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van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E, Schaper NC. The unique multidisciplinarity of diabetes-related foot disease. Diabetes Metab Res Rev 2024; 40:e3804. [PMID: 38616492 DOI: 10.1002/dmrr.3804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
Few diseases globally require treatment from so many different disciplines as diabetes-related foot disease. At least 25 different professionals may be involved: casting technicians, dermatologists, diabetes (educator) nurses, diabetologists, dieticians, endocrinologists, general practitioners, human movement scientists, infectious diseases experts, microbiologists, nuclear medicine physicians, orthopaedic surgeons, orthotists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, podiatrists, prosthetists, psychologists, radiologists, social workers, tissue viability physicians, vascular surgeons, and wound care nurses. A shared vocabulary and shared treatment goals and recommendations are then essential. The International Working Group on the Diabetic Foot (IWGDF) has produced guidelines and supporting documents to stimulate and support shared and multidisciplinary evidence-based treatment in diabetes-related foot disease. In this special virtual issue of Diabetes/Metabolism Research and Reviews, all 21 documents of the 2023 update of the IWGDF Guidelines are bundled, added with a further 6 reviews from multidisciplinary experts to drive future research and clinical innovations, based on their contributions to the International Symposium on the Diabetic Foot. We hope the readers will enjoy this special virtual issue, and widely implement the knowledge shared here in their daily clinical practice and research endeavours with the goal to improve the care for people with diabetes-related foot disease.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, the Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Fran Game
- Research and Development Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- Cross I&D, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Univ-lille, Tourcoing, France
| | - Nicolaas C Schaper
- Division Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, the Netherlands
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Hancox JE, Chaplin WJ, Hilton C, Gray K, Game F, Vedhara K. Development of a Motivation Communication Training to Aid Diabetes-Specialist Podiatrists With Adherence Discussions. Health Educ Behav 2024; 51:240-250. [PMID: 38097512 PMCID: PMC10981181 DOI: 10.1177/10901981231216744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2024]
Abstract
Diabetic foot ulcers (DFUs) impact a substantial proportion of patients with diabetes, with high recurrence rates, severe complications, and significant financial burden to health care systems. Adherence to treatment advice (e.g., limiting weight-bearing activity) is low with patients reporting dissatisfaction with the way in which advice is communicated. This study aimed to address this problem via the systematic development of a motivation communication training program. The program was designed to support diabetes-specialist podiatrists in empowering patients to actively engage with treatment. The development process followed an intervention mapping approach. Needs assessment involved observations of 24 patient-practitioner consultations within a diabetes-specialist foot clinic. This informed specification of a theory of change (self-determination theory) and relevant evidence-based communication strategies (drawing from motivational interviewing). The training program was developed iteratively with changes made following feedback from five diabetic foot health care professionals. The resulting training program, consisting of six one-hour face-to-face sessions over an 8-week period, was delivered to a further six diabetes specialist podiatrists, with five participating in postprogram telephone interviews to assess acceptability. Deductive thematic analysis of interview data revealed positive aspects of the training (e.g., valuable and relevant content), ideas for improvement (e.g., online resources and context-specific video examples), the acceptability of motivation strategies, and challenges putting the strategies into practice (such as time constraints and breaking old communication habits). This study contributes to our understanding of integrating motivation principles into routine consultations and holds potential for enhancing adherence to treatment recommendations in patients living with diabetic foot ulcers.
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Affiliation(s)
- Jennie E. Hancox
- University of Nottingham, Nottingham, UK
- Loughborough University, Loughborough, UK
| | | | | | - Katie Gray
- Derbyshire Community Health Services NHS, Bakewell, UK
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Monteiro-Soares M, Game F. Podcast on How to Classify Foot Ulcers in People with Diabetes (2023 Update of the IWGDF Guidelines on Classification). Diabetes Ther 2024:10.1007/s13300-023-01521-2. [PMID: 38509442 DOI: 10.1007/s13300-023-01521-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/14/2023] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION In this podcast, we present the result of the 2023 scheduled update of the 2019 guidelines of the International Working Group of the Diabetic Foot (IWGDF) addressing the use of systems to classify foot ulcers in people with diabetes in routine clinical practice. METHODS These guidelines were based on a systematic review of the available literature that identified 28 classifications addressed in 149 articles and, subsequently, expert opinion using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. We first assessed the value of each system independently and, in the second stage, chose the best one or two to be used in each clinical scenario. RESULTS We recommend (1) for communication among healthcare professionals to use the Site, Ischaemia, Neuropathy, Bacterial infection, Area, Depth (SINBAD) classification (first option) or consider using Wound, Ischaemia, foot Infection (WIfI) system (alternative option, when the required equipment and level of expertise are available and it is considered feasible) and in each case the individual variables that compose the systems should be described rather than a total score; (2) for predicting the outcome of an ulcer in a specific individual: no existing system could be recommended; (3) for characterising a person with an infected ulcer: the use of the IDSA (Infection Diseases Society of America)/IWGDF (first option) classification or consider using the WIfI system (alternative option, when the required equipment and level of expertise are available and it is considered as feasible); (4) for characterising a person with peripheral artery disease: consider using the WIfI system as a means to stratify healing likelihood and amputation risk; (5) for the audit of outcome(s) of populations: the use of the SINBAD score. CONCLUSION Although there is no classification that fits all purposes, it is crucial that healthcare professionals standardize the way they characterise diabetes-related foot ulcers and guide their decision-making process by using validated classification systems.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross Health School Lisbon, Lisbon and Oporto University Faculty of Medicine, Oporto, Portugal.
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.
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Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F. Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3786. [PMID: 38507616 DOI: 10.1002/dmrr.3786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND It is critical that interventions used to enhance the healing of chronic foot ulcers in diabetes are backed by high-quality evidence and cost-effectiveness. In previous years, the systematic review accompanying guidelines published by the International Working Group of the Diabetic Foot performed 4-yearly updates of previous searches, including trials of prospective, cross-sectional and case-control design. AIMS Due to a need to re-evaluate older studies against newer standards of reporting and assessment of risk of bias, we performed a whole new search from conception, but limiting studies to randomised control trials only. MATERIALS AND METHODS For this systematic review, we searched PubMed, Scopus and Web of Science databases for published studies on randomised control trials of interventions to enhance healing of diabetes-related foot ulcers. We only included trials comparing interventions to standard of care. Two independent reviewers selected articles for inclusion and assessed relevant outcomes as well as methodological quality. RESULTS The literature search identified 22,250 articles, of which 262 were selected for full text review across 10 categories of interventions. Overall, the certainty of evidence for a majority of wound healing interventions was low or very low, with moderate evidence existing for two interventions (sucrose-octasulfate and leucocyte, platelet and fibrin patch) and low quality evidence for a further four (hyperbaric oxygen, topical oxygen, placental derived products and negative pressure wound therapy). The majority of interventions had insufficient evidence. CONCLUSION Overall, the evidence to support any other intervention to enhance wound healing is lacking and further high-quality randomised control trials are encouraged.
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Affiliation(s)
- Pam Chen
- Joondalup Health Campus, Ramsay Healthcare Australia, Joondalup, Western Australia, Australia
- Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Nalini Campillo Vilorio
- Department of Diabetology, Diabetic Foot Unit, Plaza de la Salud General Hospital, Santo Domingo, Dominican Republic
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Ralf Lobmann
- Clinic for Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Pisa, Italy
| | - John Steinberg
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Prash Vas
- King's College Hospital NHS Foundation Trust, London, UK
| | - Vijay Viswanathan
- MV Hospital for Diabetes and Prof M Viswanathan Diabetes Research Center, Chennai, India
| | - Stephanie Wu
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E. Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3657. [PMID: 37243927 DOI: 10.1002/dmrr.3657] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 04/29/2023] [Indexed: 05/29/2023]
Abstract
Diabetes-related foot disease results in a major global burden for patients and the healthcare system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetes-related foot disease since 1999. In 2023, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In addition, a new guideline on acute Charcot neuro-osteoarthropathy was created. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification and management of diabetes-related foot disease based on the seven IWGDF Guidelines. We also describe the organisational levels to successfully prevent and treat diabetes-related foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of healthcare professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower-extremity amputations. The burden of foot disease and amputations is increasing at a rapid rate, and comparatively more so in middle to lower income countries. These guidelines also assist in defining standards of prevention and care in these countries. In conclusion, we hope that these updated practical guidelines continue to serve as a reference document to aid healthcare providers in reducing the global burden of diabetes-related foot disease.
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Affiliation(s)
- Nicolaas C Schaper
- Division Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, Australia
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Tourcoing; Univ-lille, Lille, France
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Bus SA, Monteiro-Soares M, Game F, van Netten JJ, Apelqvist J, Fitridge R, Senneville E, Schaper NC. Standards for the development and methodology of the 2023 IWGDF guidelines. Diabetes Metab Res Rev 2024; 40:e3656. [PMID: 37179482 DOI: 10.1002/dmrr.3656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023]
Abstract
AIMS Diabetes-related foot disease is a major source of patient burden and societal costs. Investing in evidence-based international guidelines on diabetes-related foot disease is important to reduce this burden and costs, provided the guidelines are focused on outcomes important to key stakeholders and are evidence-based and properly implemented. MATERIALS AND METHODS The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2023 updates were made using the Grading of Recommendations Assessment Development and Evaluation evidence-to-decision framework. This concerns formulating relevant clinical questions and important outcomes, conducting systematic reviews of the literature and meta-analyses where appropriate, completing summary of judgement tables, and writing recommendations that are specific, unambiguous and actionable, along with their transparent rationale. RESULTS We herein describe the development of the 2023 IWGDF Guidelines on the prevention and management of diabetes-related foot disease, which consists of seven chapters, each prepared by a separate working group of international experts. These chapters provide guidelines related to diabetes-related foot disease on prevention; classification of diabetes-related foot ulcer, offloading, peripheral artery disease, infection, wound healing interventions, and active Charcot neuro-osteoarthropathy. Based on these seven guidelines, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. CONCLUSIONS We believe that the adoption and implementation of the 2023 IWGDF guidelines by healthcare providers, public health agencies, and policymakers will improve the prevention and management of diabetes-related foot disease, and subsequently reduce the worldwide patient and societal burden caused by this disease.
