risk foot. Structured education program was only used by 4 (5%) participants. Public sector podiatrists reported greater provision of custom-made footwear (p = 0.04) and multi-disciplinary team care (p = 0.03).

CONCLUSION

NZ podiatrists generally follow international guideline recommendations with respect to screening, self-care education, appropriate footwear, and treatment of risk factors for people at-risk of diabetes-related foot disease. However there may be over-screening of people with very low to medium risk occurring in clinical practice. Increasing access to integrated healthcare, custom-made footwear and structured educational programmes appear to be areas of practice that could be developed in future to help prevent diabetes-related foot disease in NZ.

Prospective randomised placebo-controlled trial assessing the efficacy of silver dressings to enhance healing of acute diabetes-related foot ulcers

AIMS/HYPOTHESIS

Silver dressings are used for their antimicrobial properties but there is limited evidence of clinical benefit when managing diabetes-related foot ulcers (DFUs). We aimed to assess whether silver dressings in acute DFUs increased the proportion of ulcers healed compared with non-silver dressings.

METHODS

In this open-labelled, randomised controlled trial, consecutive individuals who presented to a tertiary multidisciplinary diabetic foot service with a DFU without osteomyelitis or tendon on view of <6 weeks' duration were randomised 1:1 via a computer-generated randomisation process to receive Acticoat (Smith & Nephew, England) dressing (silver group) or dressing without silver (control group) in addition to standard care. Stratified randomisation was performed to ensure that the presence of peripheral arterial disease and infection were equally managed within the two groups. The primary outcome was the proportion of ulcers healed at 12 weeks. Secondary outcomes included time to heal and to 50% ulcer reduction, rates of osteomyelitis and amputation, and need for and duration of antibiotics.

RESULTS

Seventy-six ulcers (55 participants) in the control group and 91 ulcers (63 participants) in the silver group were included. There was no difference in the proportion of ulcers healed by 12 weeks in the control vs silver group (75% vs 69%, p=0.49). After adjustment for presence of peripheral arterial disease, infection and initial ulcer size, silver dressing was not associated with odds of healing (OR 0.92; CI 0.26, 3.22; p=0.53). There was no difference in time to healing, progression to osteomyelitis, need for amputation, or duration of or need for antibiotic treatment.

CONCLUSIONS/INTERPRETATION

In individuals with acute DFUs without osteomyelitis or tendon on view, Acticoat silver dressings did not improve wound healing or reduce need for antibiotics compared with non-silver dressings.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12614001234606 FUNDING: Australian Diabetes Society-unrestricted research award.

Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

BACKGROUND

There are no current Australian guidelines on the prevention of diabetes-related foot ulceration (DFU). A national expert panel aimed to systematically identify and adapt suitable international guidelines to the Australian context to create new Australian evidence-based guidelines on prevention of first-ever and/or recurrent DFU. These guidelines will include for the first-time considerations for rural and remote, and Aboriginal and Torres Strait Islander peoples.

METHODS

The National Health and Medical Research Council procedures were followed to adapt suitable international guidelines on DFU prevention to the Australian health context. This included a search of public databases after which the International Working Group on the Diabetic Foot (IWGDF) prevention guideline was deemed the most appropriate for adaptation. The 16 IWGDF prevention recommendations were assessed using the ADAPTE and GRADE systems to decide if they should be adopted, adapted or excluded for the new Australian guideline. The quality of evidence and strength of recommendation ratings were re-evaluated with reference to the Australian context. This guideline underwent public consultation, further revision, and approval by national peak bodies.

RESULTS

Of the 16 original IWGDF prevention recommendations, nine were adopted, six were adapted and one was excluded. It is recommended that all people at increased risk of DFU are assessed at intervals corresponding to the IWGDF risk ratings. For those at increased risk, structured education about appropriate foot protection, inspection, footwear, weight-bearing activities, and foot self-care is recommended. Prescription of orthotic interventions and/or medical grade footwear, providing integrated foot care, and self-monitoring of foot skin temperatures (contingent on validated, user-friendly and affordable systems becoming available in Australia) may also assist in preventing DFU. If the above recommended non-surgical treatment fails, the use of various surgical interventions for the prevention of DFU can be considered.

CONCLUSIONS

This new Australian evidence-based guideline on prevention of DFU, endorsed by 10 national peak bodies, provides specific recommendations for relevant health professionals and consumers in the Australian context to prevent DFU. Following these recommendations should achieve better DFU prevention outcomes in Australia.

Perceptions of Diet Quality, Advice, and Dietary Interventions in Individuals with Diabetes-Related Foot Ulceration; A Qualitative Research Study

BACKGROUND

Dietary intake is a recognised contributor to healing in diabetes-related foot ulceration (DFU). However, it is currently unknown how individuals with DFU perceive their diet, and what is deemed an acceptable dietary intervention. Therefore, the aims of this study were to explore perceptions of diet quality, previous dietary advice, and dietary interventions in individuals with DFU, and secondly to determine acceptable dietary interventions in individuals with DFU to assist with wound healing.

METHODS

A qualitative study using reflexive thematic analysis was undertaken. Individuals with active or recent history of DFU were recruited from a high-risk foot service. Semi-structured interviews were undertaken.

RESULTS

Nineteen participants were included with three themes identified: A complex relationship with food, perceptions of food, diet and dietitians, and self-management. Dietary misconceptions were common. Self-perceived diet quality varied, with most unaware of how diet could impact wound healing. Many expressed barriers relating to food agency (purchasing, preparing, and accessing food). Participants expressed a strong preference for personalised, face-to-face dietary advice and nutritional supplementation.

CONCLUSIONS

There is a need for personalised dietary re-education and assistance with food agency in this cohort to overcome commonly held misconceptions of diet and improve dietary intake to facilitate wound healing.

The burden of diabetes-related foot disease among older adults in Australia

Diabetes‐related foot disease (DFD) is imposing an enormous burden on the health system and society due to the rapid growth of diabetes worldwide. Given the paucity of robust data on the disease burden of DFD in Australia, this study aimed to estimate the burden of disease due to DFD. The burden of DFD was estimated using the disability‐adjusted life‐years (DALY) approach. Data of 27 931 individuals aged 45 years and older with diabetes residing in New South Wales (NSW) from the 45 and Up Study survey were used in this study by linking it with the emergency department, hospital admissions and the deaths' registry data. The disease burden of DFD was estimated as 8915 DALY in NSW and 27 164 DALY in Australia in 2011. The burden was prominent among males and people aged 65 years and older. Most of the DALY (87%) was attributed to years of life lost or the fatal burden due to diabetes‐related lower limb amputation (DRLEA). The total monetary values of DALY of DFD for NSW and Australia were estimated at approximately AUD 2 billion and AUD 6 billion annually, respectively. Preventative and curative priorities should be given to DRLEA to reduce this burden and target males, especially those aged 65 years and older.

Trends in Diabetes Mortality in Urban and Rural China, 1987-2019: A Joinpoint Regression Analysis

Purpose

Diabetes mellitus is emerging as an epidemic worldwide, and the incidence and prevalence of diabetes have drastically changed in China over the past 30 years, but data on its mortality rate are scarce. This study aimed to analyze the time trends of mortality rates among patients with diabetes in the rural and urban population in China between 1987 and 2019.

Methods

The research data come from China's annual report on national health statistics and the Chinese Health Statistics Yearbook. Age-standardized mortality rates were calculated by using the direct method based on the World Standard Population from the WHO. Joinpoint regression analysis was employed to estimate the annual percent change and average annual percentage changes of mortality rates of diabetes mellitus.

