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Lazzarini PA, Raspovic A, Prentice J, Commons RJ, Fitridge RA, Charles J, Cheney J, Purcell N, Twigg SM. Australian evidence-based guidelines for the prevention and management of diabetes-related foot disease: a guideline summary. Med J Aust 2023; 219:485-495. [PMID: 37872875 DOI: 10.5694/mja2.52136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 08/23/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Diabetes-related foot disease (DFD) - foot ulcers, infection, ischaemia - is a leading cause of hospitalisation, disability, and health care costs in Australia. The previous 2011 Australian guideline for DFD was outdated. We developed new Australian evidence-based guidelines for DFD by systematically adapting suitable international guidelines to the Australian context using the ADAPTE and GRADE approaches recommended by the NHMRC. MAIN RECOMMENDATIONS This article summarises the most relevant of the 98 recommendations made across six new guidelines for the general medical audience, including: prevention - screening, education, self-care, footwear, and treatments to prevent DFD; classification - classifications systems for ulcers, infection, ischaemia and auditing; peripheral artery disease (PAD) - examinations and imaging for diagnosis, severity classification, and treatments; infection - examinations, cultures, imaging and inflammatory markers for diagnosis, severity classification, and treatments; offloading - pressure offloading treatments for different ulcer types and locations; and wound healing - debridement, wound dressing selection principles and wound treatments for non-healing ulcers. CHANGES IN MANAGEMENT AS A RESULT OF THE GUIDELINE For people without DFD, key changes include using a new risk stratification system for screening, categorising risk and managing people at increased risk of DFD. For those categorised at increased risk of DFD, more specific self-monitoring, footwear prescription, surgical treatments, and activity management practices to prevent DFD have been recommended. For people with DFD, key changes include using new ulcer, infection and PAD classification systems for assessing, documenting and communicating DFD severity. These systems also inform more specific PAD, infection, pressure offloading, and wound healing management recommendations to resolve DFD.
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Affiliation(s)
- Peter A Lazzarini
- Queensland University of Technology, Brisbane, QLD
- Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, QLD
| | | | | | - Robert J Commons
- Grampians Rural Health Alliance, Ballarat, VIC
- Menzies School of Research, Charles Darwin University, Darwin, NT
| | - Robert A Fitridge
- Royal Adelaide Hospital, Adelaide, SA
- University of Adelaide, Adelaide, SA
| | - James Charles
- First Peoples Health Unit, Griffith University, Gold Coast, QLD
| | | | - Nytasha Purcell
- Diabetes Feet Australia, Australian Diabetes Society, Sydney, NSW
| | - Stephen M Twigg
- University of Sydney, Sydney, NSW
- Royal Prince Alfred Hospital, Sydney, NSW
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Brocklehurst JD. The Validity and Reliability of the SINBAD Classification System for Diabetic Foot Ulcers. Adv Skin Wound Care 2023; 36:1-5. [PMID: 37861669 DOI: 10.1097/asw.0000000000000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
ABSTRACT Diabetic foot ulcers (DFUs) are a serious and costly complication of diabetes mellitus with a global prevalence of 6.3% and cost of £8,800 per unhealed DFU in the National Health Service. The three main types of DFU are neuropathic, ischemic, and neuroischemic, with an estimated prevalence of 35%, 15%, and 50%, respectively. Because 85% of lower-limb amputations in patients with diabetes are preceded by a DFU, the task of reducing the current and future burden of DFUs on an international level is of crucial importance. Classification of a DFU is an important and complex process with many independent variables that influence the wound severity. Correct classification of a DFU is important to prevent deterioration in the short term and lower-limb amputation in the long term. Both the accuracy of the clinician's interpretation of categorical data from a classification model and grasp of contextual risk factors can refine diagnoses. The term SINBAD is an acronym for six independent variables: site, ischemia, neuropathy, bacterial infection, area, and depth. This system uses comprehensive parameters with strict criteria to facilitate quick and accurate clinical decisions to prevent lower-limb amputation. In addition to providing quantitative measurement, SINBAD also spotlights the multifaceted characteristics of DFUs. By evaluating the validity and reliability of the SINBAD classification system, its applicability for the assessment of DFUs and prevention of lower-limb amputation can be better understood.
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Affiliation(s)
- Jonathan D Brocklehurst
- Jonathan D. Brocklehurst, BSc, is Lecturer and Podiatrist, The SMAE Institute, Maidenhead, Berkshire, UK. The author has disclosed no financial relationships related to this article. Submitted September 21, 2022; accepted in revised form December 9, 2022
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Matijević T, Talapko J, Meštrović T, Matijević M, Erić S, Erić I, Škrlec I. Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes. World J Clin Cases 2023; 11:1669-1683. [PMID: 36970006 PMCID: PMC10037285 DOI: 10.12998/wjcc.v11.i8.1669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.