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Affiliation(s)
- Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, the Netherlands
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation & Development, Amsterdam, the Netherlands
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide and Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eric Senneville
- Department of Infectious Diseases Gustave Dron Hospital, Tourcoing, France
- Univ-lille, Lille, France
| | - Nicolaas C Schaper
- Div. Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, the Netherlands
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Monteiro-Soares M, Hamilton EJ, Russell DA, Srisawasdi G, Boyko EJ, Mills JL, Jeffcoate W, Game F. Classification of foot ulcers in people with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3645. [PMID: 37132179 DOI: 10.1002/dmrr.3645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Classification and scoring systems can help both clinical management and audit the outcomes of routine care. AIM This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot. METHODS We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer. RESULTS We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost. CONCLUSION Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.
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Affiliation(s)
- Matilde Monteiro-Soares
- Portuguese Red Cross School of Health - Lisbon, Lisbon, Portugal
- MEDCIDS - Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Emma J Hamilton
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- University of Western Australia, Medical School, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - David A Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Gulapar Srisawasdi
- Department of Rehabilitation Medicine, Sirindhorn School of Prosthetics Orthotics, Bangkok, Thailand
- Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Edward J Boyko
- Department of Medicine, University of Washington, Seattle, Washington, USA
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph L Mills
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Chen P, Vilorio NC, Dhatariya K, Jeffcoate W, Lobmann R, McIntosh C, Piaggesi A, Steinberg J, Vas P, Viswanathan V, Wu S, Game F. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes (IWGDF 2023 update). Diabetes Metab Res Rev 2024; 40:e3644. [PMID: 37232034 DOI: 10.1002/dmrr.3644] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 04/17/2023] [Indexed: 05/27/2023]
Abstract
AIMS Principles of wound management, including debridement, wound bed preparation, and newer technologies involving alternation of wound physiology to facilitate healing, are of utmost importance when attempting to heal a chronic diabetes-related foot ulcer. However, the rising incidence and costs of diabetes-related foot ulcer management necessitate that interventions to enhance wound healing of chronic diabetes-related foot ulcers are supported by high-quality evidence of efficacy and cost effectiveness when used in conjunction with established aspects of gold-standard multidisciplinary care. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on wound healing interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. MATERIALS AND METHODS We followed the GRADE approach by devising clinical questions and important outcomes in the Patient-Intervention-Control-Outcome (PICO) format, undertaking a systematic review, developing summary of judgements tables, and writing recommendations and rationale for each question. Each recommendation is based on the evidence found in the systematic review and, using the GRADE summary of judgement items, including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability, we formulated recommendations that were agreed by the authors and reviewed by independent experts and stakeholders. RESULTS From the results of the systematic review and evidence-to-decision making process, we were able to make 29 separate recommendations. We made a number of conditional supportive recommendations for the use of interventions to improve healing of foot ulcers in people with diabetes. These include the use of sucrose octasulfate dressings, the use of negative pressure wound therapies for post-operative wounds, the use of placental-derived products, the use of the autologous leucocyte/platelet/fibrin patch, the use of topical oxygen therapy, and the use of hyperbaric oxygen. Although in all cases it was stressed that these should be used where best standard of care was not able to heal the wound alone and where resources were available for the interventions. CONCLUSIONS These wound healing recommendations should support improved outcomes for people with diabetes and ulcers of the foot, and we hope that widescale implementation will follow. However, although the certainty of much of the evidence on which to base the recommendations is improving, it remains poor overall. We encourage not more, but better quality trials including those with a health economic analysis, into this area.
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Affiliation(s)
- Pam Chen
- Joondalup Health Campus, Ramsay Healthcare Australia, Joondalup, Western Australia, Australia
- Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Nalini Campillo Vilorio
- Department of Diabetology, Diabetic Foot Unit, Plaza de la Salud General Hospital, Santo Domingo, Dominican Republic
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | | | - Ralf Lobmann
- Clinic for Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Stuttgart, Germany
| | - Caroline McIntosh
- Podiatric Medicine, School of Health Sciences, University of Galway, Galway, Ireland
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Pisa, Italy
| | - John Steinberg
- Georgetown University School of Medicine, Georgetown, Washington DC, USA
| | - Prash Vas
- King's College Hospital NHS Foundation Trust, London, UK
| | - Vijay Viswanathan
- MV Hospital for Diabetes and Prof M Viswanathan Diabetes Research Center, Chennai, India
| | - Stephanie Wu
- Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Hancox JE, Chaplin WJ, Hilton CE, Vadaszy N, Gray K, Game F, Vedhara K. Motivation communication training programme for healthcare professionals to support adherence in patients with diabetic foot ulcers: Proof of concept study. PLoS One 2024; 19:e0295180. [PMID: 38330087 PMCID: PMC10852232 DOI: 10.1371/journal.pone.0295180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 11/16/2023] [Indexed: 02/10/2024] Open
Abstract
Patients with diabetic foot ulcers have poor adherence to treatment recommendations. However, the most effective way to support adherence in this population is unknown. This study aimed to assess the preliminary effectiveness of a motivation communication training programme for healthcare professionals working with these patients, using theory and evidence-based strategies.A proof-of-concept study using a non-randomised, controlled before-and-after design. Six podiatrists took part in the motivation communication training programme. Pre-training, observation was undertaken to examine the communication style currently used by podiatrists in routine consultations. Patients' (n = 25) perceptions of podiatrist autonomy support, self-determination for limiting weight-bearing activity and average daily step count were also assessed. Post training, observations and patient measures were repeated with a different group of patients (n = 24). Observations indicated that podiatrists exhibited a more need-supportive communication style (e.g., taking time to understand patients' perspectives) after undergoing the training programme. Patients in the post-training group reported higher levels of autonomy support, while self-determination to limit weight-bearing activity remained unchanged. Although the post-training group had a lower average daily step count, the difference was not statistically significant. This is the first study to investigate implementation of motivation communication strategies in routine consultations with patients with diabetic foot ulcers. Results suggest that training can enhance healthcare professionals' motivation communication skills with potential for addressing adherence issues, however, a larger cluster randomised controlled trial is necessary to confirm this.
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Affiliation(s)
- Jennie E. Hancox
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
- School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Wendy J. Chaplin
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | | | - Noemi Vadaszy
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Katie Gray
- Derbyshire Community Health Services NHS, Bakewell, United Kingdom
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
| | - Kavita Vedhara
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
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van Netten JJ, Apelqvist J, Bus SA, Fitridge R, Game F, Monteiro-Soares M, Senneville E, Schaper NC. The International Working Group on the Diabetic Foot: Stories and Numbers Behind Three Decades of Evidence-Based Guidelines for the Management of Diabetes-Related Foot Disease. Diabetes Ther 2024; 15:19-31. [PMID: 37971638 PMCID: PMC10786793 DOI: 10.1007/s13300-023-01510-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 11/02/2023] [Indexed: 11/19/2023] Open
Abstract
Foot disease is a devastating complication of diabetes. For almost 3 decades, the mission of the International Working Group on the Diabetic Foot (IWGDF) is to produce evidence-based guidelines to inform health care providers worldwide on strategies for the prevention and management of diabetes-related foot disease. In this publication, we aim to better inform the reader about 'the story behind' the IWGDF Guidelines and thus facilitate improved uptake of the recommendations described in the guidelines. The first IWGDF Guidelines were published in 1999, and these have been successfully updated every 4 years since. With each update, IWGDF has improved the methodological rigour and extended the topics covered. This has been possible thanks to the involvement of > 100 experts from > 60 countries, all voluntarily dedicating their time. We estimate that the 2023 update of the IWGDF Guidelines required a total 10 years of full-time work, which would have cost 2 million euros if the voluntary work had been financially compensated. The IWGDF Guidelines are not only published in English but also translated to support local implementation. Currently available translations serve 2.9 billion people globally in their native language. As an independent and multidisciplinary organisation, IWGDF hopes that the 2023 update will continue to stimulate clinicians from all different disciplines to deliver the best care possible for these patients, will motivate researchers to undertake the high-quality trials needed to deliver the new evidence to advance the field further, and collectively will support people with diabetes-related foot disease to minimize their disease burdens.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Program Rehabilitation, Amsterdam Movement Sciences, Amsterdam, The Netherlands.