Results

An overall trend for increment in diabetes mortality was observed. The crude mortality rates and age-standardized mortality rates of diabetes for urban and rural residents in China showed a significant increasing trend between 1987 and 2019. Mortality due to diabetes in urban areas has been higher than in rural areas for 30 years. However, due to the rapid increase of rural diabetes mortality in the past decade, the gap between the two gradually narrowed. The age-standardized mortality rates of diabetes increased by about 38.5% in urban areas and 254.9% in rural areas over the whole study period. In addition, the age-standardized mortality rate of females with diabetes was higher than that of males, but this pattern began to change in urban areas in 2012. Finally, the age-standardized mortality rates in the elderly population in China are higher with a faster growth rate, especially in rural areas.

Conclusion

The mortality rate of diabetes is on the rise in China. The rapid growth of the mortality rate of diabetes in rural areas leads to the reduction of the urban-rural gap. Male mortality rates in urban areas have surpassed those of women. At the same time, the mortality rate of diabetes showed obvious elder-group orientation. As China's population ages, the burden of death and disability caused by diabetes and its complications will continue to increase. These results indicate that diabetes has become a significant public health problem in China. Such an effect increases the demand for strategies aimed at the prevention and treatment of diabetes mellitus. In addition to the prevention and intervention of diabetes in high-risk groups, it is also necessary to establish diabetes screening networks to identify patients with mild symptoms. Early detection and timely intervention can effectively reduce the incidence and mortality of diabetes.

The Effect of Structured Exercise Compared with Education on Neuropathic Signs and Symptoms in People at Risk of Neuropathic Diabetic Foot Ulcers: A Randomized Clinical Trial

Background and Objectives: Lifestyle interventions such as exercise prescription and education may play a role in the management of peripheral neuropathy in people with diabetes. The aim of this study was to determine the effect of undertaking an exercise program in comparison with an education program on the signs and symptoms of peripheral neuropathy in people with diabetes at risk of neuropathic foot ulceration. Materials and Methods: Twenty-four adult participants with diabetes and peripheral neuropathy were enrolled in this parallel-group, assessor blinded, randomised clinical trial. Participants were randomly allocated to one of two 8-week lifestyle interventions, exercise or education. The primary outcome measures were the two-part Michigan Neuropathy Screening Instrument (MNSI) and vibratory perception threshold (VPT). Secondary outcome measures included aerobic fitness, balance and lower limb muscular endurance. Results: Participants in both lifestyle interventions significantly improved over time for MNSI clinical signs (MD: −1.04, 95% CI: −1.68 to −0.40), MNSI symptoms (MD: −1.11, 95% CI: −1.89 to −0.33) and VPT (MD: −4.22, 95% CI: −8.04 to −0.40). Although the interaction effects did not reach significance, changes in values from pre to post intervention favoured exercise in comparison to control for MNSI clinical signs (MD −0.42, 95% CI −1.72 to 0.90), MNSI clinical symptoms (MD −0.38, 95% CI −1.96 to 1.2) and VPT (MD −4.22, 95% CI −12.09 to 3.65). Conclusions: Eight weeks of exercise training or lifestyle education can improve neuropathic signs and symptoms in people with diabetes and peripheral neuropathy. These findings support a role for lifestyle interventions in the management of peripheral neuropathy.

Social determinants of diabetes-related foot disease among older adults in New South Wales, Australia: evidence from a population-based study

BACKGROUND

Diabetes-related foot is the largest burden to the health sector compared to other diabetes-related complications in Australia, including New South Wales (NSW). Understanding of social determinants of diabetes-related foot disease has not been definitive in Australian studies. This study aimed to investigate the social determinants of diabetes-related foot disease in NSW.

METHODOLOGY

The first wave of the 45 and Up Study survey data was linked with NSW Admitted Patient Data Collection, Emergency Department Data Collection, and Pharmaceutical Benefits Scheme data resulting in 28,210 individuals with diabetes aged 45 years and older in NSW, Australia. Three outcome variables were used: diabetes-related foot disease (DFD), diabetic foot ulcer (DFU), and diabetic foot infection (DFI). They were classified as binary, and survey logistic regression was used to determine the association between each outcome measure and associated factors after adjusting for sampling weights.

RESULTS

The prevalence of DFD, DFU and DFI were 10.8%, 5.4% and 5.2%, respectively, among people with diabetes. Multivariate analyses revealed that the common factors associated with DFD, DFU and DFI were older age (75 years or more), male, single status, background in English speaking countries, and coming from lower-income households (less than AUD 20,000 per year). Furthermore, common lifestyle and health factors associated with DFD, DFU, and DFI were low physical activity (< 150 min of moderate-to-vigorous physical activity per week), history of diabetes for over 15 years, and having cardiovascular disease.

CONCLUSION

Our study showed that about 1 in 10 adults with diabetes aged 45 years and older in NSW reported DFD. Interventions, including the provision of related health services aimed at reducing all forms of DFD in NSW, are recommended to target older individuals with a long history of diabetes, and coming from lower-income households.

An exploration of the use of 3D printed foot models and simulated foot lesions to supplement scalpel skill training in undergraduate podiatry students: A multiple method study

BACKGROUND

Podiatrists regularly use scalpels in the management of foot pathologies, yet the teaching and learning of these skills can be challenging. The use of 3D printed foot models presents an opportunity for podiatry students to practice their scalpel skills in a relatively safe, controlled risk setting, potentially increasing confidence and reducing associated anxiety. This study evaluated the use of 3D printed foot models on podiatry students' anxiety and confidence levels and explored the fidelity of using 3D foot models as a teaching methodology.

MATERIALS AND METHODS

Multiple study designs were used. A repeated measure trial evaluated the effects of a 3D printed foot model on anxiety and confidence in two student groups: novice users in their second year of podiatry studies (n = 24), and more experienced fourth year students completing a workshop on ulcer management (n = 15). A randomised controlled trial compared the use of the 3D printed foot models (n = 12) to standard teaching methods (n = 15) on students' anxiety and confidence in second year students. Finally, a focus group was conducted (n = 5) to explore final year student's perceptions of the fidelity of the foot ulcer models in their studies.

RESULTS

The use of 3D printed foot models increased both novice and more experienced users' self-confidence and task self-efficacy; however, cognitive and somatic anxiety was only reduced in the experienced users. All changes were considered large effects. In comparison to standard teaching methods, the use of 3D printed foot models had similar decreases in anxiety and increases in confidence measures. Students also identified the use of 3D foot models for the learning of scalpel skills as 'authentic' and 'lifelike' and led to enhanced confidence prior to assessment of skills in more high-risk situations.

CONCLUSION

Podiatry undergraduate programs should consider using 3D printed foot models as a teaching method to improve students' confidence and reduce their anxiety when using scalpels, especially in instances where face-to-face teaching is not possible (e.g., pandemic related restrictions on face-to-face teaching).

Australian guideline on wound classification of diabetes-related foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

BACKGROUND

Wound classification systems are useful tools to characterise diabetes-related foot ulcers (DFU) and are utilised for the purpose of clinical assessment, to promote effective communication between health professionals, and to support clinical audit and benchmarking. Australian guidelines regarding wound classification in patients with DFU are outdated. We aimed to adapt existing international guidelines for wound classification to develop new evidence-based Australian guidelines for wound classification in people with diabetes and DFU.

METHODS

Recommended NHRMC procedures were followed to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines on wound classification to the Australian health context. Five IWGDF wound classification recommendations were evaluated and assessed according to the ADAPTE and GRADE systems. We compared our judgements with IWGDF judgements to decide if recommendations should be adopted, adapted or excluded in an Australian context. We re-evaluated the quality of evidence and strength of recommendation ratings, provided justifications for the recommendation and outlined any special considerations for implementation, subgroups, monitoring and future research in an Australian setting.

RESULTS

After the five recommendations from the IWGDF 2019 guidelines on the classification of DFUs were evaluated by the panel, two were adopted and three were adapted to be more suitable for Australia. The main reasons for adapting, were to align the recommendations to existing Australian standards of care, especially in specialist settings, to maintain consistency with existing recommendations for documentation, audit and benchmarking and to be more appropriate, acceptable and applicable to an Australian context. In Australia, we recommend the use of the SINBAD system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/national/international audit. In contrast to the IWGDF who recommend against usage, in Australia we recommend caution in the use of existing wound classification systems to provide an individual prognosis for a person with diabetes and a foot ulcer.

