footnote THE NEWSLETTER • March 2018
From the D-Foot Regions
Initiatives in Sinaloa and Sri Lanka Streamlining the patient’s journey
Fast-track pathway for diabetic foot ulceration Passion meets strategy
D-Foot Implementation Forum Picture quiz
Can you see beyond the obvious? Paper trail
Recent diabetic foot publications And more …
Welcome to another edition of Footnote. I hope that this finds you all fit and well. Throughout the 38 years of clinical practice I have seen a lot of changes in the management of diabetic foot complications. Some have been exciting and helpful, others not. Some of the changes have been rapid and others quite slow, and often hard work. I am sure you can all identify with this, whether changes have been in facets of clinical care, research activity and quality or strategic changes, e.g. systems of care or service provision. As I reflect back and look forward I want to highlight one of the many issues that give me some concern. In the 1980-90s within the UK, diabetic foot-care was truly
EDITOR’S NOTE Neil Baker
a Cinderella of the health care services. It has been a fight to where we are today. Having said that, things are different now in many respects, which is good. However, I would like to ask you all to think about a Chinese proverb and think about the future. “The best time to plant a tree was 20 years ago. The second-best time is now.” So, what exactly am I trying to say? Succession planning. Ensuring that the future generation of diabetic foot professionals are very well trained, skilled and equipped to deal with the rising pandemic facing them. How are we facilitating this and passing on some of the very valuable skills and knowledge to the future generation?
In this edition I would direct you to a contribution written by a student podiatrist Alexandria Armstrong, who shares her perspective of the start of her professional career. I would suggest that perhaps inter and intra-regional mentorship programmes are required in accredited centres of excellence. I would invite you to consider the future and your role and responsibility in this. D-Foot International would very warmly welcome your comments. Help us help you and the future. Best wishes to you all and keep up the great work! Neil
CONTENT Editorial Sri Lanka diabetic footcare programme Fast-track diabetic foot pathway Thoughts from an aspiring student podiatrist Sinaloa Diabetic Foot Foundation — Mexico D-Foot Implementation Forum Lancet lead-in and link Lancet commentary lead-in link and paper Clinical picture quiz Commentaries on recent key publications Pub med abstracts Infographics facts and figures
Dear Readers Welcome to the March edition of Footnote. I hope that the start of 2018 has been successful and you have managed to achieve or move towards the goals you set yourself for this year. In this edition of the newsletter we have outstanding work from Sri Lanka and Mexico, a new clinical pathways tool, a diabetic foot publication in the Lancet and more. Please read the sections to see what your colleagues have been doing. Additionally, we have the regular features including Andy Myers’ commentaries on several recently published papers, the Pub-med abstract section. And of course the clinical picture quiz. NEWS — the December edition of Footnote is now available in Spanish too. We are hope to be able to make Footnote available in other key languages too. I urge you to introduce Footnote to your peers, colleagues and anyone you may think could have an interest. Help us improve diabetic foot communication across the world. We hope you enjoy reading this edition of Footnote.
Click here to go to the Spanish issue
DIABETIC FOOTCARE PROGRAMME IN SRI LANKA The diabetic footcare programme in Sri Lanka is a collaborative partnership between D-Foot International and the Sri Lanka diabetes and cardiovascular initiative (SLDCi)/Sri Lanka college of surgeons. This is a 3-year programme that has a major focus on key issues related to diabetes including diabetic foot care. Although there have been some small-scale programmes on diabetic footcare, this initiative will aim to provide a comprehensive approach in order to establish a training and strategic development program. The programme will include amongst many other things: National training of health-care professionals Specialist diabetic foot teams and centres National foot screening Train-the-trainer programmes Please follow this link to read a full report and account of this fantastic initiative. I am sure that you will all learn something to help you wherever you work in the world.
