Footnote Summer 2018

footnote THE NEWSLETTER • Summer 2018

D-Foot Implementation Forum

When passion meets strategy D-Foot International elects three new Vice-Presidents

Meet Gulapar, José Luis and Zahid A joint statement from

D-Foot International and IWGDF Guidance Diabetic foot initiatives and conferences in

Romania and the United Kingdom The POINT Project

A competency framework for podiatry Paper trail

Recent diabetic foot publications And more …

Welcome to another edition of Footnote.

Wherever you are in the world, I hope that you get time during this summer to take a break, relax, recharge and enjoy the things around you.

I hope that you find the PubMed search and commentaries of recent diabetic foot research papers useful. For me it is a very useful section of “Footnote� particularly as a busy clinician, it is great to skim through and keep up to date, stopping at topic of interest or practice changing evidence.

For many years it has struck me that there has been and continues to be a keen research interest in Neuropathy as a diabetes complication.

This is understandable and very helpful, particularly when considering screening

EDITOR’S NOTE Neil Baker

to identify those most at risk of developing foot ulceration and the devastating eects of symptomatic neuropathies. This is great because, as an everyday clinician, I have good reliable validated tools to help me determine loss of protective sensation.

However, when it comes to reliable and validated tools for determining those with significant arterial disease it is more confusing.

Recently, several papers have been published that have demonstrated that the reliability and intra-operator variability of pulse palpation and ankle pressures are poor in experienced clinicians. Being able to identify those patients who are moving down the everrestrictive path of peripheral arterial occlusion is becoming increasingly more essential with the rising prevalence of euro-ischaemic lesions. The advent or new easy-to-use technologies in

measuring peripheral blood flow is beginning to emerge.

I hope that a push to validate these tools together with revisiting the threshold for vascular intervention is forthcoming in the near future. If not, I fear that the burden of the growing number of neuroischaemic ulcers will accelerate dramatically. It is my belief that we need to focus upon early identification and risk stratification of peripheral arterial disease and not fire fight advanced disease. I know this is a contentious view with no evidence base and thus resistance ‌ Pioneers required!

Have a great summer and enjoy the contents of Footnote.

Neil

CONTENT Welcome to the summer edition of “Footnote�. I hope that you are all enjoying the change in the season, wherever you are.

It is incredible to think that we are already half way through 2018 and I know that I am getting older but time goes by all too quickly.

So in this edition of the Newsletter we have some of the regulars including the Pubmed search, commentaries of several recently published papers, additionally we some reports of meetings and importantly a summary of D-Foot International Forum please read the sections to see what your colleagues have been doing. Of course, we have another clinical picture quiz too.

We hope you enjoy reading this edition of Footnote.

Editorial Meet the new Vice-Presidents of the D-Foot International Board A joint statement from D-Foot International and IWGDF Guidance D-Foot International Forum Report from Train-the-Foot-Trainer Eastern Europe: what’s been happening Report from a GP foot conference Romania Report from Malvern Diabetic Foot conference The POINT Project Commentaries on recent key publications Pub med abstract Picture quiz

NEWS Watch this space … We will be issuing our first Special Edition very soon.

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Meet the new Vice-Presidents of the D-Foot International Board

Gulapar Srisawasdi

Asisistant Professor of Rehabilitation in Bangkok “True success is not in the learning, but in its application to the benefit of mankind�. I can see limitations but also ways to improve diabetic foot care. I can facilitate the work of D-Foot in the Western Pacific Region and in other parts of the world.

Zahid Myan

Asisistant Professor of Medicine in Karachi We must bring standardised foot care services down to community level, implement agreed plans and develop national registries to obtain global data on diabetic foot, paricularly in developing countries. We are responsible to save limbs and reduce the suering of the people.

JosĂŠ Luis LĂĄzaro MartĂ­nez

Professor of Podiatric Surgery in Madrid.

A real transformation by a democratic scientific society is necessary to be close to the people interested in diabetic foot, to give them a voice to working together to understand and manage diabetic foot worldwide for the benefit of people with diabetes with and at risk of diabetic foot.

Joint statement of D-Foot International and IWGDF Guidance

Over the last few months, we have received a number of queries about the relationship between D-Foot International, the International Working Group on the Diabetic Foot (IWGDF) Guidance and the International Symposium on the Diabetic Foot (ISDF).

The family of the diabetic foot is relatively small. Some persons in these groups may serve in several capacities. We understand that it may not always be clear to all “who is who”, and which activities are related to which organisation.

We have prepared this joint statement to clarify both the historical background and our current activities.

Over many years, a number of diabetic foot experts have been closely involved in creating a scientific community, as well as in setting up training and education courses. Since the early 1990s, initiated by Karel Bakker, three complementary, but quite different, activities have developed: a guidance group, an implementation group with series of education programmes closely linked to implementation of the IWGDF guidelines, and a congress. Since 1991, the ISDF has been organised every 4 years and has always been a separate, independent organisation.

The IWGDF was created by a group of 45 experts and first published its guidelines in 1999. As the organisation aimed to have a national representative in each country to help implement the guidelines, it soon grew in size.

Moreover, IWGDF members and experts set up several education projects. The IWGDF guidelines are produced every 4 years and presented at the ISDF. This arrangement enables the ISDF to financially support the production and publication of the guidelines. In these different activities, Karel Bakker was frequently both the lynchpin and the driving force.

In 2000, the IWGDF implementation activities were moved to be managed

within the legal structure of the International Diabetes Federation (IDF), referred to as the ”IDF Consultative Section on the Diabetic Foot”. This arrangement came to an end in 2015.

In December 2013, Karel Bakker handed over the leadership of the IWGDF to Kristien Van Acker. Due to the growing success and demands of the implementation activities and the guidance development, changes were needed. Therefore, it was decided to appoint two Chairs: Kristien Van Acker for implementation/education, assisted by a small team of 4 renowned experts and educators to form the implementation group to help her innovate and develop further programmes and external collaborations; and Nicolaas Schaper for guidance development, each taking the lead for the activities within their respective areas of expertise.

In April 2017, after an interim legal arrangement to protect their volunteer leadership, the IWGDF implementation group became “D-Foot International”.

Simultaneously, the guidance activities were re-branded as “IWGDF Guidance”.

Both organisations continue to do what they do best: improving implementation (D-Foot International) and developing guidance (IWGDF Guidance).

Currently, Kristien Van Acker is the President of D-Foot International and chairs a Board of 11 members. The General Assembly of D-Foot is composed of the Board and the Full Members, who are the National Representatives. In its communication, D-Foot International also carries the tagline “International Working Group on the Diabetic Foot— Implementation”.

Since 2015, Nicolaas Schaper is the Chair of IWGDF Guidance, which has an Editorial Board of 6 members. The organisation is further composed of 6 working groups, each with 6-12 international experts (totalling over 50 working group members), and each with its own Chair. Additional external experts and international organisations give further input.

The ISDF is held every 4 years. The Organising Committee receives input from an International Programme Board of 22 experts and is assisted by a Local Organising Committee. The symposium is recognised as the largest global conference on the diabetic foot. In 2015, the event attracted almost 1500 participants from more than 100 countries.

The core activity of D-Foot International is to promote the global profile of diabetic foot prevention and care through ongoing awareness, guidance implementation, education, research and professional development.

The aim of D-Foot International is to prevent diabetic foot complications and reduce the number of amputations from diabetes worldwide. With its global network of nearly 200 dedicated, specialised footcare representatives in more than 150 countries, the organisation focuses on: - implementing the ’International Consensus on the Management and Prevention of the Diabetic Foot’ and other guidelines, - training healthcare professionals how to manage diabetic foot problems effectively and prevent amputations, - guiding healthcare professionals how to train and support their colleagues, - promoting the recognition of diabetic foot specialists.

D-Foot International initiated and develops various diabetic foot initiatives, including: Train-the-Foot-Trainer courses, AB(b)A auditing benchmarking and accreditation, the DIAFI data collection tool, FLIRT Bird adapted footwear, e-Learning for GPs, a diabetic foot surgery programme, and work together with various stakeholders (WHO GATE, FIP-IFP, UNFM, and others). Every two years, D-Foot International organises the “DFoot Implementation Summit”.