CONCLUSIONS

We have developed new guidelines for wound classification for people with diabetes and a foot ulcer that are appropriate and applicable for use across diverse care settings and geographical locations in Australia.

Prevalence and Burden of Diabetes-Related Foot Disease in New South Wales, Australia: Evidence from the 45 and Up Study Survey Data Linked with Health Services Data

Diabetes-related foot disease (DFD) is a major public health concern due to the higher risks of hospitalisation. However, estimates of the prevalence of DFD in the general population are not available in Australia. This study aims to estimate the prevalence of DFD and diabetes-related lower-extremity amputation (DLEA) among people aged 45 years and over in New South Wales (NSW), Australia. The NSW 45 and Up Study baseline survey data of 267,086 persons aged 45 years and over, linked with health services' administrative data from 2006 to 2012 were used in our study. Of these, 28,210 individuals had been diagnosed with diabetes, and our study identified 3035 individuals with DFD. The prevalence of DFD, diabetic foot ulcer (DFU), diabetic foot infection (DFI), diabetic gangrene (DG), and DLEA were 10.8% (95%CI: 10.3, 11.2), 5.4% (95% CI: 5.1, 5.8), 5.2% (95%CI: 4.9, 5.5), 0.4% (95%CI: 0.3, 0.5), and 0.9% (95%CI: 0.7, 1.0), respectively. DFD, DFU, DFI, DG, and DLEA were the most common among those who were older, born in Australia, from low-income households (<AUD 20,000), or were without private health insurance. Interventional messages to reduce all forms of DFD should target those who are from high-risk groups.

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

Foot Problems in Patients in Acute Care: A Point-Prevalence Survey

PURPOSE

Determine the prevalence of foot problems in an inpatient population and to describe demographic data, comorbid conditions, and type of footwear worn.

DESIGN

Observational point-prevalence cross-sectional design.

SUBJECTS AND SETTING

The study setting was a 722-bed licensed hospital in Western Australia. A convenience sampling was used to include adults hospitalized in the study setting during the period of data collection.

METHODS

A subset of foot questions, guided by a literature review, and input from foot, wound, diabetes, and psychometric researchers and clinicians, was incorporated into the hospital point-prevalence survey conducted annually for nursing safety and quality. Trained nurses collected data during the 1-day survey. Data were analyzed using descriptive statistics and 2-tailed tests; associations between study variables were analyzed.

RESULTS

Two hundred twenty-one patients participated in the survey; a majority (n = 193, 87%) self-reported at least 1 foot problem. More than half (n = 124) reported 3 foot problems and nearly one-third (n = 67) had 5 or more foot problems. Thick nails, damaged nails, and calluses and corns were the most frequently occurring foot problems. Older participants were more likely to have certain foot problems such as calluses and thick nails. Eleven (5%) participants were admitted to the hospital for a foot-related condition.

CONCLUSION

The majority of foot problems in our study were found to be minor and not the primary admitting diagnosis. However, even minor foot problems can pose a risk of worsening, especially in high-risk populations such as those with diabetes. Thus, detection is critical in overall patient assessment, and nurses play a critical role in assessment and management of minor foot problems through the delivery of skin and nail care and through collaboration with other professionals who provide specialized foot care.

Podiatrist-Delivered Health Coaching to Facilitate the Use of a Smart Insole to Support Foot Health Monitoring in People with Diabetes-Related Peripheral Neuropathy

This trial evaluated the feasibility of podiatrist-led health coaching (HC) to facilitate smart-insole adoption and foot monitoring in adults with diabetes-related neuropathy. Adults aged 69.9 ± 5.6 years with diabetes for 13.7 ± 10.3 years participated in this 4-week explanatory sequential mixed-methods intervention. An HC training package was delivered to podiatrists, who used HC to issue a smart insole to support foot monitoring. Insole usage data monitored adoption. Changes in participant understanding of neuropathy, foot care behaviours, and intention to adopt the smart insole were measured. Focus group and in-depth interviews explored quantitative data. Initial HC appointments took a mean of 43.8 ± 8.8 min. HC fidelity was strong for empathy/rapport and knowledge provision but weak for assessing motivational elements. Mean smart-insole wear was 12.53 ± 3.46 h/day with 71.2 ± 13.9% alerts not effectively off-loaded, with no significant effect for time on usage F(3,6) = 1.194 (p = 0.389) or alert responses F(3,6) = 0.272 (p = 0.843). Improvements in post-trial questionnaire mean scores and focus group responses indicate podiatrist-led HC improved participants’ understanding of neuropathy and implementation of footcare practices. Podiatrist-led HC is feasible, supporting smart-insole adoption and foot monitoring as evidenced by wear time, and improvements in self-reported footcare practices. However, podiatrists require additional feedback to better consolidate some unfamiliar health coaching skills. ACTRN12618002053202.

Training diabetes healthcare practitioners in motivational interviewing: a systematic review

Diabetes presents significant self-care challenges that require sustained motivation. Motivational Interviewing (MI) has substantial support in enhancing motivation for behavioural change, but its effective application in routine healthcare requires practitioners to acquire and use related skills. The aim of this systematic review was to investigate the impact of MI training on MI-related skills of practitioners who provide diabetes healthcare. PubMed, EMBASE and PsycINFO were searched using the terms motivational interviewing, motivation enhancement, and diabetes. Two assessors independently screened titles, abstracts and full texts for papers reporting the impact of MI training on diabetes healthcare practitioners' outcomes. Of 625 abstracts screened, 22 papers from 17 unique studies were included. All 17 studies reported some improvement in MI skills, with 14 finding improvements in more than 50% and three less than 35%. However, the risk of bias and outcome measures varied widely between studies. All studies showed diabetes healthcare practitioners acquired and applied MI skills post-training, to varying levels. Findings suggest training should include education, role play, and ongoing supervision to maintain skills.

Demographics and outcomes of inpatients with diabetic foot ulcers treated conservatively and surgically in a metropolitan hospital network

AIMS

To describe the demographics of patients with diabetic foot ulcers (DFU) and their impact on inpatient management. Secondary outcomes identified relationships of treatment modality with mortality, length of hospital admission, readmissions and post-admission care.

METHODS

Retrospective cohort study including patients with DFU admitted to a hospital network in Melbourne, Australia from 2016 to 2018. Medical records were manually reviewed for acute admission with DFU as a major presenting diagnosis; incidental ulcers and traumatic amputations were excluded. Amputations distal and proximal to the ankle were labelled 'minor' and 'major' respectively. Patients were followed until October 31, 2019.

RESULTS

Of 338 patients, 21 and 148 had major and minor amputations, and 169 were managed conservatively. 94% had ≥1 microvascular and/or macrovascular complication. Conservative management (7 days) was associated with a shorter length of stay (major 18, minor 10 days, p < 0.001). Readmission rates were not significantly different. Mortality was greatest (38%) and survival time shortest (999 days) after major amputation than after either other treatment. Other factors associated with mortality were age and a history of coronary artery disease.

CONCLUSIONS

Early identification and multi-disciplinary management of DFU is essential to reduce the significant morbidity and mortality associated with amputation in these complex patients.

What happens to our amputees? The Darling Downs experience

BACKGROUND

Major lower limb amputation is occasionally required in the management of end-stage pathology where other treatment options have failed. The primary aim of this study was to determine the 30-day and 1-year mortality rates of patients undergoing nontraumatic major lower limb amputation. Secondary aims were to investigate risk factors for poor outcomes, incidence of previous minor amputation, and the rate of subsequent major amputation.