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Affiliation(s)
- Tatjana Matijević
- Department of Dermatology and Venereology, University Hospital Center Osijek, Osijek 31000, Croatia
| | - Jasminka Talapko
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Tomislav Meštrović
- University Centre Varaždin, University North, Varaždin 42000, Croatia
- Institute for Health Metrics and Evaluation and the Department for Health Metrics Sciences, University of Washington School of Medicine, Seattle, WA 98195, United States
| | - Marijan Matijević
- Department of Surgery, National Memorial Hospital Vukovar, Vukovar 32000, Croatia
| | - Suzana Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Radiotherapy and Oncology, Clinical Hospital Center Osijek, Osijek 31000, Croatia
| | - Ivan Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Surgery, Osijek University Hospital Centre, Osijek 31000, Croatia
| | - Ivana Škrlec
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
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Commons RJ, Charles J, Cheney J, Lynar SA, Malone M, Raby E. Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:47. [PMID: 35676695 PMCID: PMC9178854 DOI: 10.1186/s13047-022-00545-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetes-related foot infections cause substantial morbidity and mortality, both globally and in Australia. There is a need for up-to-date evidence-based guidelines to ensure optimal management of patients with diabetes-related foot infections. We aimed to identify and adapt high quality international guidelines to the Australian context to become the new Australian evidence-based guideline for people with a diabetes-related foot infection. METHODS Following Australian National Health and Medical Research Council (NHMRC) procedures we identified the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines as suitable for adaptation to the Australian context. Guidelines were screened, assessed and judged by an expert panel for the Australian context using the guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Judgements led to recommendations being adopted, adapted or excluded, with additional consideration regarding their implementation, monitoring and future research for the Australian context. Clinical pathways were then developed to assist implementation. RESULTS Of 36 original diabetes-related foot infection IWGDF sub-recommendations, 31 were adopted, four were adapted and one was excluded. Adaption was primarily undertaken due to differences or clarification of the sub-recommendations' intended population. One sub-recommendation was excluded due to substantial differences in judgements between the panel and IWGDF and unacceptable heterogeneity of the target population. Therefore, we developed 35 evidence-based sub-recommendations for the Australian context that should guide best practice diagnosis and management of people with diabetes-related foot infection in Australia. Additionally, we incorporated these sub-recommendations into two clinical pathways to assist Australian health professionals to implement these evidence-based sub-recommendations into clinical practice. The six guidelines and the full protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/ . CONCLUSIONS A new national guideline for the diagnosis and management of people with diabetes-related foot infections were successfully developed for the Australian context. In combination with simplified clinical pathway tools they provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections across Australia and highlight considerations for implementation and monitoring.
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Affiliation(s)
- Robert J Commons
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia.
- Internal Medical Services, Ballarat Health Services, Ballarat, Australia.
| | - James Charles
- First Peoples Health Unit, Faculty of Health Griffith University, Gold Coast, Australia
| | | | - Sarah A Lynar
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Infectious Diseases Unit, Royal Darwin Hospital, Darwin, Australia
| | - Matthew Malone
- South West Sydney Limb Preservation and Wound Research, South Western Sydney LHD, Liverpool, Sydney, Australia
- Infectious Diseases and Microbiology, School of Medicine Western Sydney University, Campbelltown Campus, Sydney, Australia
| | - Edward Raby
- Infectious Diseases Department, Royal Perth Hospital, Perth, Australia
- Department of Microbiology, Fiona Stanley Hospital Network, PathWest Laboratory Medicine, Murdoch, Australia
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Fernando ME, Horsley M, Jones S, Martin B, Nube VL, Charles J, Cheney J, Lazzarini PA. Australian guideline on offloading treatment for foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:31. [PMID: 35513821 PMCID: PMC9069804 DOI: 10.1186/s13047-022-00538-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/11/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Pressure offloading treatment is critical for healing diabetes-related foot ulcers (DFU). Yet the 2011 Australian DFU guidelines regarding offloading treatment are outdated. A national expert panel aimed to develop a new Australian guideline on offloading treatment for people with DFU by adapting international guidelines that have been assessed as suitable to adapt to the Australian context. METHODS National Health and Medical Research Council procedures were used to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines to the Australian context. We systematically screened, assessed and judged all IWGDF offloading recommendations using best practice ADAPTE and GRADE frameworks to decide which recommendations should be adopted, adapted or excluded in the Australian context. For each recommendation, we re-evaluated the wording, quality of evidence, strength of recommendation, and provided rationale, justifications and implementation considerations, including for geographically remote and Aboriginal and Torres Strait Islander peoples. This guideline, along with five accompanying Australian DFU guidelines, underwent public consultation, further revision and approval by ten national peak bodies (professional organisations). RESULTS Of the 13 original IWGDF offloading treatment recommendations, we adopted four and adapted nine. The main reasons for adapting the IWGDF recommendations included differences in quality of evidence ratings and clarification of the intervention(s) and control treatment(s) in the recommendations for the Australian context. For Australians with plantar DFU, we recommend a step-down offloading treatment approach based on their contraindications and tolerance. We strongly recommend non-removable knee-high offloading devices as first-line treatment, removable knee-high offloading devices as second-line, removable ankle-high offloading devices third-line, and medical grade footwear as last-line. We recommend considering using felted foam in combination with the chosen offloading device or footwear to further reduce plantar pressure. If offloading device options fail to heal a person with plantar DFU, we recommend considering various surgical offloading procedures. For people with non-plantar DFU, depending on the type and location of the DFU, we recommend using a removable offloading device, felted foam, toe spacers or orthoses, or medical grade footwear. The six new guidelines and the full protocol can be found at: https://diabetesfeetaustralia.org/new-guidelines/ . CONCLUSIONS We have developed a new Australian evidence-based guideline on offloading treatment for people with DFU that has been endorsed by ten key national peak bodies. Health professionals implementing these offloading recommendations in Australia should produce better DFU healing outcomes for their patients, communities, and country.