The core activity of IWGDF Guidance is to produce international, multidisciplinary, evidence-based guidance documents to inform health professionals all over the world on the prevention and management of diabetic foot disease. These guidance documents are produced following the most rigorous and scientifically valid processes in guideline development, and are undertaken by expert health professionals and researchers from all over the world.

To stay current, the guidance documents are updated every 4 years. Under supervision of the IWGDF Guidance Editorial Board, existing guidance documents are rewritten and new chapters are added. The guidance documents, written in English, are adapted for many dierent countries and have been translated into dierent languages.

In addition, IWGDF Guidance produces systematic reviews of the evidence, which are all published with open access in an international scientific journal, as well as on the IWGDF Guidance website. As these systematic reviews are the core basis for the guidance, they are produced with a rigorous (and sometimes complex) process to enable their endorsement by international and national organisations. The next edition of the IWGDF Guidance will be presented at the ISDF in May 2019.

D-Foot International and IWGDF Guidance continue to work closely together with the common aim of creating a fruitful and reciprocal integration of implementation and guidance in the best interest of people with and at risk of diabetic foot disease, all over the world.

D-Foot Implementation Forum: when passion meets strategy Brussels, 28-29 April 2018 Zahid Miyan Asmat Nawaz Sigiriya Aebischer Perone

D-Foot International evolved from the IWGDF Implementation group and is registered as an international non-profit association under Belgian law.

D-Foot is resolutely determined to continue to be a volunteer body, working towards the global goals of prevention and optimal management of diabetic foot complications.

A small dedicated team of diabetic foot specialists from around the world form most of the D-Foot Board. They discuss, plan, develop and implement robust strategies to meet the diering needs for global diabetic foot care. The organisation has a solid governance structure and complies with all the legal requirements for a non-profit making organisation.

To consolidate and prioritise its activities, D-Foot International held an Implementation Forum meeting in Brussels from 28-29 April 2018 with invited participants.

The primary objective of the Forum was to bring together various diabetic foot stakeholder groups to come to help

identify and target strategic development and activities of D-Foot for the immediate future (1-2 years) and long term. This was primarily an awareness and brainstorming meeting which had a unique architecture independent of a strict agenda.

The Forum was designed to facilitate networking, interaction and the exchange of ideas between members of the Board, Advisory Committee, working groups, Regional representative, invited guests and representatives from their stakeholders, including industry representatives. In addition to Board members of D- Foot International, the participants included some of the most eminent diabetic foot experts from around the world.

Kristien Van Acker, President, described how D-Foot International had evolved from IWDGF – implementation section and developed further. The future growth of the organisation was openly and actively discussed in relation to the

current challenges and opportunities in prevention and management of diabetic foot.

The IWGDF guidance document was described as a map showing us where we need to strive for optimal diabetic foot management whilst implementation was seen as the journey to get there, involving practical field work.

The mission of D-Foot International is to provide quality care for patients, promote global profile of diabetic foot prevention, prevent amputations, improve quality of life, train health care professionals and promote the recognition of diabetic foot specialists.

The proposed strategic direction of the D-Foot International was presented. This comprises of awareness on diabetic foot, secondary preventive care, and integrated care by multidisciplinary foot care team, rehabilitation, palliative care and creating minimal or intermediate foot clinics. It was stressed that “Delay in the referral is our worst enemy”.

The participants were informed that efforts are being made to close the gap of available and affordable diabetic foot care. These include FLIRT project (Footwear in Low Income Regions/ countries in Teams), footwear for every diabetic project in Pakistan introducing the new concept of a footwear assistant.

Basic podiatry care needs to be introduced at the global level particularly in low income countries so that, every country can start with simple elements of podiatric care.

The governance of D-Foot International for future growth was discussed by Luc Hendrickx, Chief Executive Director. He explained the governance and strategic intend behind the Articles of Association under Belgian Law. The historical sequences of the events leading to the emergence of this “young organisation in transition” were enumerated. D-Foot’s organisational culture is inclusive, passionate, professional, open, ethical and is focused totally upon patient needs. The governance model is “lead and manage”. D-Foot’s focus is centred on what has to be achieved and encourages fostering alliances and partnerships with a wide range of organisations, stakeholders and industry.-Foot International is rapidly evolving from a volunteer-managed to a volunteer-led organisation and longterm corporate partnerships have to be developed.

Different working groups presented their work which included: •

the POINT- project (Podiatry for International Diabetic Foot Teams)

•

the FLIRT BIRD project including “Footwear for Every Diabetic” project in Pakistan

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AB(b)A (Accreditation- benchmarking and auditing)

•

Diabetic Foot Atlas

•

e-Learning packages some are already on line and available for all for free for basic education

•

Other education and competencybased training, e.g. basic diabetic foot surgery

It was underlined that the involving patients group representatives could be ameliorated.

Representatives from various organisations presented their efforts and accomplishments, expressing their support for the objectives of D-Foot International. These included: •

Peter Allton from “Undefeeted”

•

Line Kleinebreil from UNFM.

The common suggestions included:

•

Rajiv S Hanspal from International Society for Prosthetics and Orthotics (ISPO) introduced the great work of his organisations and he generously offered collaboration between ISPO and D- Foot having common goals and objectives.

•

Education and training,

•

Increased focus on the patient

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Improving the communication and increasing collaboration among the stakeholders

•

Sigiriya Aebischer Perone from International Committee of the Red Cross (ICRC) introduced the diverse humanitarian services the ICRC is undertaken across the globe specially in the low resource countries.

They all appreciated the activities and work of D-Foot International and expressed interest in mutual collaboration.

To discuss the practical problems in diabetic foot prevention and management a workshop was conducted in which the participants were divided into 4 groups. They presented their suggestions.

The representatives from the different DFoot Regions highlighted was they thought were barriers regarding diabetic footcare in their respective Regions and suggested their priorities to combat these issues.

A dedicated meeting was held with industry partners to discuss how mutual collaboration in a non-biased way could be utilised to meet the aims of D-Foot.

All industry partners presented their views, aspirations and ideas. Industry partners were present during the second day of Forum.

Finally, conclusions from all the discussions were drawn and the future plans particularly the priorities for 2018-2019 were put forward. It was concluded that D-Foot is a network where partnership is key to tackling all the identified challenges facing diabetic foot complications and cooperation with industry is important.

Building an organisation for future implementation has to be linked to translation. Whilst overviewing all of the various planned activities. It was highlighted that the Train-the-FootTrainer programmes have been implemented, whilst FLIRT-BIRD, The POINT Project, diabetic foot surgery programme, Young Academic Leaders

World Diabetes Day on diabetic foot and others initiatives are under way. The minimum package of patient education is adoptable according to the local culture. The D-Foot resources have to be developed. The data feedback from

implementation has to be gathered and global foot screening has to be ensured.

To realise all the activities, financial management and fund raising were seen as essential to ensure implementation and success.

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Train-the-Foot-Trainer Eastern Europe 2nd follow-up meeting Krakow, 10 May 2018 Vilma Urbančič Rovan

In February 2015, the European edition of Train the Foot Trainer course was held at Bled, Slovenia. The course hosted 38 participants and 8 observers from 17 countries from Central and Eastern Europe: Albania, Armenia, Bosnia-Herzegovina, Bulgaria, Croatia, Estonia, Greece, Kosovo, Latvia, Lithuania, Poland, Romania, Serbia, Slovenia, Sweden, Turkey, Ukraine.

The first follow-up meeting was held during the annual DFSG meeting in Stuttgart, Germany in 2016 this was reported in our September Newsletter 2016.

In May 2018, 24 participants from 12 countries gathered at the second follow-up meeting in Krakow, Poland.

After the welcome and a short summary of D-Foot International and its long-term vision by the President Kristien van Acker, progress reports were given by all 12 participating countries on their achievements, problems, barriers and plans for the future. The purpose of the Train-the-Foot-Trainer follow-up meeting was broadly: •

•

to create a face-to-face forum for all Train-the-Foot-Trainer participants for support and networking

Equally there has been much variation in the approaches made towards the implementation of the Train-the-FootTrainer tasks.

•

In Bosnia, primary care centres were visited and diabetic foot courses were given on the spot, they also produced a translation of the guidance document into the Bosnian language.

•

In Croatia the process was organised by top to bottom approach through national diabetes programme holding a central training course.