THE FAST-TRACK PATHWAY FOR
Young diabetologists involved in writing the “Fast-track Pathway for Diabetic Foot Ulceration”
R DIABETIC FOOT ULCERATION All over the world the advent of specialist diabetic foot clinics have clearly demonstrated a year on year improvement in clinical outcomes for patients presenting with ulcerations. Thus there has been the push to establish more multidisciplinary foot clinics or specialist foot centres. However, one big enemy that still persists, even in areas where these clinics exists, is late presentation or delayed referrals to the clinic. The factors contributing to these late presentations can be multifactorial, starting from patient’s awareness, knowledge and awareness of the healthcare professionals, the degree of interlinking with the specialist centres. However, one possible solution to the problem of late referral, is having a clear and simple pathway that is well known or understood by all healthcare professionals that come into contact with patients with diabetic foot ulceration. The fast-track pathway for diabetic foot ulceration has been developed with close collaboration between senior members of the D-Foot team and the International Diabetes Foot Care Group (IDFCC), a group of Young Academicians from 5 countries across Europe working in the
field of diabetic foot care. The project also had an unrestricted grant from URGO Medical. This fast-track pathway aims to help identify the most vulnerable patient by adopting a holistic approach in the patient’s initial assessment, with comorbidities and the clinical assessment of the ulcer. Patients can then be fast-tracked into three levels of care; (1) Severely complicated ulceration needing urgent hospitalisation. immediately, (2) Complicated ulceration needing referral to specialist foot care team within 4 days or (3) A noncomplicated ulceration that can be monitored by the local healthcare professional, but fast-tracked up to specialist care promptly within 2 weeks, if there is failure to improve. Ultimately we hope this fast-track pathway for diabetic foot ulceration can serve as a simple tool that can be adapted by all healthcare services to help streamline patients journey. Thus helping to address the problem of delayed diabetic foot referral to specialist foot care teams. severely complicated ulceration needing urgent hospitalisation,
Summary written by Chris Manu, Kings College Hospital, London UK
DYNAMIC HEALING
URGOSTART TREATMENT SIGNIFICANTLY INCREASES RATE OF WOUND CLOSURE
URGOSTART HEALS 60% MORE PATIENTS 1 WITH DIABETIC FOOT ULCER
BREAKTHRO UGH RESULTS FRO M
PUBLISHED IN THE LANCET DIABETES & ENDOCRINOL OGY
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
”
We are all too aware that the pandemic of diabetes is advancing at an alarming rate and with it the tidal wave of diabetic foot complications follows. Whilst we seek scientific and life style solutions try to deal with this we should not lose sight that we need highly skilled, dedicated and passionate clinicians to help future diabetic foot complications.
The best time to plant a tree was 20 years ago. The secondbest time is now. — Chinese proverb
Many of you have a wealth of expertise, knowledge and remarkable skills – are you passing these on in a structured and efficient way – lest they be lost!
In order to help new diabetic foot students, have access to advice and experience from seasoned doctors/innovators, some sort of global diabetic foot mentorship could or even should be created. This would help link up prospective diabetic foot students with doctors from different regions around the world who could act as a mentor, and guide/help the student figure out what direction they should take. In this mentorship network, there could be a wide variety of programs like: •
1-on-1 discussions between diabetic foot professionals and aspiring students
•
A structured development plan modelled similarly to the American “DPM Mentors Network” (http://www.dpmnetwork.org/), except on a global scale
•
Video clips (how-to videos) on special skills
•
A possible multi-mentor’s avenue, which would expose students to a variety of mentor experience
•
Tips from experienced professionals on how to get started in this field (where to apply)
This way, a newcomer from any part of the world would be able to connect with a mentor from anywhere! It also has the potential to be expanded to universities around the world, which could have “signed expert centres” endorsed by this diabetic foot network. The signed expert centres could also provide incentives to aspiring diabetic foot students, either for tuition aid, or even simply provide a foot in the door through this mentorship network. Either way, this network has the potential to be expanded, and help many aspiring students from all corners of the globe. So, share your soul…be a mentor!