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Program Rehabilitation, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Vascular and Endovascular Surgery Service, Royal Adelaide Hospital, Adelaide, Australia
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health-Lisbon, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine, Oporto University, Porto, Portugal
| | - Eric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Nicolaas C Schaper
- Division of Endocrinology, MUMC+, CARIM and CAPHRI Institute, Maastricht, The Netherlands
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Hancox JE, Hilton C, Gray K, Game F, Vedhara K. Adherence to limiting weight-bearing activity in patients with diabetic foot ulcers: A qualitative study. Int Wound J 2023; 20:3945-3954. [PMID: 37312664 PMCID: PMC10681470 DOI: 10.1111/iwj.14282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 06/01/2023] [Indexed: 06/15/2023] Open
Abstract
Patients with diabetic foot ulcers are advised to limit weight-bearing activity for ulcers to heal. Patients often disregard this advice although the reasons are not yet fully understood. This study explored (1) patients' experiences of receiving the advice and (2) factors influencing adherence to the advice. Semi-structured interviews were conducted with 14 patients with diabetic foot ulcers. Interviews were transcribed and analysed using inductive thematic analysis. Advice regarding limiting weight-bearing activity was described by patients as directive, generic and conflicting with other priorities. Rapport, empathy and rationale supported receptivity to the advice. Barriers and facilitators to limiting weight-bearing activity included demands of daily living, enjoyment of exercise, sick/disabled identity and burden, depression, neuropathy/pain, health benefits, fear of negative consequences, positive feedback, practical support, weather and active/passive role in recovery. It is important that healthcare professionals pay attention to how limiting weight-bearing activity advice is communicated. We propose a more person-centred approach in which advice is tailored to individuals' specific needs with discussion around patient priorities and constraints.
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Affiliation(s)
- Jennie E. Hancox
- School of MedicineUniversity of NottinghamNottinghamUK
- Loughborough UniversityLoughboroughUK
| | | | - Katie Gray
- Derbyshire Community Health Services NHSBakewellUK
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation TrustDerbyUK
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12
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Jeffcoate W, Game F. The Charcot Foot Reflects a Response to Injury That Is Critically Distorted by Preexisting Nerve Damage: An Imperfect Storm. Diabetes Care 2022; 45:1691-1697. [PMID: 35796768 DOI: 10.2337/dc21-2508] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 04/17/2022] [Indexed: 02/03/2023]
Abstract
It has been recognized since comprehensive descriptions by Jean-Martin Charcot in 1868 and 1883 that development of what is usually known as neuropathic osteoarthropathy (or the Charcot foot) requires the coincidence of neuropathy and inflammation. Despite this, detailed understanding of the causes has remained remarkably limited in the succeeding century and a half. The aim of this descriptive account is to draw particular attention to the processes involved in both the onset and resolution of the inflammation that is an essential component of active disease. The principal observation is that while neuropathy is common in people with diabetes, the inflammation and secondary skeletal damage that characterize neuropathic osteoarthropathy are observed in only a small minority of people with diabetes and with neuropathy. We therefore argue that the key to understanding the causes of the Charcot foot is to focus equally on those who have active disease as well as those who do not. Although neuropathy is essential for development of the disorder, neuropathy also has an adverse impact on the mechanisms involved in the onset of inflammation, and these may be critically affected in the majority of those who are susceptible. The Charcot foot is uncommon in people with diabetes (or any other cause of neuropathy) because the large majority of those with neuropathy may have also lost the capacity to mount the specific inflammatory reaction that is essential for its development.
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Affiliation(s)
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, U.K
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13
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Uddin A, Russell D, Game F, Santos D, Siddle HJ. The effectiveness of systemic antibiotics for osteomyelitis of the foot in adults with diabetes mellitus: a systematic review protocol. J Foot Ankle Res 2022; 15:48. [PMID: 35710432 PMCID: PMC9204875 DOI: 10.1186/s13047-022-00554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/08/2022] [Indexed: 11/21/2022] Open
Abstract
Background Osteomyelitis of the foot is a major complication of diabetes that can be limb and life threatening. Systemic antibiotic pharmacotherapy is often used first line to eradicate infection and allow restoration of devitalised bone. The aim is to conduct a systematic review of the effectiveness of systemic antibiotics on osteomyelitis of the foot in adults with diabetes mellitus. Methods A systematic review of all interventional studies treating osteomyelitis with systemic antibiotics in participants with diabetes mellitus and an ulcer of the foot below the malleoli will be conducted. Studies not available in English and in people below the age of 18 will be excluded. Study selection will follow the Patient Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P guidelines). The quality of the studies will be assessed using the Cochrane risk-of-bias tool (RoB 2) for all randomised controlled trials and the Newcastle–Ottawa Scale (NOS) will be used for non-randomised controlled trials. Electronic databases will be searched with no timeline restrictions. Data Extraction All identified references will be imported to the Rayyan Application. Studies for eligibility will be screened by two reviewers. One reviewer will perform the data extraction and quality appraisal will be conducted by two authors. If sufficient data is available, the quality will be analysed and a meta-analysis will be performed. Data synthesis will be conducted, and meta-analysis undertaken using RevMan 5.4.1 Meta-analysis software. Non-parametric data may be compared between selective intervention and outcomes. Discussion The results of this systematic review will identify the effectiveness of systemic antibiotic therapy on osteomyelitis of the foot in people with diabetes based on the set outcome measure criteria. The findings will establish if there are existing consistent standards or variation in practice when treating diabetic foot osteomyelitis (DFO). The study may establish if guidelines are required to standardise practice when treating DFO with systemic antibiotic therapy. This systematic review protocol will synthesise the existing evidence on the effectiveness of systemic antibiotic therapy for treating DFO. Trial registration International Prospective Register for Systematic Reviews (PROSPERO) number CRD42021245424.
Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00554-3.
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Affiliation(s)
- Akram Uddin
- Northamptonshire Healthcare NHS Foundation Trust, Essex Partnership University NHS Foundation Trust & University of Nottingham, Nottingham, UK. .,Department of Podiatric Surgery. Danetre Hospital, London Road, Northamptonshire, NN11 4DY, UK.
| | - David Russell
- Leeds Institute of Clinical Trials Research, University of Leeds (and Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust), Leeds, LS2 9JT, UK
| | - Fran Game
- University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | | | - Heidi J Siddle
- Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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14
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Game F, Gray K, Davis D, Sherman R, Chokkalingam K, Connan Z, Fakis A, Jones M. The effectiveness of a new dried human amnion derived membrane in addition to standard care in treating diabetic foot ulcers: A patient and assessor blind, randomised controlled pilot study. Int Wound J 2021; 18:692-700. [PMID: 33605543 PMCID: PMC8450798 DOI: 10.1111/iwj.13571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 11/29/2022] Open
Abstract
Recent reviews suggest that amniotic membrane products may accelerate healing of diabetic foot ulcers. A new dried human amniotic membrane (dHAM) has been used for ocular ulcers but not for diabetic foot ulcers. This was a multi‐centre, prospective, patient and observer blind, randomised controlled pilot trial, to investigate whether 2 weekly addition of the dHAM to standard care versus standard care alone increased the proportion of healed participants' index foot ulcers within 12 weeks. Thirty‐one people (mean age 59.8 years, 81% male, 87% type 2 diabetes) were randomised (15 dHAM, 16 usual care). Within 12 weeks, healing occurred in 4 (27%) ulcers in the dHAM group versus 1 (6.3%) usual care group (P = .1). Percentage wound area reduction was higher in the dHAM versus control group. (P = .0057). There was no difference in AEs between the two groups. Six participants allocated to dHAM correctly identified their treatment group, although 5 in usual care incorrectly thought they were in the intervention arm. This pilot trial result is encouraging showing that this dHAM preparation is safe and promising treatment. These results will be used to design a statistically powered, definitive double blind randomised controlled trial.
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Affiliation(s)
- Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK.,Derby Clinical Trials Support Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Katie Gray
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Daniel Davis
- Derby Clinical Trials Support Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Rachelle Sherman
- Derby Clinical Trials Support Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Kamal Chokkalingam
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Zak Connan
- Derby Clinical Trials Support Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Apostolos Fakis
- Derby Clinical Trials Support Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Michael Jones
- Derby Clinical Trials Support Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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15
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Norman G, Westby MJ, Vedhara K, Game F, Cullum NA. Effectiveness of psychosocial interventions for the prevention and treatment of foot ulcers in people with diabetes: a systematic review. Diabet Med 2020; 37:1256-1265. [PMID: 32426913 DOI: 10.1111/dme.14326] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/14/2020] [Indexed: 12/18/2022]
Abstract
AIM To identify and synthesize the evidence for the effectiveness of psychosocial interventions to promote the healing, and/or reduce the occurrence of, foot ulceration in people with diabetes. METHODS In March 2019 we searched CENTRAL, Medline, Embase and PsycInfo for randomized controlled trials of interventions with psychosocial components for people with diabetes. The primary outcomes of this review were foot ulceration and healing. We assessed studies using the Cochrane risk-of-bias tool, the TIDieR checklist and GRADE. We conducted narrative synthesis and random-effects meta-analysis. RESULTS We included 31 randomized controlled trials (4511 participants), of which most (24 randomized controlled trials, 4093 participants) were prevention studies. Most interventions were educational with a modest psychosocial component. Ulceration and healing were not reported in most studies; secondary outcomes varied. Evidence was of low or very low quality because of high risks of bias and imprecision, and few studies reported adherence or fidelity. In groups where participants had prior ulceration, educational interventions had no clear effect on new ulceration (low-quality evidence). Two treatment studies, assessing continuous pharmacist support and an intervention to promote understanding of well-being, reported healing but their evidence was also of very low quality. CONCLUSION Most psychosocial intervention randomized controlled trials assessing foot ulcer outcomes in people with diabetes were prevention studies, and most interventions were primarily educational. Ulcer healing and development were not well reported. There is a need for better understanding of psychological and behavioural influences on ulcer incidence, healing and recurrence in people with diabetes. Randomized controlled trials of theoretically informed interventions, which assess clinical outcomes, are urgently required. (PROSPERO registration: CRD42016052960).