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Affiliation(s)
- Malindu E Fernando
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Australia
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Callaghan, Australia
| | - Mark Horsley
- Department of Orthopaedics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sara Jones
- Department of Rural Health, University of South Australia, Adelaide, Australia
| | - Brian Martin
- Department of Orthopaedics, Nepean Hospital, Sydney, Australia
| | - Vanessa L Nube
- Sydney Local Health District, Department of Podiatry, Sydney, Australia
| | - James Charles
- First Peoples Health Unit, Faculty of Health, Griffith University, Gold Coast, Queensland, Australia
| | | | - Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia.
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Lazzarini PA, Raspovic A, Prentice J, Commons RJ, Fitridge RA, Charles J, Cheney J, Purcell N, Twigg SM. Guidelines development protocol and findings: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:28. [PMID: 35440052 PMCID: PMC9017044 DOI: 10.1186/s13047-022-00533-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 03/15/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Diabetes-related foot disease (DFD) is a leading cause of the Australian disease burden. The 2011 Australian DFD guidelines were outdated. We aimed to develop methodology for systematically adapting suitable international guidelines to the Australian context to become the new Australian evidence-based guidelines for DFD. METHODS We followed the Australian National Health Medical Research Council (NHMRC) guidelines for adapting guidelines. We systematically searched for all international DFD guideline records. All identified records were independently screened and assessed for eligibility. Those deemed eligible were further assessed and included if scoring at least moderate quality, suitability and currency using AGREE II and NHMRC instruments. The included international guidelines had all recommendations extracted into six sub-fields: prevention, wound classification, peripheral artery disease, infection, offloading and wound healing. Six national panels, each comprising 6-8 multidisciplinary national experts, screened all recommendations within their sub-field for acceptability and applicability in Australia using an ADAPTE form. Where panels were unsure of any acceptability and applicability items, full assessments were undertaken using a GRADE Evidence to Decision tool. Recommendations were adopted, adapted, or excluded, based on the agreement between the panel's and international guideline's judgements. Each panel drafted a guideline that included all their recommendations, rationale, justifications, and implementation considerations. All underwent public consultation, final revision, and approval by national peak bodies. RESULTS We screened 182 identified records, assessed 24 full text records, and after further quality, suitability, and currency assessment, one record was deemed a suitable international guideline, the International Working Group Diabetic Foot Guidelines (IWGDF guidelines). The six panels collectively assessed 100 IWGDF recommendations, with 71 being adopted, 27 adapted, and two excluded for the Australian context. We received 47 public consultation responses with > 80% (strongly) agreeing that the guidelines should be approved, and ten national peak bodies endorsed the final six guidelines. The six guidelines and this protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/ CONCLUSION: New Australian evidence-based guidelines for DFD have been developed for the first time in a decade by adapting suitable international guidelines. The methodology developed for adaptation may be useful for other foot-related conditions. These new guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia.
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Affiliation(s)
- Peter A Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
- Allied Health Research Collaborative, The Prince Charles Hospital, Brisbane, Australia.
| | - Anita Raspovic
- School of Allied Health, Human Services and Sport College of Science, Health & Engineering, La Trobe University, Bundoora, Australia
| | - Jenny Prentice
- Hall and Prior Health and Aged Care Group, Perth, Australia
| | - Robert J Commons
- Internal Medicine Services, Ballarat Health Services, Ballarat, Victoria, Australia
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Robert A Fitridge
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, Australia
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - James Charles
- First Peoples Health Unit, Faculty of Health, Griffith University, Gold Coast, Australia
| | | | - Nytasha Purcell
- Diabetes Feet Australia, Brisbane, Australia
- Australian Diabetes Society, Sydney, Australia
| | - Stephen M Twigg
- Sydney Medical School (Central), Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Camperdown, Australia
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