I , t o o f c i t e b a i d e h t y b d e d n u o r r u s , e f i l g y n i m z a t u m o a h g e u m o s Thro t e e m o t h g u o n e e t a n u t w r o o n f k n I e . e d b l e i e f v e h ha t n i s r e e n o i p d n a , s r s i o t h t a v n i o n t n e i m , s e r v a h I docto s l a u d i v i d n i e h t f o , l l a t e o d n i v f o i r , p d n a many e c i v d a e m e v i g o t g n i l l i e w h t e b n i ( d l y u e o n w r u d o l j fie y m t r a t s o t w o h / e r e h I w e n s o u a e c c e n b e i r e e m r exp o f y k c u l y r e v s i s i h d T i . a ) t o o t o f e c c n i e t i e r e p x diab e d n a e c i v d a f o k r o w . t e d l n e i f t s s i a h v t a n i g n i h have t y n a t u o b a s n o i t s e u q e v a h I n e h w e m , n o i t a m r o f n i f o k r o w t e n t s a v e b s i h t t o n t a y h t a m e z t i l o a o e f r I c i t e b a i d e h t n i e c i v d o a n d e n v a a , h e c o n h e i w , f l e exper s y m e k i l s r e m o c w e n e e m l t o t i s l o e t v a e l h b y e h t availa e s u a c e b r e h t i E . t r a t s y l o l t a e e r r e y h e w h t a r o ide , d l r o w t o o f c i t e b a i d I e h . t e r u o t s n o i p e x r e u s i h t expos n i a t b o p l e h o t t c a t n o g c n i o w t o e n n k o d o n n a , s e i t l have u c i f f i d e m a s e h t g n i v a h e f l m e p s l e y h m d l d u n i o f w e k a t o t h t a p t a h w / t c a t n o c o t o h w a i r d n a x . e l y l t A a e gr
SINALOA DIABETIC FOOT FOUNDATION
Enrique Aldana Navidad Podiatrist The diabetic foot is an ongoing problem, everyday statistic figures are rising, and the population is not educated enough to take actions to get to the root of the problem. Year by year the rate of patients and amputations grow around 15% to 20%. Diabetes is becoming an epidemic for the 21st century and a great challenge for world health. Figures are alarming. And the consequences of not being well informed about the health care of this situation are catastrophic. During 2016, I became aware that the key relies in educating and training on this health condition and found the way to create a foundation which had the magnificent aim to consolidate a program that could generate results for the clear understanding of what a diabetic foot implies and the continuous search for solutions.
This is how, in August 2017, Sinaloa Diabetic Foot Foundation was born, which seeks to contribute in people’s quality of life that have a vulnerability to this condition, working in prevention, health care and medical attention. In this short period of time, we have been working arduously en prevention programs, through conferences in schools, institutions, associations and picnic chats, with great reception and sensibility to this need. People that look for medical attention through the Foundation, have a social-economic study done, assessing their situation and the means to acquire an adequate treatment to their condition so to receive help to those who need it. It is hard work and a long way to go. But through it we have encountered more people that are dealing with the same endeavor and which we have join forces, schools and civil associations with different goals but the same mission to serve. And we know that along the way, more will be adding up. There is much work to do, and our Foundation offers an opportunity to cooperate with schools, society and institutions, inclusive and reciprocity, a learning space and fountain of knowledge; a way that allows the information to flow so we can accomplish the most sublime aim we seek out: which is, to consolidate a research program that generates results for a clear understanding of what a diabetic foot implies and the continuous search for solutions.
SINALOA
fundacionspd@hotmail.com www.fundacionspd.org www.facebook.com/fundacionspd
D-Foot Implementation Forum
EXPLORER STUDY
Click here to read the full article
A randomised, double-blind, controlled trial in the treatment of neuro-ischaemic foot ulcers
The results have been published of the first randomised double-blind controlled multi-centred study investigating an ulcer dressing product used in the treatment of neuro-ischaemic diabetic foot ulcers. This is a landmark study not in as much as the results but targeting the new generation of diabetic foot pathology, i.e. the most difficult ulcers to heal with neuro-ischaemia - underlying vascular disease and neuropathy. Specialist hospital centres (43) within Europe were selected as study sites. Strict inclusion /exclusion criteria were observed with randomisation stratified by study centre and wound area (1-5 cm² and 5-30vm²). Ulcers had to be Texas grade 1or 2C. Standard care was given to both the active and control arm. The active arm was treated with a sucrose octasulfate wound dressing and the control with the same dressing without sucrose octasulfate. The study period was for 20 weeks. The primary outcome, assessed by intention-to-treat, was proportion of patients with wound closure at week 20.