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Affiliation(s)
- G Norman
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - M J Westby
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - K Vedhara
- Division of Primary Care, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - F Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - N A Cullum
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Research and Innovation Division, Manchester University Foundation NHS Trust, Manchester, UK
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16
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Westby M, Norman G, Vedhara K, Game F, Cullum N. Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review. Diabet Med 2020; 37:1244-1255. [PMID: 32315474 DOI: 10.1111/dme.14310] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/16/2020] [Indexed: 12/31/2022]
Abstract
AIM To investigate whether ulceration, amputation and healing of foot ulcers in people living with diabetes are associated with psychosocial and behavioural factors. METHODS We searched MEDLINE, Embase, PsychINFO, CINAHL and The Cochrane Library to March 2019 for longitudinal studies with multivariable analyses investigating independent associations. Two reviewers extracted data and assessed risk of bias. RESULTS We identified 15 eligible studies involving over 12 000 participants. Clinical and methodological heterogeneity precluded meta-analysis, so we summarize narratively. Risk of bias was moderate or high. For ulceration, we found significantly different results for people with and without an ulcer history. For those with no ulcer history, moderate quality evidence suggests depression increases ulcer risk [three studies; e.g. hazard ratio (HR) 1.68 (1.20, 2.35) per Hospital Anxiety and Depression Scale (HADS) standard unit]. Better foot self-care behaviour reduces ulcer risk [HR 0.61 (0.40, 0.93) per Summary of Diabetes Self-Care Activities scale standard unit; one study]. For people with diabetes and previous ulcers, low- or very low-quality evidence suggests little discernible association between ulcer recurrence and depression [e.g. HR 0.88 (0.61, 1.27) per HADS standard unit], foot self-care, footwear adherence or exercise. Low-quality evidence suggests incomplete clinic attendance is strongly associated with amputation [odds ratio (OR) 3.84 (1.54, 9.52); one study]. Evidence for the effects of other psychosocial or behavioural factors on ulcer healing and amputation is very low quality and inconclusive. CONCLUSIONS Psychosocial and behavioural factors may influence the development of first ulcers. More high quality research is needed on ulcer recurrence and healing. (Open Science Framework Registration: https://osf.io/ej689).
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Affiliation(s)
- M Westby
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation , Manchester, UK
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - G Norman
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation , Manchester, UK
| | - K Vedhara
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - F Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - N Cullum
- Division of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation , Manchester, UK
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17
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Vas P, Rayman G, Dhatariya K, Driver V, Hartemann A, Londahl M, Piaggesi A, Apelqvist J, Attinger C, Game F. Effectiveness of interventions to enhance healing of chronic foot ulcers in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3284. [PMID: 32176446 DOI: 10.1002/dmrr.3284] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 11/06/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022]
Abstract
The management of diabetic foot ulcers (DFU) remains a challenge, and there is continuing uncertainty concerning optimal approaches to wound healing. The International Working Group of the Diabetic Foot (IWGDF) working group on wound healing has previously published systematic reviews of the evidence in 2008, 2012 and 2016 to inform protocols for routine care and to highlight areas which should be considered for further study. The working group has now updated this review by considering papers on the interventions to improve the healing of DFU's published between June 2014 and August 2018. Methodological quality of selected studies was independently assessed by a minimum of two reviewers using the recently published 21-point questionnaire as recommended by IWGDF/European Wound Management Association, as well as the previously incorporated Scottish Intercollegiate Guidelines Network criteria. Of the 2275 papers identified, 97 were finally selected for grading following full text review. Overall, there has been an improvement in study design and a significant rise in the number of published studies. While previous systematic reviews did not find any evidence to justify the use of newer therapies, except for negative pressure wound therapy in post-surgical wounds, in this review we found additional evidence to support some interventions including a sucrose-octasulfate dressing, the combined leucocyte, fibrin and platelet patch as well as topical application of some placental membrane products, all when used in addition to usual best care. Nonetheless, the assessment and comparison of published trials remains difficult with marked clinical heterogeneity between studies: in patient selection, study duration, standard of usual care provision and the timing and description of the clinical endpoints.
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Affiliation(s)
- Prashanth Vas
- Diabetes Foot Clinic, King's College Hospital, London, UK
| | - Gerry Rayman
- Diabetes Centre and Research Unit, East Suffolk and North East Essex Foundation Trust, Colchester, UK
| | - Ketan Dhatariya
- Department of Diabetes, Norfolk and Norwich University Hospitals NHS Foundation Trust, University of East Anglia, Norwich, UK
| | - Vickie Driver
- School of Medicine, Brown University, Providence, RI
| | - Agnes Hartemann
- Pitié-Salpêtrière Hospital, APHP, Paris 6 University, ICAN, Lyon, France
| | - Magnus Londahl
- Department of Endocrinology, Skane University Hospital, Lund, Lund University, Lund, Sweden
- Department of Clinical Sciences, Lund, Lund University, Lund, Sweden
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Pisa, Italy
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Malmö, Sweden
| | - Chris Attinger
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington DC, WA
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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18
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Monteiro-Soares M, Russell D, Boyko EJ, Jeffcoate W, Mills JL, Morbach S, Game F. Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3273. [PMID: 32176445 DOI: 10.1002/dmrr.3273] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has been publishing evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This publication represents a new guideline addressing the use of classifications of diabetic foot ulcers in routine clinical practice and reviews those which have been published. We only consider systems of classification used for active diabetic foot ulcers and do not include those that might be used to define risk of future ulceration. The guidelines are based on a review of the available literature and on expert opinion leading to the identification of eight key factors judged to contribute most to clinical outcomes. Classifications are graded on the number of key factors included as well as on internal and external validation and the use for which a classification is intended. Key factors judged to contribute to the scoring of classifications are of three types: patient related (end-stage renal failure), limb-related (peripheral artery disease and loss of protective sensation), and ulcer-related (area, depth, site, single, or multiple and infection). Particular systems considered for each of the following five clinical situations: (a) communication among health professionals, (b) predicting the outcome of an individual ulcer, (c) as an aid to clinical decision-making for an individual case, (d) assessment of a wound, with/without infection, and peripheral artery disease (assessment of perfusion and potential benefit from revascularisation), and (d) audit of outcome in local, regional, or national populations. We recommend: (a) for communication among health professionals the use of the SINBAD system (that includes Site, Ischaemia, Neuropathy, Bacterial Infection and Depth); (b) no existing classification for predicting outcome of an individual ulcer; (c) the Infectious Diseases Society of America/IWGDF (IDSA/IWGDF) classification for assessment of infection; (d) the WIfI (Wound, Ischemia, and foot Infection) system for the assessment of perfusion and the likely benefit of revascularisation; and (e) the SINBAD classification for the audit of outcome of populations.
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Affiliation(s)
- Matilde Monteiro-Soares
- Departamento de Medicina da Comunidade, Informação e Decisão em Saúde, Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
| | - David Russell
- Department of Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, UK
| | | | - William Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust-City Campus, Nottingham, United Kingdom
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Stephan Morbach
- Department of Diabetes and Angiology, Marienkrankenhaus gGmbH, Soest, Germany
- Institute for Health Services Research and Health Economics, Services Research and Health Economics, Faculty of Medicine, Heinrich-Heine- University, Düsseldorf, Germany
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
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Abstract
Classification and scoring systems can help both clinical management and audit outcomes of routine care. The aim of this study was to assess published systems of diabetic foot ulcers (DFUs) to determine which should be recommended for a given clinical purpose. Published classifications had to have been validated in populations of > 75% people with diabetes and a foot ulcer. Each study was assessed for internal and external validity and reliability. Eight key factors associated with failure to heal were identified from large clinical series and each classification was scored on the number of these key factors included. Classifications were then arranged according to their proposed purpose into one or more of four groups: (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) aid clinical management decision making for an individual case, and (d) audit to compare outcome in different populations. Thirty-seven classification systems were identified of which 18 were excluded for not being validated in a population of >75% DFUs. The included 19 classifications had different purposes and were derived from different populations. Only six were developed in multicentre studies, just 13 were externally validated, and very few had evaluated reliability.Classifications varied in the number (4 - 30), and definition of individual items and the diagnostic tools required. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalization, limb amputation, mortality, and cost. Despite the limitations, there was sufficient evidence to make recommendations on the use of particular classifications for the indications listed above.