METHODS

All nontraumatic, major lower limb amputations performed at Toowoomba Hospital during an 18-year period were retrospectively reviewed. Mortality data were obtained from the Queensland Registry of Births, Deaths and Marriages. Kaplan-Meier analysis was performed to determine survival after amputation.

RESULTS

A total of 147 patients were included in the study, with 104 undergoing below knee and 43 undergoing above knee amputations. Ten patients identified as having an Aboriginal and Torres Strait Islander background. For all patients, the 30-day mortality was 4.1% and 1-year mortality was 21.1%. For Indigenous patients, 30-day mortality was 10%. Previous minor amputation had occurred in 40 patients. Twenty-nine patients underwent further minor surgery after their initial major amputation, with thirteen requiring subsequent major amputation. Factors that increased mortality risk were the presence of peripheral vascular disease, an American Society of Anesthesiologists score of four and age greater than 65 years.

CONCLUSION

The morbidity and mortality following major lower limb amputation is significant. The findings of this study highlight the importance of preventative measures to minimize the incidence of lower limb amputations in the future.

Diabetes-related foot disease in Australia: a systematic review of the prevalence and incidence of risk factors, disease and amputation in Australian populations

Background

Diabetes-related foot disease (DFD) is a leading cause of global hospitalisation, amputation and disability burdens; yet, the epidemiology of the DFD burden is unclear in Australia. We aimed to systematically review the literature reporting the prevalence and incidence of risk factors for DFD (e.g. neuropathy, peripheral artery disease), of DFD (ulcers and infection), and of diabetes-related amputation (total, minor and major amputation) in Australian populations.

Methods

We systematically searched PubMed and EMBASE databases for peer-reviewed articles published until December 31, 2019. We used search strings combining key terms for prevalence or incidence, DFD or amputation, and Australia. Search results were independently screened for eligibility by two investigators. Publications that reported prevalence or incidence of outcomes of interest in geographically defined Australian populations were eligible for inclusion. Included studies were independently assessed for methodological quality and key data were extracted by two investigators.

Results

Twenty publications met eligibility and were included. There was high heterogeneity for populations investigated and methods used to identify outcomes. We found within diabetes populations, the prevalence of risk factors ranged from 10.0–58.8%, of DFD from 1.2–1.5%, and the incidence of diabetes-related amputation ranged from 5.2–7.2 per 1000 person-years. Additionally, the incidence of DFD-related hospitalisation ranged from 5.2–36.6 per 1000 person-years within diabetes populations. Furthermore, within inpatients with diabetes, we found the prevalence of risk factors ranged from 35.3–43.3%, DFD from 7.0–15.1% and amputation during hospitalisation from 1.4–5.8%.

Conclusions

Our review suggests a similar risk factor prevalence, low but uncertain DFD prevalence, and high DFD-related hospitalisation and amputation incidence in Australia compared to international populations. These findings may suggest that a low proportion of people with risk factors develop DFD, however, it is also possible that there is an underestimation of DFD prevalence in Australia in the few limited studies, given the high incidence of hospitalisation and amputation because of DFD. Either way, studies of nationally representative populations using valid outcome measures are needed to verify these DFD-related findings and interpretations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00447-x.

Silver Sulfadiazine Eradicates Antibiotic-Tolerant Staphylococcus aureus and Pseudomonas aeruginosa Biofilms in Patients with Infected Diabetic Foot Ulcers

Infections are among the most frequent and challenging events in diabetic foot ulcers (DFUs). Pathogenic bacteria growing in biofilms within host tissue are highly tolerant to environmental and chemical agents, including antibiotics. The present study was aimed at assessing the use of silver sulfadiazine (SSD) for wound healing and infection control in 16 patients with DFUs harboring biofilm-growing Staphylococcus aureus and Pseudomonas aeruginosa. All patients received a treatment based on a dressing protocol including disinfection, cleansing, application of SSD, and application of nonadherent gauze, followed by sterile gauze and tibio-breech bandage, in preparation for toilet surgery after 30 days of treatment. Clinical parameters were analyzed by the T.I.M.E. classification system. In addition, the activity of SSD against biofilm-growing S. aureus and P. aeruginosa isolates was assessed in vitro. A total of 16 patients with S. aureus and P. aeruginosa infected DFUs were included in the study. Clinical data showed a statistically significant (p < 0.002) improvement of patients’ DFUs after 30 days of treatment with SSD with significant amelioration of all the parameters analyzed. Notably, after 30 days of treatment, resolution of infection was observed in all DFUs. In vitro analysis showed that both S. aureus and P. aeruginosa isolates developed complex and highly structured biofilms. Antibiotic susceptibility profiles indicated that biofilm cultures were significantly (p ≤ 0.002) more tolerant to all tested antimicrobials than their planktonic counterparts. However, SSD was found to be effective against fully developed biofilms of both S. aureus and P. aeruginosa at concentrations below those normally used in clinical preparations (10 mg/mL). These results strongly suggest that the topical administration of SSD may represent an effective alternative to conventional antibiotics for the successful treatment of DFUs infected by biofilm-growing S. aureus and P. aeruginosa.

Factors influencing Australian podiatrists' behavioural intentions to adopt a smart insole into clinical practice: a mixed methods study

BACKGROUND

Diabetes is the leading cause of lower limb amputation in Australia, costing the Australian health care system an estimated A$1.6 billion annually. Podiatrists are the primary foot health care provider in Australia. Research suggests that health professional attitudes can impact patient utilisation of e-health technologies, such as wearable foot monitoring devices aimed at preventing foot ulceration. The aim of this study was to explore factors that impact the intentions of Australian podiatrists to adopt smart insole foot monitoring technology.

METHODS

A mixed methods explanatory sequential design was undertaken. One hundred and eleven Australian podiatrists completed an online version of the validated Unified Theory of Acceptance and Use of Technology (UTAUT) questionnaire. Multiple regression analysis was used to determine the strongest predictive model of podiatrists' behavioural intention to adopt technology. Additionally, two focus groups were conducted, and thematic analysis was performed to explore podiatrists' perceived barriers and enablers to smart insole adoption.

RESULTS

One hundred and eleven Australian podiatrists completed the online UTAUT questionnaire. The majority of respondents practiced in the private sector (58.6%) and were female (50.5%), with Victoria the most common practice location (39.6%). Significant positive correlations existed between behavioural intention and six psychosocial domains including performance expectancy (r = 0.64, p < 0.001), effort expectancy (r = 0.47, p < 0.001), attitude (r = 0.55, p < 0.001), social influence (r = 0.45, p < 0.001), facilitating conditions (r = 0.36, p < 0.001), and self-efficacy (r = 0.30, p < 0.002). Multiple regression analysis determined that performance expectancy alone was most predictive of behavioural intention to adopt a smart insole into clinical practice (adjusted R2 = 42%, p < 0.001). Qualitative analyses revealed that podiatrists believed that the insole would increase patient knowledge, engagement and self-efficacy. However, concerns were raised about cost, footwear issues and the device's utility with elderly and remote populations.

CONCLUSIONS

Performance expectancy was the most important psychosocial factor predicting the intentions of Australian podiatrists to adopt smart insole foot monitoring technologies. While Australian podiatrists are open to adopting smart insoles into clinical practice, evidence of the device's efficacy is a precursor to adoption. Other perceived barriers to adoption including device cost, compatibility with off-loading, footwear issues and patient age also need to be addressed prior to implementation and clinical adoption.

The outcomes and experience of people receiving community-based nurse-led wound care: A systematic review

AIMS AND OBJECTIVES

To review the literature related to the outcomes and experience of people receiving nurse-led care for chronic wounds in the community.

BACKGROUND

Chronic wounds lead to a poor quality of life and are an economic burden to the Australian healthcare system. A lack of awareness into the significance of chronic wounds leads to limited resources being available to facilitate the provision of evidence-based care. The majority of chronic wounds are managed by nurses in the community, and a better understanding into current models of care is required to inform future practice.