•

Czech Republic seems to be far ahead with 28 years of experience in foot care, reimbursement of footcare activities and the Podiatric section of Czech Diabetes Society established in 2005.

to give activity progress reports on Diabetic foot care implementation.

Much activity has taken place since the Bled Train-the-Foot-Trainer course in 2016. The levels of footcare, their position in the healthcare system together with the degree of governmental support have evolved substantially between countries.

•

In Romania, the establishment of national Podiatry Association had generated a conflict about the competencies with the national physician’s association and jeopardised the use of a generous EU grant obtained for improvement of diabetic footcare.

•

In Greece, foot meetings and new foot clinics had been stimulated by the National association for the study of diabetic foot, there is also a School of Podiatry in Athens.

•

In Slovenia, strong efforts had been undertaken towards the integration the footcare education in the regular educational system. Improvement of foot-care level is one of the priorities in the National diabetes programme.

•

In Poland, 35 diabetic foot centres had been established, e-learning, and courses for doctors and nurses

A presentation by Kurt Gerok Andersson from Sweden convincingly demonstrated that the costs spent for the foot care saves money and emphasised the need for health economic work.

The Romanian example sent a strong message that legal issues should always be considered. The participants agreed that defining an official diagnosis of diabetic foot in the International Classification of Diseases (ICD) would make the negotiations with decision makers easier.

The forum of delegates voiced the need for a good data collection system and a footcare position statement is required.

Finally, Kristien van Acker emphasised the meaning of support groups which help to prevent burn-out and, last but not least, the need to have clear ideas about organisational issues.

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th The 17 Malvern

Diabetic Foot Conference

Malvern, 16-17 May 2018

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Located at the foot of the Malvern Hills, the dramatic setting of Malvern Theatres was, once again, the venue for the 18th Malvern Diabetic Foot Conference. The 3-day biannual international event, held from May 16th to 17th, brought together international experts and delegates from over 30 countries with the aim of improving our understanding of diabetic foot disease, which is fast emerging as a global healthcare challenge in its own right.

The overarching theme of the opening day was the state of the diabetic foot in 2018 and how we could improve further.

We heard that the National Health Service in England spends over 1 billion pounds on diabetes foot care. Nearly two-thirds is spent on treating foot ulcers in an outpatient setting, while hospital spend accounts for one-third of the expenditure. A high quality multidisciplinary diabetes foot service will help reduce unnecessary amputations but the importance of referral speed and developing a culture of sharing information between primary and secondary care teams was highlighted. The National Inpatient Diabetes Audit (NaDIA, UK) continues to provide unique insight, and while it constantly reminds us that more needs to be done, the progressive reduction in the incidence of hospital acquired diabetes foot ulcerations is an encouraging indicator of the positive impact of the annual audit. In Western

Europe, in particular Belgium and Germany, pioneering work to develop a high quality, integrated foot care service has had led to the creation of tiered system of diabetic foot clinics, which recognise each other’s strengths and allows flow of patients according to their needs.

Day 2 of the conference consisted of 4 sessions including oral abstract presentations and importantly, the first joint symposium with the first British Orthopaedic Foot and Ankle Society (BOFAS). Early in the day, the need to understand and critically appraise published diabetic foot studies to inform practice was argued. We were reminded that despite many published studies, the selection of the correct dressing is not straightforward. This also applies to the correct choice and duration of antibiotics, with emerging evidence supporting the notion that the duration of intravenous therapy required may be shorter than previously thought. The joint symposium focused on how to achieve a high degree of limb salvage in diabetic foot osteomyelitis through precise microbiological characterisation, collaboration between teams, and where necessary, the use of advanced orthopaedic reconstructive or plastic surgical techniques.

On the final day, the delegates were updated on new medical and surgical management perspectives of diabetic foot care, in particular on the management of Charcot Neuroarthropathy. In addition, the wide spectrum of peripheral arterial disease was discussed, ranging from the obvious to the often underrecognized below the ankle disease. The symposium was closed by the chairs, Prof Andrew Boulton and Prof Gerry Rayman, who thanked all the delegates, industry supporters and speakers while reminding us that the next symposium will be held at the same venue between the 13th to 15th May 2020. Overall, this 3day meeting provided an up-to-date overview while facilitating likeminded physicians, surgeons, podiatrists, orthotists, nursing and allied health sta to share and reflect on their experience and ideas on the diabetic foot.

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Educational programmes to reduce amputations in Romania Norina Alinta Gavan

Primary care as first line to reduce the number of amputation. D-Foot International teaching materials as base for learning program. Say STOP. ACT Now.

In November 2017, the Association of Podiatry initiated the Educational Program for Reduction of Amputation in Romania. Having as main partner the National Society of Family Medicine, and under the aegis of D-Foot International, we organised an educational program for updating and increasing the level of information of family doctors in the field of diabetic neuropathy and diabetic foot.

The end goal of this educational program is to reduce the number of amputations in patients with diabetes.

In Romania, the number of lower limb amputations caused by diabetic neuropathy is still very high. The studies published mentioned that 65,2% from people with diabetes have diabetic neuropathy, 14,8% have a history of foot ulcerations and 3,6% had one amputation until the year of 2012.

People with diabetes that have major complications caused by this aliction, such as diabetic neuropathy, need the best care possible in order to successfully treat it. These patients, as well as those that suer from various leg problems, should be treated by a

multidisciplinary team that includes at least the diabetologist, the surgeon, the family doctor, and the podiatrist. These are the recommendations put forth by the International Diabetes Federation, based on the claim that lower limb amputations can be reduced by up to 85% when a diabetes foot care team also include a podiatrist.

In order to raise the awareness on the diabetic foot problem in Romania, the organisers have hosted a series of oline events meant to bring together family doctors, national and international diabetic foot experts and mass media guests.

From February 9-10th 2018, a Train-theFoot-Trainer training was held to train 25 family doctors with trainer competences on the management of diabetic neuropathy and diabetic foot. These family doctors became trainers themselves and they will educate other family doctors across the country on the prevention, diagnostic and treatment of these major complications of diabetes.

The faculty for the trainers was formed from the Bled Train-the-Foot-Trainer people and other opinion leaders from Romania, who are involved since years in this amputation reducing actions.

On March 29th 2018, in Bucharest, was hosted a debate with mass media guests and diabetic foot experts in order to increase the attention to diabetic foot care and its role to decrease the number of amputations and prolong the lives of these patients.

Say STOP! ACT Now! The project was launched on Friday, March 30th 2018, in Bucharest, with a 2 hours symposium that featured international foot experts, Dr. Kristien van Acker, President of DFoot International and David Dunning, Representative of FIP-IFP. This educational program has an online component in form of two electronic courses about diabetic neuropathy and

the diabetic foot, each course with 4 lessons. The courses are hosted by the eLearning platform of the National Society of Family Medicine.

June is marked by the start of the oneday hand-on workshops on screening of diabetic foot. The Association of Podiatry in partnership with the National Society for Family Medicine intend to train 1.000 physicians for practicing the most simple medical tests for screening of diabetic neuropathy, peripheral arterial disease and for preventing the ulcerations in their patients with diabetes.

All the training materials as curricula, power point presentations, movies, questionnaires are based on the D-Foot International online materials.

The organizers want to thank D-Foot International for welcoming their initiative and taking it under their umbrella.

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Explorer is the first clinical trial that has been conducted in neuro-ischaemic diabetic foot ulcer to evaluate the efficacy of UrgoStart2 • It is a double-blind randomized controlled trial conducted on 240 patients, in 5 European countries • UrgoStart allowed patients to reach complete wound closure 60 days sooner vs standard of care alone1

1. Michael Edmonds, José Luis Lázaro-Martínez, Jesus Manuel Alfayate-García, Jacques Martini, Jean-Michel Petit, Gerry Rayman, Ralf Lobmann, Luigi Uccioli, Anne Sauvadet, Serge Bohbot, Jean-Charles Kerihuel, Alberto Piaggesi.Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial Lancet Diabetes Endocrinol 2018 ;6 :186-196 2. D.R. Shanahan. The Explorer Study: the first double-blind RCT to assess the efficacy of TLC-NOSF on DFUs. Journal of Wound Care Vol. 22, Iss. 2, 14 Feb 2013, 78 - 81

Editor’s note You may remember in a previous Footnote we brought to your attention the joint collaboration between D-Foot International and the International Federation of Podiatrists (FIP-IFP). We would like to now share with you how things are progressing.