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Affiliation(s)
- Matilde Monteiro-Soares
- Departamento de Medicina da Comunidade, Informação e Decisão em Saúde (MEDCIDS), Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
| | | | - William Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - David Russell
- Department of Vascular Surgery, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephan Morbach
- Department of Diabetes and Angiology, Marienkrankenhaus gGmbH, Soest, Germany
- Institute for Health Services Research and Health Economics, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Rayman G, Vas P, Dhatariya K, Driver V, Hartemann A, Londahl M, Piaggesi A, Apelqvist J, Attinger C, Game F. Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3283. [PMID: 32176450 DOI: 10.1002/dmrr.3283] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 10/20/2019] [Accepted: 11/06/2019] [Indexed: 12/16/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In conjunction with advice from internal and external reviewers and expert consultants in the field, this update is based on a systematic review of the literature centred on the following: the Population (P), Intervention (I), Comparator (C) and Outcomes (O) framework; the use of the SIGN guideline/Cochrane review system; and the 21 point scoring system advocated by IWGDF/EWMA. This has resulted in 13 recommendations. The recommendation on sharp debridement and the selection of dressings remain unchanged from the last recommendations published in 2016. The recommendation to consider negative pressure wound therapy in post-surgical wounds and the judicious use of hyperbaric oxygen therapy in certain non-healing ischaemic ulcers also remains unchanged. Recommendations against the use of growth factors, autologous platelet gels, bioengineered skin products, ozone, topical carbon dioxide, nitric oxide or interventions reporting improvement of ulcer healing through an alteration of the physical environment or through other systemic medical or nutritional means also remain. New recommendations include consideration of the use of sucrose-octasulfate impregnated dressings in difficult to heal neuro-ischaemic ulcers and consideration of the use of autologous combined leucocyte, platelet and fibrin patch in ulcers that are difficult to heal, in both cases when used in addition to best standard of care. A further new recommendation is the consideration of topical placental derived products when used in addition to best standard of care.
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Affiliation(s)
- Gerry Rayman
- Diabetes Centre and Research Unit, East Suffolk and North East Essex Foundation Trust, UK
| | - Prashanth Vas
- Diabetes Foot Clinic, King's College Hospital, London, UK
| | - Ketan Dhatariya
- Department of Diabetes, Norfolk and Norwich University Hospitals NHS Foundation Trust, and University of East Anglia, Norwich, UK
| | - Vickie Driver
- Brown University School of Medicine, Providence, Rhode Island
| | - Agnes Hartemann
- Pitié-Salpêtrière Hospital, APHP, Paris 6 University, ICAN, Paris, France
| | - Magnus Londahl
- Department of Endocrinology, Skane University Hospital, Lund, and Department of Clinical Sciences, Lund, Lund University, Sweden
| | - Alberto Piaggesi
- Diabetic Foot Section, Department of Medicine, University of Pisa, Italy
| | - Jan Apelqvist
- Department of Endocrinology, University Hospital of Malmö, Sweden
| | - Chris Attinger
- Department of Plastic Surgery, Medstar Georgetown University, Hospital, Washington, DC, USA
| | - Fran Game
- Department of Diabetes and Endocrinology, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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Liu Z, Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2018; 10:CD010318. [PMID: 30328611 PMCID: PMC6517143 DOI: 10.1002/14651858.cd010318.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. People with DM are prone to developing foot ulcers and, if these do not heal, they may also undergo foot amputation surgery resulting in postoperative wounds. Negative pressure wound therapy (NPWT) is a technology that is currently used widely in wound care. NPWT involves the application of a wound dressing attached to a vacuum suction machine. A carefully controlled negative pressure (or vacuum) sucks wound and tissue fluid away from the treated area into a canister. A clear and current overview of current evidence is required to facilitate decision-making regarding its use. OBJECTIVES To assess the effects of negative pressure wound therapy compared with standard care or other therapies in the treatment of foot wounds in people with DM in any care setting. SEARCH METHODS In January 2018, for this first update of this review, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We identified six additional studies for inclusion in the review. SELECTION CRITERIA Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any brand of NPWT in the treatment of foot wounds in people with DM, irrespective of date or language of publication. Particular effort was made to identify unpublished studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. We presented and analysed data separately for foot ulcers and postoperative wounds. MAIN RESULTS Eleven RCTs (972 participants) met the inclusion criteria. Study sample sizes ranged from 15 to 341 participants. One study had three arms, which were all included in the review. The remaining 10 studies had two arms. Two studies focused on postamputation wounds and all other studies included foot ulcers in people with DM. Ten studies compared NPWT with dressings; and one study compared NPWT delivered at 75 mmHg with NPWT delivered at 125 mmHg. Our primary outcome measures were the number of wounds healed and time to wound healing.NPWT compared with dressings for postoperative woundsTwo studies (292 participants) compared NPWT with moist wound dressings in postoperative wounds (postamputation wounds). Only one study specified a follow-up time, which was 16 weeks. This study (162 participants) reported an increased number of healed wounds in the NPWT group compared with the dressings group (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.03 to 2.01; low-certainty evidence, downgraded for risk of bias and imprecision). This study also reported that median time to healing was 21 days shorter with NPWT compared with moist dressings (hazard ratio (HR) calculated by review authors 1.91, 95% CI 1.21 to 2.99; low-certainty evidence, downgraded for risk of bias and imprecision). Data from the two studies suggest that it is uncertain whether there is a difference between groups in amputation risk (RR 0.38, 95% CI 0.14 to 1.02; 292 participants; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision).NPWT compared with dressings for foot ulcersThere were eight studies (640 participants) in this analysis and follow-up times varied between studies. Six studies (513 participants) reported the proportion of wounds healed and data could be pooled for five studies. Pooled data (486 participants) suggest that NPWT may increase the number of healed wounds compared with dressings (RR 1.40, 95% CI 1.14 to 1.72; I² = 0%; low-certainty evidence, downgraded once for risk of bias and once for imprecision). Three studies assessed time to healing, but only one study reported usable data. This study reported that NPWT reduced the time to healing compared with dressings (hazard ratio (HR) calculated by review authors 1.82, 95% CI 1.27 to 2.60; 341 participants; low-certainty evidence, downgraded once for risk of bias and once for imprecision).Data from three studies (441 participants) suggest that people allocated to NPWT may be at reduced risk of amputation compared with people allocated to dressings (RR 0.33, 95% CI 0.15 to 0.70; I² = 0%; low-certainty evidence; downgraded once for risk of bias and once for imprecision).Low-pressure compared with high-pressure NPWT for foot ulcersOne study (40 participants) compared NPWT 75 mmHg and NPWT 125 mmHg. Follow-up time was four weeks. There were no data on primary outcomes. There was no clear difference in the number of wounds closed or covered with surgery between groups (RR 0.83, 95% CI 0.47 to 1.47; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision) and adverse events (RR 1.50, 95% CI 0.28 to 8.04; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision). AUTHORS' CONCLUSIONS There is low-certainty evidence to suggest that NPWT, when compared with wound dressings, may increase the proportion of wounds healed and reduce the time to healing for postoperative foot wounds and ulcers of the foot in people with DM. For the comparisons of different pressures of NPWT for treating foot ulcers in people with DM, it is uncertain whether there is a difference in the number of wounds closed or covered with surgery, and adverse events. None of the included studies provided evidence on time to closure or coverage surgery, health-related quality of life or cost-effectiveness. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making regarding the use of NPWT to treat foot wounds in people with DM.
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Affiliation(s)
- Zhenmi Liu
- West China Hospital, Sichuan UniversityWest China School of Public HealthChengduSichuanChina610041
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Robert J Hinchliffe
- St George's Healthcare NHS TrustSt George's Vascular Institute4th Floor, St James WingBlackshaw RoadLondonUKSW17 0QT
| | - Nicky Cullum
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthManchesterUKM13 9PL
| | - Fran Game
- Derby Hospitals NHS Foundation TrustDepartment of Diabetes and EndocrinologyUttoxeter RoadDerbyUKDE22 3NE
| | - Nikki Stubbs
- St Mary's HospitalLeeds Community Healthcare NHS Trust3 Greenhill RoadLeedsUKLS12 3QE
| | - Michael Sweeting
- University of LeicesterDepartment of Health Sciences, College of Life SciencesGeorge Davies CentreUniversity RoadLeicesterUKLE1 7RH
| | - Frank Peinemann
- Children's Hospital, University of ColognePediatric Oncology and HematologyKerpener Str. 62CologneGermany50937
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Metcalf L, Musgrove M, Bentley J, Berrington R, Bunting D, Mousley M, Thompson J, Sprengel M, Turtle-Savage V, Game F, Jeffcoate W. Prevalence of active Charcot disease in the East Midlands of England. Diabet Med 2018; 35:1371-1374. [PMID: 29782669 DOI: 10.1111/dme.13679] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2018] [Indexed: 11/29/2022]
Abstract
AIMS To undertake a prospective point prevalence study of the prevalence of active Charcot neuro-inflammatory osteoarthropathy (Charcot disease) in a circumscribed part of England and to audit the time elapsing between disease onset and first diagnosis. METHODS The prevalence of active Charcot disease of the foot during a single month was assessed by specialist foot care teams at seven secondary care services in the East Midlands region of England. RESULTS A total of 90 cases were identified, representing 4.3 per 10 000 of the 205 033 total diabetes population of the region. The time elapsed from first presentation to any healthcare professional until diagnosis was also assessed. While the diagnosis was suspected or confirmed in one-third of patients within 2 weeks, it was not made for 2 months or more in 23 patients (24%). CONCLUSIONS Non-specialist professionals should have greater awareness of the existence of this uncommon complication of diabetes in the hope that earlier diagnosis will lead to lesser degrees of deformity.