DESIGN

A systematic quantitative literature review.

METHODS

A systematic search was conducted in four electronic databases, and the inclusion criteria were as follows: English language, peer-reviewed, published from 2009-2019 and primary research. The data were compiled into an Excel database for reporting as per the Pickering and Byrne (Higher Education Research & Development, 33, 534.) method of systematic quantitative literature review. This review used the PRISMA checklist. The Mixed Methods Appraisal Tool was used for quality appraisal.

RESULTS

Twelve studies were included in the review. Home nursing care, social community care and nursing within a wound clinic were identified as three types of nurse-led care in the literature. The findings demonstrate that nurse-led care was cost-effective, reported high levels of client satisfaction and contributed to improved wound healing and reduced levels of pain.

CONCLUSIONS

Nurse-led care is a positive experience for people with chronic wounds and leads to better outcomes. The findings suggested a need for further client education and specialised training for healthcare practitioners managing chronic wounds.

RELEVANCE TO CLINICAL PRACTICE

This review demonstrates that nurse-led care for people with chronic wounds in the community is cost-effective and improves client outcomes. Raising awareness into the significance of chronic wounds aims to promote the resources required to facilitate evidence-based care.

Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review

BACKGROUND

Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown.

METHODS

The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self-management; pre-ulcer treatment; orthotic interventions; and foot- and mobility-related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre-ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables.

RESULTS

We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self-care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom-made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot- and mobility-related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting.

CONCLUSIONS

Structured education for patients and health care professionals, callus removal, custom-made therapeutic footwear, and foot- and mobility-related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.

The foot-health of people with diabetes in regional and rural Australia: baseline results from an observational cohort study

Background

There is limited Australian epidemiological research that reports on the foot-health characteristics of people with diabetes, especially within rural and regional settings. The objective of this study was to explore the associations between demographic, socio-economic and diabetes-related variables with diabetes-related foot morbidity in people residing in regional and rural Australia.

Methods

Adults with diabetes were recruited from non-metropolitan Australian publicly-funded podiatry services. The primary variable of interest was the University of Texas diabetic foot risk classification designated to each participant at baseline. Independent risk factors for diabetes-related foot morbidity were identified using multivariable analysis.

Results

Eight-hundred and ninety-nine participants enrolled, 443 (49.3%) in Tasmania and 456 (50.7%) in Victoria. Mean age was 67 years (SD 12.7), 9.2% had type 1 diabetes, 506 (56.3%) were male, 498 (55.4%) had diabetes for longer than 10 years and 550 (61.2%) either did not know the ideal HbA1c target or reported that it was ≥7.0. A majority had peripheral neuropathy or worse foot morbidity (61.0%). Foot morbidity was associated with male sex (OR 2.42, 95% CI 1.82–3.22), duration of diabetes > 20 years (OR 3.25, 95% CI 2.22–4.75), and Tasmanian residence (OR 3.38, 95% CI 2.35–4.86).

Conclusions

A high proportion of the regional Australian clinical population with diabetes seen by the publicly-funded podiatric services in this study were at high risk of future limb threatening foot morbidity, and participants residing in Northern Tasmania are more likely to have worse diabetes-related foot morbidity than those from regional Victoria. Service models should be reviewed to ensure that diabetes-related foot services are appropriately developed and resourced to deliver interdisciplinary evidence-based care.

Amputations in patients with diabetic foot ulcer: a retrospective study from a single centre in the Northern Territory of Australia

BACKGROUND

Lower extremity amputations (LEAs) in diabetic patients are common in the indigenous population. There is no published data from the Northern Territory.

METHODS

All patients with diabetic foot ulcer, presenting for the first time to the multi-disciplinary foot clinic at Royal Darwin Hospital, between January 2003 and June 2015, were included. These patients were followed until 2017, or death. LEA rates over the follow-up period and the risk factors were studied.

RESULTS

Of the 513 included patients, 62.8% were males and 48.2% were indigenous. The majority (93.6%) had type 2 diabetes with median diabetes duration of 7.0 years (interquartile range 3-12). During the follow-up period of 5.8 years (interquartile range 3.1-9.8), a total of 435 LEAs (16.6% major; 34.7% minor) occurred in 263 patients (mean age 57.0 ± 11.8 years). In multivariate analysis, the following variables were associated with LEAs (adjusted odds ratio (95% confidence interval)): prior LEA (4.49 (1.69-11.9)); peripheral vascular disease (2.67 (1.27-5.59)); forefoot ulcer (7.72 (2.61-22.7)); Wagner grade 2 (3.71 (1.87-7.36)); and Wagner grade 3 (17.02 (3.77-76.72)). Indigenous patients were 1.8 times more likely to have LEAs than non-indigenous patients. Indigenous amputees were approximately 9 years younger than their non-indigenous counterparts.

CONCLUSION

Half of patients presenting with diabetic foot ulcer had LEA during follow-up. Prior LEAs, peripheral vascular disease, forefoot ulcers and higher Wagner grades were independent risk factors for LEA. Indigenous patients were at higher risk for LEAs and were younger at the time of amputation.

Reasons for (non-)adherence to self-care in people with a diabetic foot ulcer

We aimed to explore reasons for (non-)adherence to self-care among people with diabetic foot ulcers, as well as barriers and solutions to improving their self-care adherence. We performed a qualitative study, recruiting people with a diabetic foot ulcer from a community diabetic foot clinic. Semistructured interviews were held with participants. Data saturation occurred after 9 and was confirmed after 11 participant interviews. Interviews were audio-taped, transcribed verbatim and analyzed using the framework approach. Findings were mapped and the World Health Organization's (WHO) adherence dimensions were applied to themes identified. The key themes identified were (1) participants performed recommended practices in self-care; (2) participants relied heavily on care support; (3) motivations for self-care came from "staying well"; and (4) there was a disparity between self-care knowledge and understanding. Barriers identified included poor mobility and visibility, difficulty wearing offloading devices or using wound dressings, and frustration with lack of progress. Solutions to improve adherence included integrating self-care as routine, improved education, more external help and improving visibility. All five WHO adherence dimensions played a role in (non-)adherence to diabetic foot ulcer self-care. We conclude that adherence to recommended diabetic foot ulcer self-care was limited at best, and reasons for nonadherence were multidimensional. Based on the factors related to (non-)adherence and the barriers and solutions described, we suggest clinicians obtain a broad view of a person's situation when aiming to improve self-care adherence.

Where do we stand? The availability and efficacy of diabetes related foot health programs for Aboriginal and Torres Strait Islander Australians: a systematic review

Background

Aboriginal and Torres Islander Australians experience considerably higher rates of diabetes and diabetes related foot complications and amputations than non-Indigenous Australians. Therefore there is a need to identify aspects of Aboriginal and Torres Islander focussed foot health programs that have had successful outcomes in reducing diabetes related foot complications. Wider knowledge and implementation of these programs may help reduce the high burden of diabetes related foot disease experienced by Aboriginal and Torres Islander Australians.

Methods

PubMeD, Informit Indigenous collection, CINAHL, SCOPUS, the Cochrane Library and grey literature sources were searched to 28th August 2018. We included any published reports or studies of stand-alone diabetes related foot care interventions, programs, services, educational resources or assessment of these interventions, designed for Aboriginal and Torres Strait Islander Australians.

Results

Thirteen studies detailing interventions in the Northern Territory, New South Wales, Queensland and Western Australia met the inclusion criteria. Five reports described delivery of podiatry services while the other eight investigated educational and training programs. Half of the reports related to aspects of the Indigenous Diabetic Foot program which provides culturally appropriate foot education and training workshops for health care providers. One article reported quantitative data related to clinical patient outcome measures.

Conclusions

No state- or nation-wide foot health programs for prevention of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians were identified. One program achieved high adherence to the national guidelines regarding timing of podiatry review treatments through use of an evidence based foot risk classification tool and provision of services in a culturally appropriate centre.