This is an exciting and potentially far-reaching and milestone forward move towards promoting the competency-based training for podiatric care in people with diabetes across Europe and worldwide.

Please read the following article to learn more. The competency training curriculum will soon be published in the Diabetic Foot Journal.

ARTICLE

The POINT project Podiatry for International Diabetic Foot Teams Pauline Wilson, Neil Baker, Kristien Van Acker, Norina Gavan, Esther Garcia Morales, Matthew Garafoulis, Stuart Baird, Caroline Teugels, Luc Hendrix, Meike Fransen Citation: Wilson P, Baker N, Van Acker K et al (2018) The POINT project. The Diabetic Foot Journal 21(2): XX–XX

Article points 1. Podiatrists are important in the overall management of diabetic foot through prevention, management and remission 2. The presence and practice of podiatry is greatly varied worldwide with low and middle income countries often without appropriately trained health care professionals 3. A The point document guides multi-disciplinary teams as to which podiatric skills are needed to deliver evidence based foot care irrespective of the presence of podiatrists.

Key words - Collaboration - Competency - Podiatry

Authors Pauline Wilson is Xxx International Federation of Podiatrists and D-Foot international; Neil Baker is Xxx D-Foot international; Kristien van Acker is Xxx D- Foot international; Norina Gavan is Xxx International Federation of Podiatrists and D-Foot international; Esther Gardcia Morales is Xxx D-Foot international; Matthew Garafoulis is Xxx International Federation of Podiatrists; Stuart Baird is Xxx International Federation of Podiatrists; Caroline Teugels is Xxx International Federation of Podiatrists; Luc Hendrix is Xxx D- Foot international; Mieke Fransen is Xxx International Federation of Podiatrists

1

The POINT project is a collaboration between D-Foot international and the International Federation of Podiatrists. The point documents create a standardised staged competency framework for the inclusion of podiatric skills worldwide in the management of diabetic foot disease. The presence of podiatrists with unique skill sets as part of the multidisciplinary diabetic foot team is well established in the literature. Many countries, especially those in lower- and middle-income regions do not have podiatrists available as part of their team. The point document, which is a multidisciplinary consensus, identifies the skills needed to provide podiatric skills across four levels irrespective of the presence of podiatrists. The point document provides guidance for three groups: firstly, for diabetic foot teams in identifying areas of strength and weakness; secondly, for teams without podiatrists to identify the podiatric skills needed; finally, for decision makers to be informed of the skills, which can be provided by podiatrists. The point document is now to be disseminated widely for local translation and implementation.

T

he POINT (podiatry for international diabetic foot teams) project is a collaboration between D-Foot International and The International Federation of Podiatrists (FIP-IFP). D-Foot international, formerly the Implementation arm of the International Working Group of the Diabetic Foot (IWGDF), is an international non-profit registered association, promoting the global profile of diabetic foot prevention and care through awareness, guidance, education, research and professional development (www.d-foot.org). It is a multidisciplinary network of clinicians involved in the management of diabetic foot disease with a network of over 150 countries around the world. FIP-IFP is an international membership organisation of podiatrists representing 28 countries. It has, for 70 years, promoted the practice of podiatry worldwide showcasing what podiatrists can offer in all areas of lower-limb and foot health.

The aims and objectives of this collaboration were to: n Facilitate the introduction of a staged podiatry competency training framework in countries where diabetes foot care infrastructures currently exist n In relation to the above, provide a standardised staged competency based framework for podiatry training on a regional/international levels n Utilise the D-Foot-initiated foot care as an access point for development of podiatry in countries where podiatry does not formerly exist n To explore definitions regarding differing levels of podiatry/diabetic foot care and to align the skill levels associated with each level.

The presence of diabetes continues to increase globally with an estimated 629 million people living with the condition worldwide by 2045 (International Diabetes Federation, 2017). Even The Diabetic Foot Journal Vol 21 No 2 2018

The POINT project

if the prevalence of diabetic foot disease remains stable, the number of people suffering from the condition will continue to increase due to the increase in numbers of people with diabetes (Susan et al, 2010). In 1989, the St. Vincent declaration, a joint initiative between the World Health Organization (WHO) and the International Diabetes Federation (IDF) included 5-year targets for improving outcomes in patients with diabetes including reducing amputation rate by half (Krans et al, 1992). Nearly 30 years later, the reality is that that with an increase in the prevalence of diabetes, the rates of ulceration and subsequent lowerextremity amputation continue to rise (Buckley et al, 2012). Patients with diabetes should receive best practice irrespective of geographical location (World Health Organization, 2002).

The role of the podiatrist in the maintenance of mobility and good foot and lower-limb health is acknowledged in the literature (Brodie et al, 2001; Alcacer-Pitarch et al, 2011). The specific role of podiatrists in the management of the diabetic foot covers a broad range of practical skills throughout the disease process and is crucial to the effective management of the condition (Boulton et al, 2005; Sloan et al, 2010). The particular skills of podiatrists in the assessment of gait patterns and pressure reduction are pivotal in the prevention of ulceration in the neuropathic foot (Kim et al, 2012). Despite the evidence and guidance supporting the inclusion of podiatrists, there remains a great variance in diabetic foot management and practice worldwide (Abbas et al 2011; Holman et al 2012).

IWGDF produces evidence-based guidance to support clinicians and healthcare systems to strive for best practice in diabetic foot management every 4 years using the GRADE recommendations (Guyatt et al, 2011). Such guidance will only have an impact on clinical outcomes when it is implemented (Woolf et al, 1999). This guidance recommends the inclusion of podiatrists in the delivery of care for patients with diabetic foot disease. In the absence of suitably skilled podiatrists to deliver guidance based care the implementation of guidance becomes difficult. In countries where guidance has been fully incorporated, the profession of podiatry is well established.

The POINT team was made up of representatives from both organisations across a variety of

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geographical and professional boundaries. The authors met to discuss the challenges in delivering good podiatric care to patients with diabetic foot disease in the absence of podiatrists or where podiatry has been under-developed. The authors also discussed the challenge of the myriad of different names and titles for podiatry globally.

We give gracious acknowledgement to the Podiatry Competency Framework for Integrated Diabetic Foot Care (TRIEPodD-UK, 2012), which identified skills across six levels of podiatric practice needed in the UK. The authors utilised this document as a basis for the identification of skills and adapted it for practice in the international arena. The skills identified by discussion and aided by the TRIEPodUK document were wide ranging and covered the breadth of management of diabetic foot disease. Dependent on geographical location and resources, skills were performed by different members of the multidisciplinary diabetic foot team (MDT). Through MDT discussions, members achieved consensus on what constitutes podiatric input into the management of diabetic foot disease.

The consensus and the resulting POINT document illustrates that the skills needed are more important than the profession delivering them.

Podiatrists are often heralded as the gatekeepers to the MDT and have a specific set of skills, which can identify those in need of targeted interventions (Rogers et al 2010, Paisley et al 2018). Data have shown that it is not just about the interventions given, but the delivery of interventions as part of a multidisciplinary team that leads to improved outcomes (Jeffcoate and Young, 2018; Paisley et al, 2018).

Unlike many healthcare professionals, the presence and practice of podiatry varies around the globe (Brockmann et al, 2009). This is of particular relevance in low- and middle-income countries where healthcare services are less developed yet 75% of the global population with diabetes live in these countries and the practice is podiatry is less developed (International Diabetes Federation, 2017).

The POINT document is an attempt to guide MDT’s to which skills are needed in the delivery of evidence-based diabetic foot care irrespective of the inclusion of podiatry in individual teams.

The arguments for the delivery of diabetic

Page points 1. The role of the podiatrist in the assessment of gait patterns and pressure reduction are pivotal in the prevention of ulceration in patients with neuropathy.

2. The skills identified were wide ranging and covered the whole area of diabetic foot disease.

3. Multidisciplinary team working leads to improved outcomes.

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Box 1. The POINT document’s practices across 13 separate domains of diabetic foot care.