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Affiliation(s)
- L Metcalf
- Nottingham Healthcare NHS Foundation Trust Nottingham, Nottingham, UK
| | - M Musgrove
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK
| | - J Bentley
- Lincolnshire Community Health Services NHS Trust, Lincoln, UK
| | - R Berrington
- University Hospitals Leicester NHS Trust, Leicester, UK
| | - D Bunting
- Derbyshire Community Health Services NHS Foundation Trust, Derby, UK
| | - M Mousley
- Northamptonshire Healthcare NHS Foundation Trust, Northampton, UK
| | - J Thompson
- Nottingham Healthcare NHS Foundation Trust Nottingham, Nottingham, UK
| | - M Sprengel
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK
| | - V Turtle-Savage
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK
| | - F Game
- Diabetes and Endocrinology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - W Jeffcoate
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, Nottingham, UK
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Frankel AH, Kazempour-Ardebili S, Bedi R, Chowdhury TA, De P, El-Sherbini N, Game F, Gray S, Hardy D, James J, Kong MF, Ramlan G, Southcott E, Winocour P. Management of adults with diabetes on the haemodialysis unit: summary of guidance from the Joint British Diabetes Societies and the Renal Association. Diabet Med 2018; 35:1018-1026. [PMID: 30152585 DOI: 10.1111/dme.13676] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2018] [Indexed: 12/29/2022]
Abstract
Diabetic nephropathy remains the principal cause of end-stage renal failure in the UK and its prevalence is set to increase. People with diabetes and end-stage renal failure on maintenance haemodialysis are highly vulnerable, with complex comorbidities, and are at high risk of adverse cardiovascular outcomes, the leading cause of mortality in this population. The management of people with diabetes receiving maintenance haemodialysis is shared between diabetes and renal specialist teams and the primary care team, with input from additional healthcare professionals providing foot care, dietary support and other aspects of multidisciplinary care. In this setting, one specialty may assume that key aspects of care are being provided elsewhere, which can lead to important components of care being overlooked. People with diabetes and end-stage renal failure require improved delivery of care to overcome organizational difficulties and barriers to communication between healthcare teams. No comprehensive guidance on the management of this population has previously been produced. These national guidelines, the first in this area, bring together in one document the disparate needs of people with diabetes on maintenance haemodialysis. The guidelines are based on the best available evidence, or on expert opinion where there is no clear evidence to inform practice. We aim to provide clear advice to clinicians caring for this vulnerable population and to encourage and improve education for clinicians and people with diabetes to promote empowerment and self-management.
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Affiliation(s)
- A H Frankel
- Imperial College Healthcare NHS Trust, London, UK
| | - S Kazempour-Ardebili
- Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Iran
| | - R Bedi
- Imperial College Healthcare NHS Trust, London, UK
| | | | - P De
- Birmingham City Hospital (Sandwell and West Birmingham Hospitals NHS Trust), Birmingham, UK
| | | | - F Game
- Derby Teaching Hospitals NHS Foundation Trust and University of Nottingham, UK
| | - S Gray
- East and North Herts NHS Trust, UK
| | - D Hardy
- East and North Herts NHS Trust, UK
| | - J James
- University Hospitals of Leicester NHS Trust, UK
| | - M-F Kong
- University Hospitals of Leicester NHS Trust, UK
| | - G Ramlan
- North Middlesex University Hospital NHS Trust, UK
| | | | - P Winocour
- Queen Elizabeth II Hospital, Welwyn Garden City, UK
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24
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Affiliation(s)
- Fran Game
- Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS Foundation Trust, Derby DE22 3NE, UK.
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Clokie M, Greenway AL, Harding K, Jones NJ, Vedhara K, Game F, Dhatariya KK. New horizons in the understanding of the causes and management of diabetic foot disease: report from the 2017 Diabetes UK Annual Professional Conference Symposium. Diabet Med 2017; 34:305-315. [PMID: 28029181 DOI: 10.1111/dme.13313] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 01/24/2023]
Abstract
Diabetes-related foot disease remains a common problem. For wounds, classic teaching recommends the treatment of any infection, offloading the wound and ensuring a good blood supply, as well as ensuring that the other modifiable risk factors are addressed and optimized. There remain, however, several questions about these and other aspects of the care of diabetes-related foot disease. Some of these questions are addressed in the present report; in particular, the impact of newer technologies in the identification of any organisms present in a wound, as well as the use of novel approaches to treat infections. The use of new remote sensing technology to identify people at risk of developing foot ulceration is also considered, in an attempt to allow early intervention and prevention of foot ulcers. The psychological impact of foot disease is often overlooked, but with an increasing number of publications on the subject, the cause-and-effect role that psychology plays in foot disease, such as ulcers and Charcot neuroarthropathy, is considered. Finally, because of heterogeneity in diabetic foot studies, comparing results is difficult. A recently published document focusing on ensuring a standardized way of reporting foot disease trials is discussed.
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Affiliation(s)
- M Clokie
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, Rhondda Cynon Taf
| | - A L Greenway
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, Rhondda Cynon Taf
| | - K Harding
- Medical School, Cardiff University, Heath Park, Cardiff, Rhondda Cynon Taf
| | - N J Jones
- Welsh Wound Innovation Centre, Rhodfa Marics, Ynysmaerdy, Rhondda Cynon Taf
| | - K Vedhara
- Department of Health Psychology, Division of Primary Care, Nottingham University, Nottingham, UK
| | - F Game
- Department of Diabetes, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Frankel A, Kazempour-Ardebili S, Bedi R, Chowdhury TA, De P, El-Sherbini N, Game F, Gray S, Hardy D, James J, Kong MF, Ramlan G, Southcott E, Winocour P. Management of adults with diabetes on the haemodialysis unit: summary of new guidance from the Joint British Diabetes Societies (JBDS) and the Renal Association. Br J Diabetes 2016. [DOI: 10.15277/bjd.2016.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
One of the commonest complications of type 2 diabetes is renal disease. Treatment guidelines emphasise the need for tight glycaemic control to reduce the development of future complications; however, with the development of renal impairment, the benefit of tight glycaemic control must be weighed against the potential for adverse effects from drugs or their metabolites which may accumulate. In this article, the glucose-lowering drugs used in the management of type 2 diabetes are reviewed, with particular emphasis on newer guidelines and agents.
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Affiliation(s)
- Fran Game
- Department of Diabetes and Endocrinology, Derby Hospitals NHS FT, Derby, UK
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Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2013:CD010318. [PMID: 24132761 DOI: 10.1002/14651858.cd010318.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. Negative pressure wound therapy can be used to treat these wounds and a clear and current overview of current evidence is required to facilitate decision-making regarding its use. OBJECTIVES To assess the effects of negative pressure wound therapy compared with standard care or other adjuvant therapies in the healing of foot wounds in people with DM. SEARCH METHODS In July 2013, we searched the following databases to identify reports of relevant randomised controlled trials (RCTs): Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); The Database of Abstracts of Reviews of Effects (DARE); The NHS Economic Evaluation Database; Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. SELECTION CRITERIA Published or unpublished RCTs that evaluate the effects of any brand of negative pressure wound therapy in the treatment of foot wounds in people with diabetes, irrespective of publication date or language of publication. Particular effort was made to identify unpublished studies. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, risk of bias assessment and data extraction. MAIN RESULTS We included five studies in this review randomising 605 participants. Two studies (total of 502 participants) compared negative pressure wound therapy with standard moist wound dressings. The first of these was conducted in people with DM and post-amputation wounds and reported that significantly more people healed in the negative pressure wound therapy group compared with the moist dressing group: (risk ratio 1.44; 95% CI 1.03 to 2.01). The second study, conducted in people with debrided foot ulcers, also reported a statistically significant increase in the proportion of ulcers healed in the negative pressure wound therapy group compared with the moist dressing group: (risk ratio 1.49; 95% CI 1.11 to 2.01). However, these studies were noted to be at risk of performance bias, so caution is required in their interpretation. Findings from the remaining three studies provided limited data, as they were small, with limited reporting, as well as being at unclear risk of bias. AUTHORS' CONCLUSIONS There is some evidence to suggest that negative pressure wound therapy is more effective in healing post-operative foot wounds and ulcers of the foot in people with DM compared with moist wound dressings. However, these findings are uncertain due to the possible risk of bias in the original studies. The limitations in current RCT evidence suggests that further trials are required to reduce uncertainty around decision making regarding the use of NPWT to treat foot wounds in people with DM.
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Affiliation(s)
- Jo C Dumville
- Department of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK, M13 9PL
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Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database Syst Rev 2013. [DOI: 10.1002/14651858.cd010318] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Abstract
AIMS Current National Institute for Health and Clinical Excellence guidelines state that patients with diabetes should have annual examination of their feet to exclude signs of sensory impairment. The VibraTip is a new disposable device producing a vibratory stimulus, which has been developed in order to screen for peripheral sensory neuropathy in diabetes. This study was designed to evaluate the device by assessing intra-rater reliability and comparing the ability of the VibraTip to detect or exclude peripheral sensory neuropathy with other bedside methods. METHODS One hundred and forty-one patients with diabetes (Type 1 or Type 2) were examined for diabetic peripheral sensory neuropathy using a Neurothesiometer, 10-g monofilament, a 128-Hz tuning fork, a Neurotip™ and a VibraTip. The failure to perceive the Neurosthesiometer stimulus at ≥ 25 V in either foot was considered the reference method for the presence of peripheral sensory neuropathy. Receiver operating characteristic curves were produced for each device and the sensitivity, specificity, predictive values and likelihood ratios for the diagnosis of peripheral sensory neuropathy were calculated. Repeat testing with the VibraTip was performed in 18 patients and intra-rater reliability assessed using Cronbach alpha. RESULTS Analysis of the area under the receiver operating characteristic curves showed that the 10-g monofilament was significantly better than the 128-Hz tuning fork (P = 0.0056) and the Neurotip (P = 0.0022), but was no different from the VibraTip (P = 0.3214). The alpha coefficient for the VibraTip was calculated to be 0.882, indicating good reliability. CONCLUSIONS The VibraTip is a device comparable with the 10-g monofilament and therefore could be considered a useful tool for screening for peripheral sensory neuropathy in diabetes.