Relationship between Body Mass Index and T-Scores of Bone Mineral Density in the Hip and Spine Regions among Older Adults with Diabetes: A Retrospective Review

Diabetes mellitus (DM) cases are increasing worldwide, especially in Saudi Arabia. Previous studies suggested a positive relationship between body mass index (BMI) and bone mineral density (BMD) levels. Generally, patients with low BMI (<18.5 kg/m²) have reduced BMD levels and, thus, low T-scores; hence, they are categorized as osteopenic or osteoporotic. In this study, we aimed to determine whether a relationship between BMI and BMD T-scores in the hip and spine regions of patients with diabetes exists. This retrospective record review investigated older adult patients with diabetes in King Abdulaziz University Hospital (n=198; age 50-90 years) who underwent BMD scan between January 1, 2016, and June 25, 2018, regardless of their sex but limited to type 2 DM. The height and weight of all subjects were recorded, and BMI was calculated and categorized. We used SPSS version 21 for data analysis; measures of central tendencies, Pearson's correlations, chi-square tests, and independent t-tests were employed. We found positive relationships between BMI and BMD T-scores in the hip and spine regions (right femoral neck: R=+0.214, P ≤ 0.002; total right hip: R=+0.912, P ≤ 0.001; left femoral neck: R=+0.939, P ≤ 0.001; total left hip: R=+0.885, P ≤ 0.001; and total lumbar region: R=+0.607, P ≤ 0.001). Low BMI (<18.5 kg/m²) could be a risk factor for osteoporosis, whereas normal/high BMI could be protective against osteoporosis among adults with diabetes.

High-Resolution Spectral Analysis Accurately Identifies the Bacterial Signature in Infected Chronic Foot Ulcers in People With Diabetes

Diabetic foot infections are a major cause of hospitalization, and delayed treatment can lead to numerous complications. The aim of this research was to investigate high-resolution spectroscopy of the wound center and periwound area for real-time estimation of multispectral signature of bacteria at the base of diabetic foot ulcers. We investigated the spectrum of the reflected visual light from diabetic foot ulcers and developed a method that identifies the presence of bacteria in the wound infections. We undertook a prospective pilot study on 18 patients with type 1 and type 2 diabetes and chronic diabetic foot ulcers. The spectral coefficients were directly compared with the results from the wound swab. The results of the multispectral analysis demonstrated 100% sensitivity, with 100% negative predictive values of identifying the presence of the bacteria, which was the cause of the infection in the wound. The results of our study suggest that the changes in the multispectral properties of the wound can be used to identify the presence of bacteria in the infected area using a noninvasive device without any contact with the wound. This technique holds great promise for real-time objective evaluation of the wound infection status beyond the standard visual assessment of diabetic foot ulcers.

Diabetic Foot Australia guideline on footwear for people with diabetes

Background

The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes.

Methods

We reviewed new footwear publications, (inter)national guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations.

Result

We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate- or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate- or high-risk of foot ulceration to wear their footwear at all times, both indoors and outdoors. (6) Motivate people with diabetes at intermediate- or high-risk of foot ulceration (or their relatives and caregivers) to check their footwear, each time before wearing, to ensure that there are no foreign objects in, or penetrating, the footwear; and check their feet, each time their footwear is removed, to ensure there are no signs of abnormal pressure, trauma or ulceration. (7) For people with a foot deformity or pre-ulcerative lesion, consider prescribing medical grade footwear, which may include custom-made in-shoe orthoses or insoles. (8) For people with a healed plantar foot ulcer, prescribe medical grade footwear with custom-made in-shoe orthoses or insoles with a demonstrated plantar pressure relieving effect at high-risk areas. (9) Review prescribed footwear every three months to ensure it still fits adequately, protects, and supports the foot. (10) For people with a plantar diabetic foot ulcer, footwear is not specifically recommended for treatment; prescribe appropriate offloading devices to heal these ulcers.

Conclusions

This guideline contains 10 key recommendations to guide health professionals in selecting the most appropriate footwear to meet the specific foot risk needs of an individual with diabetes.

Plantar pressures are elevated in people with longstanding diabetes-related foot ulcers during follow-up

Objective

High plantar pressures are implicated in the development of diabetes-related foot ulcers. Whether plantar pressures remain high in patients with chronic diabetes-related foot ulcers over time is uncertain. The primary aim of this study was to compare plantar pressures at baseline and three and six months later in participants with chronic diabetes-related foot ulcers (cases) to participants without foot ulcers (controls).

Methods

Standardised protocols were used to measure mean peak plantar pressure and pressure-time integral at 10 plantar foot sites (the hallux, toes, metatarsals 1 to 5, mid-foot, medial heel and lateral heel) during barefoot walking. Measurements were performed at three study visits: baseline, three and six months. Linear mixed effects random-intercept models were utilised to assess whether plantar pressures differed between cases and controls after adjusting for age, sex, body mass index, neuropathy status and follow-up time. Standardised mean differences (Cohen’s d) were used to measure effect size.

Results

Twenty-one cases and 69 controls started the study and 16 cases and 63 controls completed the study. Cases had a higher mean peak plantar pressure at several foot sites including the toes (p = 0.005, Cohen’s d = 0.36) and mid-foot (p = 0.01, d = 0.36) and a higher pressure-time integral at the hallux (p<0.001, d = 0.42), metatarsal 1 (p = 0.02, d = 0.33) and mid-foot (p = 0.04, d = 0.64) compared to controls throughout follow-up. A reduction in pressure-time integral at multiple plantar sites over time was detected in all participants (p<0.05, respectively).

Conclusions

Plantar pressures assessed during gait are higher in diabetes patients with chronic foot ulcers than controls at several plantar sites throughout prolonged follow-up. Long term offloading is needed in diabetes patients with diabetes-related foot ulcers to facilitate ulcer healing.

Epidemiology of diabetic foot disease and diabetes-related lower-extremity amputation in Australia: a systematic review protocol

BACKGROUND

Diabetic foot disease is associated with major morbidity, mortality, costs, and reduction of a person's quality of life. Investigating the epidemiology of diabetic foot disease is the backbone of diabetic foot research and clinical practice, yet the full burden of diabetic foot disease in Australia is unknown. This study aims to describe the protocol for a systematic review of the epidemiology of diabetic foot disease and diabetes-related lower-extremity amputation in Australia.

METHODS-SEARCH

The systematic review will be performed according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed and EMBASE will be searched for publications in any language and without restrictions to date. Two independent investigators will screen publications for eligibility, with publications reporting Australian population-based incidence or prevalence of diabetic foot disease or diabetes-related lower-extremity amputation to be included. Additionally, a forward literature search will be performed in Google Scholar, and a grey literature search will be performed to identify government publications.

METHODS-ASSESSMENT

Quality assessment will be performed using customised checklists. The summary statistic used for each study will be an incidence or prevalence proportion of diabetic foot disease or diabetes-related lower-extremity amputation. The standard error for each proportion will be calculated. A meta-analysis will be performed when three or more publications of adequate quality, reporting on similar outcomes and in similar populations, are identified.

DISCUSSION

The results of this systematic review can be used to adequately inform stakeholders in the field of diabetic foot disease on the extent of the problem in incidence and prevalence of diabetic foot disease in Australia, and to help guide appropriate use of resources to reduce the burden of this disease.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016050740.

The financial burden of surgical and endovascular treatment of diabetic foot wounds

OBJECTIVE

The cost of treating diabetes-related disease in New Zealand is increasing and is expected to reach New Zealand dollars (NZD) 1.8 billion in 2021. The financial burden attached to the treatment of diabetic foot wounds is difficult to quantify and reported costs of treatment vary greatly in the literature. As of yet, no study has captured the true total cost of treating a diabetic foot wound. In this study, we investigate the total minimum cost of treating a diabetic foot ulcer at a tertiary institution.