Generic skills

Assessment /diagnosis

Dermatology

Diagnostic imaging

Pharmacology

Peripheral vascular disease

Charcot foot

Ulcer prevention

Surgery

Dermatology

Wound care

Painful peripheral neuropathy

Research /audit and leadership

foot care in a multidisciplinary manner are well made and prevalent throughout the literature and guidance (Edmonds et al 1986; Apelqvist et al 2000; Krishnan et al 2008; Moore et al, 2014).

There is a lot of evidence regarding the structure of MDTs and their geographical delivery (Moore et al, 2014). Such teams traditionally were hospital based with care focussing on the management of the acute foot episode of the disease (Edmonds et al, 1986; Driver et al, 2010; Mickan et al, 2005; Rogers et al, 2010; Chiu et al 2011). Prescriptive team models appear to be less relevant in modern practice due to the variety in healthcare settings, delivery and reimbursement models, which can vary widely (Basu and Hassenplug, 2012; Faulkner et al, 2012). The international drive towards integrated, person-centred healthcare means that an MDT no longer refer to teams based in the one location, but upon shared characteristics (Fitzgerald et al, 2009; Driver et al 2010; Chiu et al 2011).

The POINT document aims to be broad enough to implement across all types of teams irrespective of structure or location of care (Vyt, 2008; World Health Organization, 2017). Any decision on the individual design of teams are politically sensitive and are best made at local level where the individual team members are best placed to design services around the local population and service needs (Porche, 2006; Donaldson et al, 2014). The patient with diabetic foot disease is a challenge with multiple morbidities requiring the input from a large number of different professionals (Boulton et al, 2005; Bus, 2012). At different times in the journey of diabetes, different professionals will be at the forefront in the design and delivery of care, while still operating within the MDT (Plank et 3

al, 2003; Armstrong et al, 2013). Each location will have its own challenges even within the same region.

The consensus among the members of the POINT team is that while ideally all the skills identified are performed by health care workers with specific podiatric training the reality is likely to be much different. The POINT document includes practices across 13 separate domains of diabetic foot care (Box 1).

The document is designed to be as comprehensive as possible without being prescriptive about the way in which care should be delivered. As with most multidisciplinary discussions, the group reached a compromise identifying four distinct levels of care, which could be defined as podiatric practice globally. Each level in the document is an increase on the previous level in complexity of skill. This makes for a lengthy document because within each level there is further distinction between knowledge and skills. There is an implied understanding that individual practitioners at any level are aware of their own limitations of knowledge and practice.

Practitioners currently practising within the arena may find this quite repetitive and such explicit detail unnecessary. The POINT team feel that this is imperative in order to prevent any confusion across language and cultural barriers. All skills identified at levels 2, 3, and 4 are in addition to those at level 1. Practitioners at levels 1 and 2 of practice should be supervised by those with higher levels of practice. Ideally, this supervision and support should be delivered by colleagues within the same team environment where the expertise is available locally.

In the opinion of the group, a country where podiatric practice is well established is likely to have practices towards levels 3 and 4 of the model although this may be dependent on the legislative frameworks in place.

The aim of the POINT guide to podiatric practice in the management of diabetic foot disease is three-fold: n As a training and development tool for existing MDTs to assist them in identifying areas of strength and weakness. Acknowledging limitations within MDT practice is an important part of the reflective cycle for each team for quality improvement. Care should be delivered consistently across all domains of the model The Diabetic Foot Journal Vol 21 No 2 2018

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n For areas where podiatric practice is not available as part of the current MDT to identify the skills needed in the absence of podiatrists. For these teams, the model may be of use in lobbying healthcare systems for increased resources. If a team is able to identify areas of need this can be addressed in future service and training planning n The tool may be of use for decision makers to be informed of the range of skills required to deliver multidisciplinary diabetic foot teams, as well as the pivotal role which podiatrists can play in the overall management of diabetic foot disease. The POINT document may enable the identification of skills in the design of training programmes either at a local informal level or more formally at a regional or national level.

The POINT project team are aware that MDT foot practice is enhanced by the inclusion of podiatrists (Driver et al, 2010), but cognisant that in the absence of a definitive training syllabus for the role of diabetic foot specialist podiatrists, it can be difficult for diabetic foot MDTs to implement best practice.

This model is not designed to be a syllabus for training podiatrists, but a guide to the skills needed to deliver evidence-based care irrespective of professional or geographical boundaries.

A glossary of terms is also included to aid comprehension across language and cultural barriers.

As practitioners with an interest in the management of the diabetic foot, many of whom work in multidisciplinary teams, the authors know that the benefits of team working extend beyond the clinical outcome. Informal learning and networking that occurs between team members is valuable to the patient experience, as well as to the strengthening of relationships between team members (Li et al, 2009). It has been well documented that a well-co-ordinated team that communicates well leads to better patient outcomes (Coulter et al, 2013). Andrew Carnegie said: “Teamwork is the ability to work together toward a common vision — the ability to direct individual accomplishments toward organisational objectives. It is the fuel that allows common people to attain uncommon results” (Mercer and Myers, 2013). The

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POINT team and both organisations share the common vision for the inclusion of podiatry across the globe in the management of this condition, which places a large burden on both patients and societies. Together, the inclusion of podiatrists as gatekeepers to MDTs can be promoted. Dissemination and implementation of this document is now a priority for both organisations. The first step has been to reach consensus, now the challenge really begins. n Abbas ZG, Lutale JK, Bakker K et al (2011) The ‘Step by Step’ Diabetic Foot Project in Tanzania: a model for improving patient outcomes in less-developed countries. Int Wound J 8(2): 169–75 Alcacer-Pitarch B, Siddle HJ, Buch MH et al (2011). Foot health needs in people with systemic sclerosis: an audit of foot health care provision. Clin Rheumatol 30(12): 1611–5 Apelqvist J, Larsson J (2000) What is the most effective way to reduce incidence of amputation in the diabetic foot?.

Diabetes Metab Res Rev 16(Suppl 1): S75–83 Basu S, Hassenplug JC (2012) Patient access to medical devices — a comparison of US and European review processes. N Engl J Med 367(6): 485–8 Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J (2005) The global burden of diabetic foot disease. Lancet 366(9498): 1719–24 Brockmann M, Clarke L, Winch C (2009) Difficulties in Recognising Vocational Skills and Qualifications Across Europe. (In) Assessment in Education: Principles, Policy & Practice 16(1): pp97–109 Brodie BS (2001) Health determinants and podiatry. J R Soc Promot Health 121(3): 174–6 Buckley CM, O’Farrell A, Canavan RJ et al (2012) Trends in the incidence of lower extremity amputations in people with and without diabetes over a five-year period in the Republic of Ireland. PLoS One 7(7): e41492 Bus SA (2012) Priorities in offloading the diabetic foot. Diabetes Metab Res Rev 28(Suppl 1): 54–9 Chiu CC, Huang CL, Weng SF et al (2011) A multidisciplinary diabetic foot ulcer treatment programme significantly improved the outcome in patients with infected diabetic foot ulcers. J Plast Reconstr Aesthet Surg 64(7): 867–72 Coulter A, Roberts S, Dixon A (2013) Delivering Better Services for People with Long-Term Conditions. Building the House of Care. The King’s Fund, London pp1–28 Donaldson L, Rutter P, Henderson M (2014) The Right Time, the Right Place: An Expert Examination of the Application of Health and Social Care Governance Arrangements for Ensuring the Quality of Care Provision in Northern Ireland.