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Affiliation(s)
- N Bracewell
- Department of Orthopaedic and Accident Surgery, University of Nottingham, Nottingham, UK
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Game F. Management of diabetes around emergency and elective procedures. Ann R Coll Surg Engl 2012; 94:293-6. [PMID: 22943220 PMCID: PMC3954366 DOI: 10.1308/003588412x13171221591655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Diabetes is a common disease worldwide with a multitude of complications and high mortality. Moreover, its prevalence is increasing and many of our patients will have diabetes. We have known for almost 50 years that patients with diabetes undergo surgical procedures at a higher rate than patients who do not have the condition1 and that they spend 45% longer in a hospital bed than patients with diabetes admitted to a medical ward.2
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Affiliation(s)
- F Game
- Royal Derby Hospital, Uttoxeter Road, Derby DE22 3NE, UK.
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Abstract
BACKGROUND The acute Charcot foot is thought to occur in people who have a number of predisposing factors, of which distal neuropathy is the most important. But while occurrence in the contralateral foot is not infrequent, recurrence in the same foot seems to be very rare. CASE REPORT A case is described in which discrete episodes of inflammation of the midfoot occurred in the same foot over a period of 14 years, and were attributed to acute Charcot neuroarthropathy (Charcot foot). There was coincidental evidence of osteomyelitis of the 4(th) toe but there was no suspicion that the inflammatory episodes of the midfoot were the result of bone infection and they settled without treatment with antibiotics. CONCLUSION This case had clinically diagnosed recurrences of inflammation and destruction typical of the acute Charcot foot over an extended period, and this is most unusual. The implications of the rarity of such recurrences are discussed.
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Affiliation(s)
- S Rudrappa
- Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, UK
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Abstract
Diabetes is a common disease worldwide with a multitude of complications and high mortality. Moreover, its prevalence is increasing and many of our patients will have diabetes. We have known for almost 50 years that patients with diabetes undergo surgical procedures at a higher rate than patients who do not have the condition1 and that they spend 45% longer in a hospital bed than patients with diabetes admitted to a medical ward.2
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Affiliation(s)
- F Game
- Derby Hospitals NHS Foundation Trust, UK.
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35
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Abstract
Diabetes is a common disease worldwide with a multitude of complications and high mortality. Moreover, its prevalence is increasing and many of our patients will have diabetes. We have known for almost 50 years that patients with diabetes undergo surgical procedures at a higher rate than patients who do not have the condition1 and that they spend 45% longer in a hospital bed than patients with diabetes admitted to a medical ward.2
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Affiliation(s)
- F Game
- Derby Hospitals NHS Foundation Trust, UK.
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Abstract
Over two decades ago, the St. Vincent Declaration set a 50% reduction of lower-limb amputations as a principal target for patients with diabetes. During this time, enormous strides have been taken in our understanding of diabetic foot disease, the complexities of wound healing and the organization of care to prevent what is one of the most feared complications of the disease. Despite this, we are aware that worldwide, we have not achieved the target set in 1989, with current estimations being that a limb is lost to diabetes somewhere in the world every 30 s. However, it has to be remembered that amputation is a treatment and not a disease, and it is indeed a treatment usually prescribed at the end of a long chronic illness. It is well known that patients whose disease is severe enough for amputation to be considered frequently have other complications of their diabetes, cardiovascular and peripheral vascular diseases and end-stage renal disease, in particular. The life expectancy of the patients is therefore frequently reduced, and their functional status poor even prior to the intervention of surgeons. Just as the functional status of the patients is often a contra-indication to other disease treatments, chemotherapy for some cancers, for example, then we should be considering carefully whether we should be removing limbs from patients whose functional and medical status will not improve significantly as a result. Equally, there may be patients who may benefit from an early amputation and ambulation with a prosthesis.
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Affiliation(s)
- Fran Game
- Department of Diabetes and Endocrinology, Derby Hospitals NHS Foundation Trust, Derby, UK.
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McInnes A, Jeffcoate W, Vileikyte L, Game F, Lucas K, Higson N, Stuart L, Church A, Scanlan J, Anders J. Foot care education in patients with diabetes at low risk of complications: a consensus statement. Diabet Med 2011; 28:162-7. [PMID: 21219423 PMCID: PMC3040291 DOI: 10.1111/j.1464-5491.2010.03206.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To define and agree a practical educational framework for delivery by all healthcare professionals managing patients with diabetes, particularly those at low risk of developing foot complications. METHODS A consensus meeting of a multidisciplinary expert panel. Prior to the meeting, relevant clinical papers were disseminated to the panel for review. The consensus was largely based upon the experts' clinical experience and judgement. RESULTS Four main health behaviours were identified for those at low risk of developing foot complications, namely: control of blood glucose levels; attendance at annual foot screening examination; reporting of any changes in foot health immediately; and the engagement in a simple daily foot care routine. CONCLUSION There is currently little evidence-based literature to support specific foot care practices. Patients with diabetes at low risk of developing complications should be encouraged to undertake a basic foot care regimen to reduce their likelihood of developing complications.
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Affiliation(s)
- A McInnes
- School of Health Professions, University of Brighton, 49 Darley Road, Brighton, UK.
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Abstract
OBJECTIVE To compare the mortality of patients with an acute Charcot foot with a matched population with uninfected neuropathic foot ulcers (NFUs). RESEARCH DESIGN AND METHODS Data were extracted from a specialist departmental database, supplemented by hospital records. The findings were compared with the results of earlier populations with Charcot foot and uninfected NFUs managed from 1980. Finally, the results of all patients with acute Charcot foot and all control subjects managed between 1980 and 2007 were compared with normative mortality data for the U.K. population. RESULTS A total of 70 patients presented with an acute Charcot foot (mean age 57.4 +/- 12.0 years; 48 male [68.6%]) between 2001 and 2007; there were 66 matched control subjects. By 1 October 2008, 13 (eight male; 18.6%) patients with a Charcot foot had died, after a median of 2.1 years (interquartile range 1.1-3.3). Twenty-two (20 male; 33.3%) control subjects had also died after a median of 1.3 years (0.6-2.5). There was no difference in survival between the two groups (log-rank P > 0.05). Median survival of all 117 patients with acute Charcot foot managed between 1980 and 2007 was 7.88 years (4.0-15.4) and was not significantly different from the control NFU patients (8.43 years [3.4-15.8]). When compared with normative U.K. population data, life expectancy in the two groups was reduced by 14.4 and 13.9 years, respectively. CONCLUSIONS These data confirm that the mortality in patients presenting to our unit with either an acute Charcot foot and an uninfected neuropathic ulcer was unexpectedly high.
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Affiliation(s)
- Juliette van Baal
- Foot Ulcer Trials Unit, Nottingham University Hospitals Trust, City Hospital Campus, Nottingham, UK
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Abstract
Although osteomyelitis occurs in approximately 10-20% of patients with diabetes-related foot ulcers, no widely accepted guideline is available for its treatment. In particular, little consensus exists on the place of surgery. A number of experts claim that early surgical excision of all infected or necrotic bone is essential. Others suggest that surgery should not be performed routinely, but instead only in patients who do not respond to antibiotic treatment or in case of particular clinical indications. Unfortunately, no studies have directly compared the two approaches. Over 500 cases of conservative (that is, nonsurgical) management with resolution rates of 60-80% have been described previously. Most patients in these series, however, received prolonged courses of broad-spectrum antibiotics, which increase the risk of diarrhea caused by Clostridium difficile or the emergence of multidrug-resistant organisms. By contrast, relatively few series of primarily surgical management have been published, with widely differing outcomes, and some of them also reported high recurrence rates. Further research is required to establish the relative importance of each approach, but the available data clearly indicate that a combined assessment and treatment by surgeons and physicians together is essential for many patients.
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Affiliation(s)
- Fran Game
- Foot Ulcer Trials Unit, Nottingham University Hospitals NHS Trust, City campus, Hucknall Road, Nottingham NG5 1PB, UK.
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40
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Abstract
It is frequently stated that diabetic foot ulcers should be managed by a multidisciplinary team, comprising individuals who can deliver all the necessary and wide-ranging skills: medical and surgical, podiatric, nursing and orthotic. Whilst there are some data to support this multidisciplinary approach there is little to guide us in ensuring the patient is seen by the right professional for the right treatment at the right time. This article will examine the evidence supporting the most effective use of the multidisciplinary team. It will look at medical managements of ulcers including dressings, offloading and the treatment of infection, either cellulitis or osteomyelitis. By contrast, the role of surgery in offloading, and the treatment of osteomyelitis will be examined, as well as the role of vascular surgery. The most important aspect of management choice, however, is the need to focus on the needs of the person with a diabetic foot ulcer rather than simply on the treatment of the ulcer in isolation. Other complications of diabetes, which may have an effect on wound healing such as glycaemic control, renal failure and visual disturbance will be explored.Finally, there will be discussion of the relevance of outcome measure, both of ulcers as well as those more patient-centred. The ways in which these can be used to monitor individual clinical responses to treatment will be described, as well as their potential use as an aid to comparison of the effectiveness of treatment protocols adopted in different centres.