METHODS

A retrospective audit of hospital and interhospital records was performed to identify adult patients with diabetes who were treated operatively for a diabetic foot wound by the department of vascular surgery at Auckland Hospital between January 2009 and June 2014. Costs from the patients' admissions and outpatient clinics from their first meeting to the achievement of a final outcome were tallied to calculate the total cost of healing the wound. The hospital's expenses were calculated using a fully absorbed activity-based costing methodology and correlated with a variety of demographic and clinical factors extracted from patients' electronic records using a general linear mixed model.

RESULTS

We identified 225 patients accounting for 265 wound episodes, 700 inpatient admissions, 815 outpatient consultations, 367 surgical procedures, and 248 endovascular procedures. The total minimum cost to the Auckland city hospital was NZD 10,217,115 (NZD 9,886,963 inpatient costs; NZD 330,152 outpatient costs). The median cost per wound episode was NZD 29,537 (NZD 28,491 inpatient costs; NZD 834 outpatient cost). Wound healing was achieved in 70% of wound episodes (average length of healing, 9 months); 19% of wounds had not healed before the patient's death. Of every 3.5 wound episodes, one required a major amputation. Wound treatment modality, particularly surgical management, was the strongest predictor of high resource utilization. Wounds treated with endovascular intervention and no surgical intervention cost less. Surgical management (indiscriminate of type) was associated with faster wound healing than wounds managed endovascularly (median duration, 140 vs 224 days). Clinical risk factors including smoking, ischemic heart disease, hypercholesterolemia, hypertension, and chronic kidney disease did not affect treatment cost significantly.

CONCLUSIONS

We estimate the minimum median cost incurred by our department of vascular surgery in treating a diabetic foot wound to be NZD 30,000 and identify wound treatment modality to be a significant determinant of cost. While readily acknowledging our study's inherent limitations, we believe it provides a real-world representation of the minimum total cost involved in treating diabetic foot lesions in a tertiary center. Given the increasing rate of diabetes, we believe this high cost reinforces the need for the establishment of a multidisciplinary diabetic foot team in our region.

The silent overall burden of foot disease in a representative hospitalised population

The aims of this study were to investigate the point prevalence, and associated independent factors, for foot disease (ulcers, infections and ischaemia) in a representative hospitalised population. We included 733 (83%) of 883 eligible adult inpatients across five representative Australian hospitals on one day. We collected an extensive range of self-reported characteristics from participants. We examined all participants to clinically diagnose foot disease (ulcers, infections and ischaemia) and amputation procedures. Overall, 72 participants (9·8%) [95% confidence interval (CI):7·2-11·3%] had foot disease. Foot ulcers, in 49 participants (6·7%), were independently associated with peripheral neuropathy, peripheral arterial disease, previous foot ulcers, trauma and past surgeon treatment (P < 0·05). Foot infections, in 24 (3·3%), were independently associated with previous foot ulcers, trauma and past surgeon treatment (P < 0·01). Ischaemia, in 33 (4·5%), was independently associated with older age, smokers and past surgeon treatment (P < 0·01). Amputation procedures, in 14 (1·9%), were independently associated with foot infections (P < 0·01). We found that one in every ten inpatients had foot disease, and less than half of those had diabetes. After adjusting for diabetes, factors linked with foot disease were similar to those identified in diabetes-related literature. The overall inpatient foot disease burden is similar in size to well-known medical conditions and should receive similar attention.

Remote ischaemic conditioning in the context of type 2 diabetes and neuropathy: the case for repeat application as a novel therapy for lower extremity ulceration

An emerging treatment modality for reducing damage caused by ischaemia–reperfusion injury is ischaemic conditioning. This technique induces short periods of ischaemia that have been found to protect against a more significant ischaemic insult. Remote ischaemic conditioning (RIC) can be administered more conveniently and safely, by inflation of a pneumatic blood pressure cuff to a suprasystolic pressure on a limb. Protection is then transferred to a remote organ via humoral and neural pathways. The diabetic state is particularly vulnerable to ischaemia–reperfusion injury, and ischaemia is a significant cause of many diabetic complications, including the diabetic foot. Despite this, studies utilising ischaemic conditioning and RIC in type 2 diabetes have often been disappointing. A newer strategy, repeat RIC, involves the repeated application of short periods of limb ischaemia over days or weeks. It has been demonstrated that this improves endothelial function, skin microcirculation, and modulates the systemic inflammatory response. Repeat RIC was recently shown to be beneficial for healing in lower extremity diabetic ulcers. This article summarises the mechanisms of RIC, and the impact that type 2 diabetes may have upon these, with the role of neural mechanisms in the context of diabetic neuropathy a focus. Repeat RIC may show more promise than RIC in type 2 diabetes, and its potential mechanisms and applications will also be explored. Considering the high costs, rates of chronicity and serious complications resulting from diabetic lower extremity ulceration, repeat RIC has the potential to be an effective novel advanced therapy for this condition.

A cost-effectiveness analysis of optimal care for diabetic foot ulcers in Australia

In addition to affecting quality of life, diabetic foot ulcers (DFUs) impose an economic burden on both patients and the health system. This study developed a Markov model to analyse the cost-effectiveness of implementing optimal care in comparison with the continuation of usual care for diabetic patients at high risk of DFUs in the Australian setting. The model results demonstrated overall 5-year cost savings (AUD 9100·11 for those aged 35-54, $9391·60 for those aged 55-74 and $12 394·97 for those aged 75 or older) and improved health benefits measured in quality-adjusted life years (QALYs) (0·13 QALYs, 0·13 QALYs and 0·16 QALYs, respectively) for high-risk patients receiving optimal care for DFUs compared with usual care. Total cost savings for Australia were estimated at AUD 2·7 billion over 5 years. Probabilistic sensitivity analysis showed that optimal care always had a higher probability of costing less and generating more health benefits. This study provides important evidence to inform Australian policy decisions on the efficient use of health resources and supports the implementation of evidence-based optimal care in Australia. Furthermore, this information is of great importance for comparable developed countries that could reap similar benefits from investing in these well-known evidence-based strategies.

Gait parameters of people with diabetes-related neuropathic plantar foot ulcers

BACKGROUND

Foot ulceration associated with diabetic peripheral neuropathy is a global concern. Biomechanical investigation allows the identification of gait abnormalities that may adversely affect ulcer healing. The objective of this case-control study was to compare the gait parameters of cases with diabetes-related foot ulcers to controls.

METHODS

Three-dimensional movement analyses were performed on 21 people with diabetes-related neuropathic plantar foot ulcers (cases), 69 people with diabetes without a foot ulcer history (diabetes controls) and 56 healthy controls. Outcome data were reported as mean differences, 95% confidence intervals and Cohen's d effect sizes. Binary logistic regressions were used to adjust for age, sex and body mass index.

FINDINGS

People with foot ulcers had a smaller plantar flexion (Cohen's d=-0.6 vs. diabetes controls and d=-0.8 vs. healthy controls), knee flexion (d=-0.6 vs. diabetes controls and d=-1.0 vs. healthy controls) and pelvic obliquity (d=-0.9 vs. diabetes controls and d=-0.7 vs. healthy controls) (all P<0.05). They also had a significantly greater range of anterior-posterior ground reaction force (d=1.0 vs. diabetes controls and d=1.7 vs. healthy controls) and total vertical ground reaction force (d=0.9 vs. diabetes controls and d=1.1 vs. healthy controls) and significantly slower walking speed and smaller step length compared to controls (all P<0.05).

INTERPRETATION

People with plantar foot ulcers have considerably different gait parameters to controls. Whether the observed gait parameters contributed to the ulcer development or are a response to the ulcer is currently unclear and needs further investigation.