Social Services and Public Safety. The Department of Health, Belfast Driver VR, Fabbi M, Lavery LA, Gibbons G (2010) The costs of diabetic foot: the economic case for the limb salvage team. J Vasc Surg 52(3 Suppl): 17S–22S Edmonds ME, Blundell MP, Morris ME et al (1986) Improved survival of the diabetic foot: the role of a specialised foot clinic. Q J Med 60(2): 763–71 Faulkner E, Annemans L, Garrison L et al (2012) Challenges in the development and reimbursement of personalized medicine — payer and manufacturer perspectives and implications for health economics and outcomes research: a report of the ISPOR Personalized Medicine Special Interest Group. Value Health 15(8): 1162–71 Fitzgerald RH, Mills JL, Joseph W, Armstrong DG (2009) The diabetic rapid response acute foot team: 7 essential skills for targeted limb salvage. Eplasty 9: e15 Guyatt GH, Oxman AD, Schünemann HJ et al (2011) GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 64(4): 380–2 Holman N, Young RJ, Jeffcoate WJ (2012) Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 55(7): 1919–25

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International Diabetes Federation (2017) IDF Diabetes Atlas (8th edn.) International Diabetes Federation, Brussels Jeffcoate W, Young B (2018) Reducing amputation in diabetes: work from the West Country provides both evidence and a tool-kit. Diabet Med 35(1): 8–9 Kim PJ, Attinger CE, Evans KK, Steinberg JS (2012) Role of the podiatrist in diabetic limb salvage. J Vas Surg 56(4): 1168–72 Krans HM, Porta M, Keen H (1992) Diabetes care and research in Europe: the St Vincent Declaration action programme, implementation document. In: Diabetes Care and Research in Europe: The St Vincent Declaration Action Programme; Implementation Document. Health Psychology Research, London Krishnan S, Nash F, Baker N et al (2008) Reduction in diabetic amputations over 11 years in a defined UK population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care 31(1): 99–101 Mercer DK, Myers S (2013) Theory into practice: a cry from the field for innovative leadership development. Educational Considerations 41(1): 2–5 Mickan SM, Rodger SA (2005) Effective health care teams: a model of six characteristics developed from shared perceptions. J Interprof Care 19(4): 358–70 Moore ZB, Corbett G, McGuiness LQ (2014) Exploring the concept of a team approach to wound care: Managing wounds as a team. J Wound Care 23(Suppl 5b): S1–S38 Li LC, Grimshaw JM, Nielsen C et al (2009) Evolution of Wenger’s concept of community of practice. Implementation Science 4(1): 11 Paisey RB, Abbott A, Levenson R et al (2018) Diabetes-related major lower limb amputation incidence is strongly related

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to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England. Diabetic Med 35(1): 53–62 Plank J, Haas W, Rakovac I et al (2003) Evaluation of the impact of chiropodist care in the secondary prevention of foot ulcerations in diabetic subjects. Diabetes Care 26(6): 1691–5 Porche Jr RA (2006) Doing More with Less: Lean Thinking and Patient Safety in Health Care. Institute for Healthcare Improvement, Chicago, Il Rogers LC, Andros G, Caporusso J et al (2010). Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg 52(3 Suppl): 23S–27S Sloan FA, Feinglos MN, Grossman DS (2010) Receipt of care and reduction of lower extremity amputations in a nationally representative sample of US elderly. Health Serv Res 45(6 Pt 1): 1740–62 van Dieren S, Beulens JW, van der Schouw YT et al (2010) The global burden of diabetes and its complications: an emerging pandemic. Eur J Cardiovasc Prev Rehabil 17(Suppl 1): S3–8 Vyt A (2008) Interprofessional and transdisciplinary teamwork in health care. Diabetes Metab Res Rev 24(Suppl 1): S106–9 Woolf SH, Grol R, Hutchinson A et al (1999) Potential benefits, limitations, and harms of clinical guidelines. BMJ 318(7182): 527–30 World Health Organization (2017) WHO Framework on Integrated People-Centred Health Services. WHO, Geneva.

Available at: https://bit.ly/1xFqNWt (accessed 24.04.2018) World Health Organization (1999) Diabetes: The Cost of Diabetes (Fact sheet No. 236). WHO, Geneva. Available at: https://bit.ly/2jjH7bs (accessed 30.04.2018)

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t c a r t s b A n a c S Meloni M, Izzo V, Giurato L, Del Giudice C, Da Ros V, Cervelli V, Gandini R, Uccioli.

Recurrence of critical limb ischemia after endovascular intervention in patient with diabetic foot ulcers.

Adv Wound Care (New Rochelle). 2018 Jun 1 7(6): 171-176.

(Pubmed ID#29892493 – Free PMC article).

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5994148/

This is an interesting article by a team of Italian physicians who evaluated a group of 304 patients undergoing interventional angioplasty for the treatment of diabetic foot tissue loss. Understandably, this is a very common intervention seen with diabetic foot disease, and some disagreement persists with respect to the specific indications for open vs. endovascular revascularization. What makes this article interesting, however, is that the aim was to evaluate the durability of the intervention. In fact they found that nearly 25% of patients required a second angioplasty at a mean of 3.5 months following the index procedure, and that the patients who required a second angioplasty had a higher rate of poor clinical outcome. I think this calls into focus a relative weakness within our specialty with respect to the evaluation of arterial flow as it relates to healing potential. Too often we consider this a categorical variable (i.e. either the limb has “PAD” or “No PAD” or the limb has been “Revascularized” vs. “Not Revascularized), while in actuality we should probably be considering this as more of a continuous outcome and embracing the relative gray of this important variable to clinical success.

Hoffman J, Haastert B, Brune M, Kaltheuner M, Begun A, Chernyak N, Icks A. How do patients with diabetes report their comorbidities?

Comparison with administrative data.

Clin Epidemiol. 2018 Apr 30; 10: 499-509.

(Pubmed ID 29750054 – Free PMC Article).

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5933335/ Foot disease is only one of many potential sequela associated with the pathogenesis of the diabetes mellitus disease process. This clever investigation by a team of German physicians sought to study the perceptions of patients with respect to their disease. They specifically asked a random sample of patients with diabetes about the presence or absence of 14 comorbidities closed related to diabetes, and then checked this against the patient’s medical record. Foot ulceration was one of two conditions (the other being eye disease) that was poorly self-reported by patients, indicating that we could probably all be doing a better job with respect to the education of our patients, increasing awareness of selfmanagement, and encouraging their active participation in care.

Fife CE, Eckert KA, Carter MJ. Publicly reported wound healing rates: The fantasy and the reality.

Adv Wound Care (New Rochelle). 2018 Mar 1; 7(3): 77-94. (Pubmed ID#29644145 – Free PMC Article).

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5833884/ Particularly for readers in the US, this article has particular relevance as insurance carriers have moved increasingly closer toward outcomebased reimbursement strategies. It begins by asking a seemingly basic question: What is a normal healing rate for a diabetic foot ulcer and for a venous leg ulcer? The answer, of course, depends on who you ask!

Their review of data on the websites of 44 commercial clinics in 44 US states found relatively high reported rates of healing (at least 80% with a mean time of 4.3 weeks), while a review of data from randomized controlled trials found relatively lower rates of healing (approximately 40% with no studies reporting a mean time close to 4 weeks). This is an important study that can provide some insight into reasonable expectations for both patients and physicians, as well as help bridge the gap between high-controlled scientific studies and real-world practice.

Kim PJ, Attinger CE, Bigham T, Hagerty R, Platt S, Anghel E, Steinberg JS, Evans KK. Clinic-based debridement of chronic ulcers has minimal impace on bacteria.

Wounds. 2018 May; 30(5): 138-143. (Pubmed ID#29521643).

Link: http://www.woundsresearch.com/article/clinic-baseddebridement-chronic-ulcers-has-minimal-impact-bacteria Outpatient, clinic-based, serial excisional debridement of chronic wounds represents a very common practice. However, this study found no effect of this intervention when primarily considering the bacteria in and around wounds. Most basically, their results found that the amount of and types of bacteria were similar pre- and post-debridement in their clinic. However, the authors appropriately state that these results should be interpreted “thoughtfully�. The presence of bacteria is not necessarily correlated with outcome measures such as wound healing, and many studies have reported on the beneficial effects towards improved wound healing with serial debridement. And although it may dismay our infectious disease colleagues, the effects of debridement go well beyond the presence or absence of bacteria in a wound. The primary target of debridement is likely not bacteria, but rather the proinflammatory cytokines leading to the presence of a chronic inflammatory state.

Ingram JR, Cawley S, Coulman E, Gregory C, Thomas-Jones E, Pickles T, Cannings-John R, Francis NA, Harding K, Hood K, Piguet V. Levels of wound calprotectin and other inflammatory biomarkers aid in deciding which patient with a diabetic foot ulcer need antibiotic therapy (INDUCE study).

Diabet Med. 2018 Feb; 35(2): 255-261. (Pubmed ID#: 28734103 – Free PMC article).