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Affiliation(s)
- Fran Game
- Nottingham City Hospital, Nottingham NG5 1PB. UK.
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Abstract
AIMS To explore the relationships between time to healing of diabetic foot ulcers and baseline characteristics of both patients and their ulcers. METHODS All patients were included who were referred to a specialist clinic over a 4-year period. Age, gender, type and duration of diabetes, ulcer site, ulcer duration and baseline characteristics were recorded. Postcode was used to derive an index of social deprivation. Patients were followed up to 1 year. The primary outcome measure was time to healing. Those who died or had an ulcer-related amputation were censored at the time of death or amputation and classified as unhealed. RESULTS Mean age of 449 participants (63.7% male) was 66.7 years; 42.7% had evidence of peripheral arterial disease, and 80% had peripheral neuropathy. Median ulcer duration at presentation was 29 days; 60.5% ulcers had an area of < 1 cm(2) and 68.3% of all ulcers healed without amputation during the follow-up period. Univariate analysis revealed dose-response relationships between time to healing and increasing duration of diabetes, increasing ulcer area, ulcer site and peripheral arterial disease. No associations were found with age, gender, diabetes type, deprivation index, peripheral neuropathy or infection. The relationship between healing time and ulcer area, peripheral arterial disease and diabetes duration remained significant on multivariate analysis. CONCLUSIONS The dominant factors influencing healing are cross-sectional area at presentation and the degree of peripheral arterial disease. Further work is needed to define how those at greatest risk may be identified and best managed.
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Affiliation(s)
- P Ince
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, UK
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Hinchliffe RJ, Kirk B, Bhattacharjee D, Roe S, Jeffcoate W, Game F. The effect of haemodialysis on transcutaneous oxygen tension in patients with diabetes—a pilot study. Nephrol Dial Transplant 2006; 21:1981-3. [PMID: 16702198 DOI: 10.1093/ndt/gfl241] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Established renal failure in diabetes is associated with a high incidence of foot ulcers and gangrene, and these are major causes of morbidity and mortality. It has been suggested that this problem is particularly associated with the onset of renal replacement therapy, and since there is evidence that haemodialysis causes hypoxaemia, we have undertaken a pilot study to determine the effect of haemodialysis on lower limb transcutaneous oxygen tension (TcpO2). METHODS TcpO2 was measured on the dorsum of the foot through a single dialysis treatment and over the succeeding 4 h using a transcutaneous monitor (TCM400/3, Radiometer Ltd, Copenhagen, Denmark). RESULTS The median age (range) of the 10 (7 male) participants was 73 (58-83) years. The median duration of diabetes was 16.5 (7-30) years and that of dialysis treatment 29 (10-88) months. The median (range) baseline TcpO2 on the dorsum of the foot was 54.5 (51-77) mmHg and 54.0 (24-87) at the end of dialysis. Median TcpO2 at 1, 2 and 4 h after the end of dialysis was 50.0 (33-81), 49.0 (24-78) and 47.0 (20-78) mmHg. Analysis by ANOVA suggested a trend towards a difference between median TcpO2 concentrations at different time points (F(1.752, 15.765) = 3.359, P = 0.066). CONCLUSIONS The data identified a trend towards a fall in lower limb TcpO2, and that this fall continued for at least 4 h after the end of treatment. Dialysis-associated lower limb hypoxia may be a factor leading to the increased incidence of critical limb ischaemia in this group and further work is needed to define its cause and implications for clinical care.
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Affiliation(s)
- Robert J Hinchliffe
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, NG5 1PB
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Abstract
The pathogenesis of the acute Charcot foot of diabetes remains unclear. All patients with this condition have evidence of peripheral neuropathy, with loss of protective sensation and abnormal foot biomechanics. However, the acute Charcot foot is also characterised by a pronounced inflammatory reaction and the pathogenic significance of this inflammation has received little attention. We suggest that an initial insult--which may or may not be detected--is sufficient to trigger an inflammatory cascade through increased expression of proinflammatory cytokines, including TNFalpha and interleukin 1beta. This cascade then leads to increased expression of the nuclear transcription factor, NF-kappaB, which results in increased osteoclastogenesis. Osteoclasts cause progressive bone lysis, leading to further fracture, which in turn potentiates the inflammatory process. The potential role of proinflammatory cytokines suggests the possibility of new treatments for this sometimes devastating complication of diabetes.
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Affiliation(s)
- William J Jeffcoate
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham NG5 1PB, UK.
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Abstract
AIMS Measures of healing rate may not give a complete indication of the effectiveness of overall management of diabetic foot ulcers. Apart from healing and speed of healing, the outcomes of greatest importance to the patient are avoidance of any amputation and remaining free from any recurrence. We have documented the number of patients presenting with diabetic foot ulcers who become ulcer free and examined the value of documenting ulcer-free survival. METHODS All referrals to a specialist diabetic foot clinic over a 31-month period were analysed and outcomes were determined after a minimum follow-up of 6 months. RESULTS Three hundred and seventy patients were referred with a total of 1031 ulcers. One hundred and twenty-one (32.7%) never became ulcer free: 56 (46.3% of 121) remained unhealed, the ulcers of 12 (9.9% of 121) had been resolved by amputation, two remained unhealed after amputation (1.7% of 121) and 51 (13.8% of 370) had died. Two hundred and thirty-one (62.4% of 370) became ulcer free at some stage. Five of these were excluded because of an earlier amputation. Ninety-one of the remaining 226 (40.3%) developed a recurrent or new ulcer after a median 126 days. Of the 135 who did not have a recurrence, 133 (58.8% of 226; 35.9% of 370) survived ulcer free and with limbs intact, while two died. Outcome was unknown in 18 (4.9%). Those who never became ulcer free were older (P < 0.001) and with a greater prevalence of ischaemia (P < 0.001). Those who healed but went on to suffer a new ulcer had a greater prevalence of neuropathy (P = 0.027) than those who remained ulcer free. CONCLUSIONS The use of ulcer-free survival can be used as an indication of the effectiveness of foot ulcer management. It could be adopted as a measure to compare performance between different specialist units.
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Affiliation(s)
- N Pound
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, UK.
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46
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Abstract
AIM To undertake a pilot study to determine the feasibility of a definitive trial of the effect of close glycaemic control on healing of foot ulcers in diabetes. METHODS All patients attending a dedicated multidisciplinary clinic for the management of established ulcers over a 20-week period were systematically screened for inclusion in a randomised, single-blinded study. FINDINGS Two hundred individuals with foot ulcers attended the clinic during the recruitment period, but only nine met the predefined inclusion and exclusion criteria. One of these was withdrawn because of an adverse event immediately before recruitment, two proved incapable of administering insulin injections and were withdrawn prior to randomization. Four withheld consent, and one was advised to withhold consent by his community nurse. One was randomised and completed the 3-month study. The study was abandoned at 20 weeks when it was decided that it would be unlikely that a sufficient number of suitable patients would ever be recruited, and that it would therefore be unethical to approach further subjects. CONCLUSIONS It was concluded that although evidence is required to guide future practice in this field, the study design chosen was not feasible.
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Affiliation(s)
- I Idris
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, UK.
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Jeffcoate W, Game F, Hartemann-Heurtier A. [Infection of the diabetic foot]. Journ Annu Diabetol Hotel Dieu 2005:131-41. [PMID: 16161313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- W Jeffcoate
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham NG5 IPB, Royaume Uni
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Abstract
OBJECTIVE To determine the mortality of a population of patients diagnosed with Charcot neuropathic osteoarthropathy managed by a single specialist unit and to compare the results with a control population. METHODS We have undertaken a retrospective analysis of all cases of Charcot foot on the comprehensive database which has been maintained at the specialist diabetic foot clinic at the City Hospital, Nottingham since 1982. Survival and the incidence of amputation (major and minor) was compared with a control population referred with uncomplicated neuropathic ulceration. Controls were individually matched for gender, age (+/-2 years), disease type, disease duration (+/-2 years) and year of referral (+/-3 years). RESULTS Forty-seven cases (21 female, 26 male) of Charcot foot were identified, of whom 18 (38.3%) had Type 1 diabetes. Mean age and disease duration at presentation were 59.2 +/- 13.4 (sd) and 16.2 +/- 11.2 years, compared with 59.7 +/- 12.6 and 16.3 +/- 11.2 years, respectively, in the controls. Twenty-one (44.7%) of those with Charcot had died, after a mean interval of 3.7 +/- 2.8 years. This compared with 16 (34.0%) after a mean 3.1 +/- 2.7 years in the control group. Mean duration of follow-up in the survivors was 4.7 +/- 4.9 years (Charcot) and 5.3 +/- 3.9 years (controls). A total of 11 (23.4%) Charcot patients had had a major amputation on the side of the index lesion, compared with five (10.6%) controls. There was no difference between the two groups (P > 0.05, Chi-square). CONCLUSIONS The mortality in this group of patients with Charcot foot was higher than expected. Nevertheless, there was no difference between those with Charcot and those with uncomplicated neuropathic ulceration. It is possible that it is neuropathy, rather than Charcot osteoarthropathy, which is independently associated with increased mortality in diabetes. The mechanism underlying any such association is not known. There is a need for a formal, prospective, multicentre study to investigate the life expectancy and cardiovascular risk of those with Charcot osteoarthropathy.
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Affiliation(s)
- A Gazis
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham NG5 1PB, UK
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Affiliation(s)
- F Game
- Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, City Hospital, Nottingham, UK
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