Prevalence and Risk Factors of Lower Limb Amputation in Patients with End-Stage Renal Failure on Dialysis: A Systematic Review

Background. Renal dialysis has recently been recognised as a risk factor for lower limb amputation (LLA). However, exact rates and associated risk factors for the LLA are incompletely understood. Aim. Prevalence and risk factors of LLA in end-stage renal failure (ESRF) subjects on renal dialysis were investigated from the existing literature. Methods. Published data on the subject were derived from MEDLINE, PubMed, and Google Scholar search of English language literature from January 1, 1980, to July 31, 2015, using designated key words. Results. Seventy studies were identified out of which 6 full-text published studies were included in this systematic review of which 5 included patients on haemodialysis alone and one included patients on both haemodialysis and peritoneal dialysis. The reported findings on prevalence of amputation in the renal failure on dialysis cohort ranged from 1.7% to 13.4%. Five out of the six studies identified diabetes as the leading risk factor for amputation in subjects with ESRF on renal dialysis. Other risk factors identified were high haemoglobin A1c, elevated c-reactive protein, and low serum albumin. Conclusions. This review demonstrates high rate of LLA in ESRF patients receiving dialysis therapy. It has also identified diabetes and markers of inflammation as risk factors of amputation in ESRF subjects on dialysis.

Direct inpatient burden caused by foot-related conditions: a multisite point-prevalence study

OBJECTIVE

The aims of this point-prevalence study were to investigate a representative inpatient population to determine the prevalence of people admitted to hospital for the reason of a foot-related condition, and identify associated independent factors.

METHODS

Participants were adult inpatients in 5 different representative hospitals, admitted for any reason on the day of data collection. Maternity, mental health and cognitively impaired inpatients were excluded. Participants were surveyed on a range of self-reported demographic, social determinant, medical history, foot disease history, self-care, footwear, past foot treatment prior to hospitalisation and reason for admission variables. Physical examinations were performed to clinically diagnose a range of foot disease and foot risk factor variables. Independent factors associated with being admitted to hospital for the primary or secondary reason of a foot-related condition were analysed using multivariate logistic regression.

RESULTS

Overall, 733 participants were included; mean (SD) age 62 (19) years, male 55.8%. Foot-related conditions were the primary reason for admission in 54 participants (7.4% (95% CI 5.7% to 9.5%)); 36 for foot disease (4.9%), 15 foot trauma (2.1%). Being admitted for the primary reason of a foot-related condition was independently associated with foot infection, critical peripheral arterial disease, foot trauma and past foot treatment by a general practitioner and surgeon (p<0.01). Foot-related conditions were a secondary reason for admission in 28 participants (3.8% (2.6% to 5.6%)), and were independently associated with diabetes and current foot ulcer (p<0.01).

CONCLUSIONS

This study, the first in a representative inpatient population, suggests the direct inpatient burden caused by foot-related conditions is significantly higher than previously appreciated. Findings indicate 1 in every 13 inpatients was primarily admitted because of a foot-related condition with most due to foot disease or foot trauma. Future strategies are recommended to investigate and intervene in the considerable inpatient burden caused by foot-related conditions.

Non-traumatic lower limb amputation in patients with end-stage renal failure on dialysis: an Australian perspective

BACKGROUND

End-stage renal failure (ESRF) and dialysis have been identified as a risk factor for lower limb amputations (LLAs). High rate of ESRF amongst the Australian population has been reported, however till date no study has been published identifying magnitude and risk factors of LLA in subjects on renal dialysis.

OBJECTIVE

The study aims to document trends in the prevalence and identify risk factors of non-traumatic LLA in Australian patients on dialysis.

METHODS

A retrospective review of all patients (218) who attended the regional dialysis center between 1st January 2009 and 31st December 2013 was conducted. Demographic, clinical and biochemical data were analyzed.

RESULTS

We identified a high prevalence of 13.3% of LLAs amongst Australian patients with ESRF on dialysis at our center. The associated risk factors were the presence of diabetes (OR 1.67 [1.49-1.88] p < 0.001), history of foot ulceration (OR 81 [18.20-360.48] p < 0.001), peripheral arterial disease (OR 31.29 [9.02-108.56] p < 0.001), peripheral neuropathy (OR 31.29 [9.02-108.56] p < 0.001), foot deformity (OR 23.62 [5.82-95.93] p < 0.001), retinopathy (OR 6.08 [2.64-14.02] p < 0.001), dyslipidemia (OR 4.6 [1.05-20.05] p= 0.049) and indigenous background (OR 3.39 [1.38-8.33] p= 0.01). 75% of the amputees had aboriginal heritage. We also identified higher HbA1c and CRP levels as well as low serum albumin, hemoglobin and vitamin D levels to have a strong association with LLAs (p < 0.05).

CONCLUSION

There is high prevalence of LLAs amongst Australian indigenous patients with diabetes on dialysis in North Queensland. Other strongly associated risk factors include history of foot ulceration, foot deformity and peripheral neuropathy as well as high HbA1c levels and low serum albumin levels.

Improved wound management at lower cost: a sensible goal for Australia

Chronic wounds cost the Australian health system at least US$2·85 billion per year. Wound care services in Australia involve a complex mix of treatment options, health care sectors and funding mechanisms. It is clear that implementation of evidence-based wound care coincides with large health improvements and cost savings, yet the majority of Australians with chronic wounds do not receive evidence-based treatment. High initial treatment costs, inadequate reimbursement, poor financial incentives to invest in optimal care and limitations in clinical skills are major barriers to the adoption of evidence-based wound care. Enhanced education and appropriate financial incentives in primary care will improve uptake of evidence-based practice. Secondary-level wound specialty clinics to fill referral gaps in the community, boosted by appropriate credentialing, will improve access to specialist care. In order to secure funding for better services in a competitive environment, evidence of cost-effectiveness is required. Future effort to generate evidence on the cost-effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision-making activities, reduce health care costs and improve patient outcomes.

Prevalence of foot disease and risk factors in general inpatient populations: a systematic review and meta-analysis

OBJECTIVE

To systematically review studies reporting the prevalence in general adult inpatient populations of foot disease disorders (foot wounds, foot infections, collective 'foot disease') and risk factors (peripheral arterial disease (PAD), peripheral neuropathy (PN), foot deformity).

METHODS

A systematic review of studies published between 1980 and 2013 was undertaken using electronic databases (MEDLINE, EMBASE and CINAHL). Keywords and synonyms relating to prevalence, inpatients, foot disease disorders and risk factors were used. Studies reporting foot disease or risk factor prevalence data in general inpatient populations were included. Included study's reference lists and citations were searched and experts consulted to identify additional relevant studies. 2 authors, blinded to each other, assessed the methodological quality of included studies. Applicable data were extracted by 1 author and checked by a second author. Prevalence proportions and SEs were calculated for all included studies. Pooled prevalence estimates were calculated using random-effects models where 3 eligible studies were available.

RESULTS

Of the 4972 studies initially identified, 78 studies reporting 84 different cohorts (total 60 231 517 participants) were included. Foot disease prevalence included: foot wounds 0.01-13.5% (70 cohorts), foot infections 0.05-6.4% (7 cohorts), collective foot disease 0.2-11.9% (12 cohorts). Risk factor prevalence included: PAD 0.01-36.0% (10 cohorts), PN 0.003-2.8% (6 cohorts), foot deformity was not reported. Pooled prevalence estimates were only able to be calculated for pressure ulcer-related foot wounds 4.6% (95% CI 3.7% to 5.4%)), diabetes-related foot wounds 2.4% (1.5% to 3.4%), diabetes-related foot infections 3.4% (0.2% to 6.5%), diabetes-related foot disease 4.7% (0.3% to 9.2%). Heterogeneity was high in all pooled estimates (I(2)=94.2-97.8%, p<0.001).

CONCLUSIONS

This review found high heterogeneity, yet suggests foot disease was present in 1 in every 20 inpatients and a major risk factor in 1 in 3 inpatients. These findings are likely an underestimate and more robust studies are required to provide more precise estimates.