Link: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5811820/ One of the easiest, and perhaps because of this relative ease, over utilized interventions for the treatment of diabetic foot ulcerations is antibiotic therapy. However, most people agree that antibiotics should only be prescribed for the treatment of acute, active infections as opposed to clinically uninfected chronic wounds. This can make for challenging clinical decision making, particularly in situations of deep chronic wounds with necrotic and fibrotic tissue build-up. This study sought to investigate how inflammatory biomarkers (specifically venous white cell count, C-reactive protein, procalcitonin, and wound calprotectin) assist in the this clinical decision making. Their specific algorithm only yielded a specificity of 0.81 and sensitivity of 0.64, and although potentially promising for future investigations, emphasizes infection as a clinical, as opposed to laboratory, diagnosis.

Q ui z CLINICAL PICTURE QUIZ Welcome to another clinical picture quiz. I hope that you found the last one interesting and of some clinical value. Once again, I have opted to present something simple but the next clinical quiz I hope will be more challenging.

Please look at the picture carefully and consider all that you see, I agree that you cannot see much of the feet in the picture but ‌ Here are some questions to provoke some thoughts: 1. What age group do you think this patient is?

2. Describe the most obviously presenting feature that you see and where it is.

3. Can you determine what this is and why it is there?

4. Are there any other features/ pathologies that you can see?

5. What do you think this feature is?

6. What would you do?

ANSWERS AND SUGGESTIONS Looking at the overall condition of the skin and condition of the nails it would be most likely that this patient is a young to middle aged adult and is most likely male.

The most outstanding and obvious feature of these feet is the green area under the medial distal half of the left 1st nail plate. You will notice that the leading edge of the nail has been cut obliquely and short suggesting someone has tried to see if there was a collection of pus or fluid. The green colour is denser in the central area and fades towards the edges with a cream coloured halo in the proximal edge. This is strongly suggestive of separation of the nail plate from the nail bed with likely onychophosis (skin and debris under the nail plate). Onychophosis usually occurs in the nail sulcus (groove) but can extend subungually in certain circumstances. You will also notice there is some localised discreet callus at the distal end of the medial sulcus at the free edge of the nail.

This condition is called Chloronychia. The discolouration can vary from blue-green to dark green to bluish grey. This condition is usually confined to one or two nails, is not painful although the sulcus and or cuticle can be inflamed. It is an infection caused by Pseudomonas Aeruginosa.

These bacteria only flourish in damp/wet environments and required an entry point as do all. The nail plate is separated from the nail bed most likely due to repetitive stubbing trauma, which would have caused nailplate/bed separation.

Other features and pathologies that can be seen: There are several other presenting pathologies/features that can be seen in the photo. Firstly, it is very evident that the 1st nail on the right is also discoloured – white, in the distal 1/3rd of the medial nail plate extending diagonally from mid -sulcus to the middle of the leading free edge. Again, this due to separation of the nail plate from the bed with almost certainly moist onychophosis. Once again this is most likely due to microtrauma from stubbing. The discolouration also has a slight orange tinge to it particularly in the sulcus and several white flecks can also be seen in the nail plate. This might indicate an early fungal toenail infection.

The feature that leads to the idea that repeated minor stubbing injury is occurring is that there are discreet small circular inflamed areas over the medial aspect of the 1st interphalangeal dorsal surface. These lesions also appear slightly swollen but well defined suggesting they are not new but longstanding. If you look closely you will see

that pre-callus formation is beginning to occur over these areas. This is almost certainly due to extensor hallucis longus overpull possibly resulting from a mobile plantar flexed 1st ray. I would suggest that examining the rearfoot /forefoot relationship would be advantageous and my guess would be an inverted forefoot (mobile not fixed) with resultant plantarflexion of the 1st ray leading to extensor overpull. If you look very carefully you can just make out the prominent extensor hallucis tendon at the base of the left great toe.

The other main feature is on the right 2nd toe. The toe is clawed with slight medial deviation and dorsiflexion of the proximal and lateral deviation and plantarflexion of the intermediate phalanges. There is evident trauma to the dorsal surface of the proximal interphalangeal joint. There is some inflamed soft tissue swelling over the joint which is most likely an adventitious bursitis, with some pre-callus formation. Again, if you look at the base of the toe you can just see the outline of the Extensor Digitorum longus.

This again is suggestive of extensor overpull which may be due to a hypermobile midtarsal joint, mobile inverted forefoot or muscle wasting due to motor neuropathy.

Another feature is the presence of callus at the distal margin of the right medial 1st nail sulcus suggestive of trauma – again in

keeping with the main presenting features.

Often callus in nail grooves are dismissed without a second thought, but it is there as a result of altered foot function. As such I would challenge you to consider this very subtle clinical presentation a little more closely and ask “what is causing this to occur�? How does it relate to other pathologies seen, e.g. the clawing of the toes in this case? Is callus in the nail sulci pathologic?

To treat chloronychia or pseudomonas infection there are several options. The simplest and one that is usually eective is to cut back the loose nail plate remove all of the moist subungual debris (maybe send some for microbiology and perhaps microscopy too) and allow the area to dry out. Additionally, to try to prevent further trauma to the area. The use of topical agents that suppress the growth or kill pseudomonas can also be useful, these may include antibiotics, vinegar, povidone iodine and even bleach diluted to 1:4 in water.

Unless there is a nail bed infection, systemic antibiotics e.g. Ciprofloxacin are not normally required.

Of equal value is determining the cause of the trauma, triggering of the 1st and clawing of the 2nd toe and then looking to deal with these. All of the aforementioned pathologies are ulcers waiting to happen. So, this will involve a biomechanical assessment, using

functional foot orthoses if this is a sensate foot, determining whether this should be rigid, semi-flexible and whether there should be intrinsic and or extrinsic posting to the rear and forefoot. If the foot is insensate then again should a semifunctional or accommodative orthosis be used. Consider extra depth therapeutic footwear with a rocker sole and determine the optimal position and angle of the rocker in an insensate foot. Prevention is better than ulceration and potential amputation!!

I hope this has been useful and the above are only my view and suggestions.

If you want to make comments or suggestions feel free to send them in and we will do our best to create a feedback section in the next Footnote

Click here to go to the abstracts

ABSTRACTS GALORE The Predictive Factors Associated With Comorbidities for Treatment Response in Outpatients With King Classification III Diabetes Foot Ulcers.

A randomized controlled trial comparing helium-neon laser therapy and infrared laser therapy in patients with diabetic foot ulcer.

Staphylococcus aureus requires less virulence to establish an infection in diabetic hosts.

Characteristics, prevalence, and outcomes of diabetic foot ulcers in Africa. A systemic review and meta-analysis.

The Society for Vascular Surgery Wound, Ischemia, and footInfection (WIfI) classification system predicts wound healing better than direct angiosome perfusion in diabetic foot wounds.

Intervention planning for the REDUCE maintenance intervention: a digital intervention to reduce reulceration risk among patients with a history of diabetic foot ulcers.

Perioperative and long-term all-cause mortality in patients with diabetes who underwent a lower extremity amputation.

Hemostatic state augmented with platelet indices among Sudanese diabetic septic foot.

Association between VEGF genetic variants and diabetic foot ulcer in Chinese Han population: A case-control study.

Effect of negative pressure wound therapy on molecular markers in diabetic foot ulcers.

Increasing diabetic patient engagement and self-reported medication adherence using a web-based multimedia programme.

Plantar blood flow response to accumulated pressure stimulus in diabetic people with different peak plantar pressure: a non-randomized clinical trial.

Radiotracer Imaging Allows for Noninvasive Detection and Quantification of Abnormalities in Angiosome Foot Perfusion in Diabetic Patients With Critical Limb Ischemia and Nonhealing Wounds.

Ultrasound-assisted debridement of neuroischaemic diabetic footulcers, clinical and microbiological effects: a case series.

Perception of diabetic foot ulcers among general practitioners in four European countries: knowledge, skills and urgency.

Microcurrent as an adjunct therapy to accelerate chronic wound healing and reduce patient pain.

Clinical application of a 3D-printed scaffold in chronic wound treatment: a case series.

Incidence and Risk Factors of Diabetic Foot Ulcer: A PopulationBased Diabetic Foot Cohort (ADFC Study)-Two-Year Follow-Up Study.

Severe Pain During Wound Care Procedures: A Cross Sectional Study Protocol.

Empowerment of type 2 diabetic patients visiting Fuladshahr diabetes clinics for prevention of diabetic foot.

Diabetic foot syndrome (DFS) in patients with diabetes. A multicenter German/Austrian DPV analysis on 33,870 DFS patients among 358,986 adult subjects with diabetes.

Low-level laser irradiation modifies the effect of hyperglycemia on adhesion molecule levels.

A high ankle-brachial index is associated with obesity and low serum 25hydroxyvitamin D in patients with diabetes.

Salient features and outcomes of Charcot foot - An oftenoverlooked diabetic complication: A 17-year-experience at a diabetic center in Bangkok.

Click here to go to the abstracts

Clinico-microbiological Profile of Septic Diabetic Foot with Special Reference to Anaerobic Infection.

Establishing Differences in Thermographic Patterns between the Various Complications in Diabetic Foot Disease.

Remote Temperature Monitoring in Diabetic Foot Ulcer Detection.

Understanding Diabetic Induction of Cellular Senescence: A Concise Review.

A Post-marketing Surveillance Study of Chronic Wounds Treated With a Native Collagen Calcium Alginate Dressing.

Safety and Efficacy of an Autologous Blood Clot Product in the Management of Texas 1A or 2A Neuropathic Diabetic Foot Ulcers: A Prospective, Multicenter, Open Label Pilot Study.

A Total Offloading Foot Brace for Treatment of Diabetic Foot Ulcers: Results From a Halted Randomized Controlled Trial.

Accelerated healing of a diabetic foot ulcer using autologous stromal vascular fraction suspended in platelet-rich plasma.

Follow up of MRI bone marrow edema in the treated diabetic Charcot foot - a review of patient charts.

Transcutaneous oxygen pressure as a predictor for short-term survival in patients with type 2 diabetes and foot ulcers: a comparison with anklebrachial index and toe blood pressure.

Factors associated with amputation among patients with diabetic footulcers in a Saudi population.

Platelet-rich plasma as an additional therapeutic option for infected wounds with multi-drug resistant bacteria: in vitro antibacterial activity study.

Illness Perception as a Predictor of Foot Care Behavior Among People With Type 2 Diabetes Mellitus in Indonesia.

Barriers to foot care in patients with diabetes as identified by healthcare professionals.

Building a scalable diabetic limb preservation program: four steps to success.

Use of Leukocyte Platelet (L-PRF) Rich Fibrin in Diabetic Foot Ulcer with Osteomyelitis (Three Clinical Cases Report).

Development of a Pharmacoeconomic Model to Demonstrate the Effect of Clinical Pharmacist Involvement in Diabetes Management.

Gait Shear and Plantar Pressure Monitoring: A Non-Invasive OFS Based Solution for e-Health Architectures.

The Clinical Value of Diffusion Weighted Magnetic Resonance Imaging in Diabetic Foot Infection.

Impact of heart failure and dialysis in the prognosis of diabetic patients with ischemic foot ulcers.

Effectiveness of viable cryopreserved placental membranes for management of diabetic foot ulcers in a real world setting.

Human recombinant epidermal growth factor in skin lesions: 77 cases in EPItelizando project.

Efficacy and safety of the combination of isosorbide dinitrate spray and chitosan gel for the treatment of diabetic foot ulcers: A double-blind, randomized, clinical trial.

An aseptically processed, acellular, reticular, allogenic human dermis improves healing in diabetic foot ulcers: A prospective, randomised, controlled, multicentre follow-up trial.

A Factor Increasing Venous Contamination on Bolus Chase Threedimensional Magnetic Resonance Imaging: Charcot Neuroarthropathy.

A novel technique: Indocyanine green angiography to prognosticate healing of foot ulcer in critical limb ischemia.

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Impaired vibrotactile sense in children and adolescents with type 1 diabetes Signs of peripheral neuropathy.

Decreasing an Offloading Device's Size and Offsetting Its Imposed Limb Length Discrepancy Lead to Improved Comfort and Gait.

Association of Hemoglobin A1c and Wound Healing in Diabetic FootUlcers.

Contemporary critical limb ischemia: Asian multidisciplinary consensus statement on the collaboration between endovascular therapy and wound care.

Dynamic contrast-enhanced magnetic resonance imaging for differentiating osteomyelitis from acute neuropathic arthropathy in the complicated diabetic foot.

Neurotensin-loaded PLGA/CNC composite nanofiber membranes accelerate diabetic wound healing.

Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians.

Exosomes from adipose-derived stem cells overexpressing Nrf2 accelerate cutaneous wound healing by promoting vascularization in a diabetic foot ulcer rat model.

Outpatient Negative-Pressure Wound Therapy Following Surgical Debridement: Results and Complications.

Prospective Analysis of Surgical Bone Margins After Partial FootAmputation in Diabetic Patients Admitted With Moderate to Severe FootInfections.

Publicly Reported Wound Healing Rates: The Fantasy and the Reality.

An evaluation of an ultrasonic debridement system in patients with diabetic foot ulcers: a case series.

Interobserver reliability of the ankle-brachial index, toe-brachial index and distal pulse palpation in patients with diabetes.

MiR-34a Regulates Axonal Growth of Dorsal Root Ganglia Neurons by Targeting FOXP2 and VAT1 in Postnatal and Adult Mouse.

Health Sensors, Smart Home Devices, and the Internet of Medical Things: An Opportunity for Dramatic Improvement in Care for the Lower Extremity Complications of Diabetes.

Use of Dehydrated Human Amnion/Chorion Membrane Allografts in More Than 100 Patients with Six Major Types of Refractory Nonhealing Wounds.

Low molecular-weight fucoidan protects against hindlimb ischemic injury in type 2 diabetic mice through enhancing endothelial nitric oxide synthase phosphorylation.

Efficacy and long-term longitudinal follow-up of bone marrow mesenchymal cell transplantation therapy in a diabetic patient with recurrent lower limb bullosis diabeticorum.

Reliability of Infrared Thermography Images in the Analysis of the Plantar Surface Temperature in Diabetes Mellitus.

Comparing the Diagnostic Accuracy of Simple Tests to Screen for Diabetic Peripheral Neuropathy: Protocol for a Cross-Sectional Study.

The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification independently predicts wound healing in diabetic foot ulcers.

Multicenter, randomized controlled, observer-blinded study of a nitric oxide generating treatment in foot ulcers of patients with diabetes - ProNOx1 study.

Assessment of telomerase activity in leukocytes of type 2 diabetes mellitus patients having or not foot ulcer: Possible correlation with other clinical parameters.

Relationship between plasma angiogenic growth factors and diabetic foot ulcers. Charcot Foot Deformity.

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Negative Pressure Wound Therapy Followed by Basic Fibroblast Growth Factor Spray as a Recovery Technique in Partial Necrosis of Distally Based Sural Flap for Calcaneal Osteomyelitis: A Case Report.

Stereological and molecular studies on the combined effects of photobiomodulation and human bone marrow mesenchymal stem cell conditioned medium on wound healing in diabetic rats.

Prevalence and related risk factors of diabetic foot ulcer in Ahvaz, south west of Iran.

Collagen Powder in Wound Healing.

Clinical efficacy analysis of transverse tibial bone transport combined with vacuum drainage for the treatment of diabetic foot ulcer].

Association between diabetic peripheral neuropathy and heart rate variability in subjects with type 2 diabetes.

A Perioperative Approach to Increase Limb Salvage When Treating FootUlcers in Patients With Diabetes.

The effects of Vibro-medical insole on vibrotactile sensation in diabeticpatients with mild-to-moderate peripheral neuropathy.

Burn aggravated infected wart in a patient with type 2 diabetes: a medical challenge.

Immuno-modulatory effect of local rhEGF treatment during tissue repair in diabetic ulcers.

Utilization of a Viable Human Amnion Membrane Allograft in Elderly Patients With Chronic Lower Extremity Wounds of Various Etiologies.

Effect of a New Purified Collagen Matrix With Polyhexamethylene Biguanide on Recalcitrant Wounds of Various Etiologies: A Case Series.

Application of Viable Cryopreserved Human Placental Membrane Grafts in the Treatment of Wounds of Diverse Etiologies: A Case Series.

Diabetic retinopathy in patients with diabetic foot syndrome in South India.

Anxiety and Depression Among Adult Patients With Diabetic Foot: Prevalence and Associated Factors.

Closing wounds. Together.

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