Whether you did or did not read the dressing study, we thought it would be only fitting to also let you read a commentary/critique on this study written by Professor Fran Game (UK). It gives an unbiased view of the research study including its methodology, results and application. Of course, there is never a perfect study but there are some that tick only a few or many boxes of an ideal study. Reading a commentary/critique of a paper and then looking at the paper again can be very helpful for those new to clinical research or wanting to consider undertaking a similar study.
Click here to read the comment
t c a r t s b A n a c S Ramanujam CL, Han D, Zgonis T. Medical imaging and laboratory analysis of diagnostic accuracy in 107 consecutive hospitalized patients with diabetic foot osteomyelitis and partial foot amputations. Foot Ankle Spec. 2017 Dec 1. (Pubmed ID#: 29291264).


This study represents another of a recent series of investigations from different authors attempting to determine which combination of clinical, radiographic and laboratory diagnostic testing is the most accurate with respect to the diagnosis of diabetic foot osteomyelitis. It is becoming clear that the diagnosis probably should not be made based on a single “gold standard� test in many situations, but instead should probably represent a clinical decision based on a collection of diagnostic information. The specific interesting results from this study tended to emphasize plain film radiographic findings and the erythrocyte sedimentation rate, as opposed to more advanced imaging studies and laboratory analyses, and found relative discordance between the histopathologic and microbiologic analysis of bone biopsy samples. This later finding has been observed in several other studies and calls into question which specific testing should be performed on a bone biopsy sample. And although including a cohort of over 100 participants, the relatively wide confidence intervals observed for some of the outcomes likely provides evidence of the extensive variability seen in these patients.
Drampalos E, Mohammad HR, Kosmidis C, Balal M, Wong J, Pillai A. Single stage treatment of diabetic foot calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocompositive: The Silo technique. Foot (Edinb). 2017 Nov 23; 34: 40-44 (Pubmed ID#: 29278835). The treatment of heel tissue loss with associated calcaneal osteomyelitis represents one of the most clinically challenging seqeula of diabetic foot disease. This pathology is often associated with a high rate of major amputation even following multiple surgical interventions and long courses of antibiotics. This article provides an interesting technique of utilizing an antibiotic-impregnated biocomposite inserted through drill holes following partial calcanectomy. The authors originally utilized magnetic resonance imaging to determine the extent of the bone infection, resected accordingly, and then drilled into the remaining viable bone with a 3.2mm drill bit. These tunnels were then packed with the impregnated biocomposite. This technique represents an interesting way to potentially preserve bone and avoid major amputation.
Bruhn-Olszewska B, Korzon-Burakowska A, Wegrzyn G, JakobkiewiczBanecka J. Prevalence of polymorphisms in OPG, RANKL and RANK as potential markers for Charcot arthropathy development. Sci Rep.2017 Mar 29;7(1): 501. (Pubmed ID#:28356555). The treatment of Charcot neuroarthropathy represents an interesting dichotomy. On the one hand are extensive reconstructive surgeries involving arthrodeses of multiple joints with the use of internal and external fixation. On the other hand are tremendous strides made through contemporary bench work into the single nucleotide polymorphisms regulating bone metabolism that have been increasingly shown to contribute to the pathogenesis of the disease process. This investigation contributes to the latter and provides evidence of polymorphisms consistently found in patients with Charcot neuroarthropathy and diabetic neuropathy. Results such as these are encouraging not only for the early diagnosis of Charcot, but potentially for early interventions prior to joint destruction and potentially even preventative interventions.
Wukich DK, Raspovic KM, Suder NC. Patients with diabetic foot disease fear major lower-extremity amputation more than death. Foot Ankle Spec. 2018 Feb;11(1):17-21. (Pubmed ID#: 28817962). This team of authors have recently produced a series of investigations into the more psychosocial aspects of diabetic foot disease. In this specific investigation, a cohort of 461 patients with diabetes were interviewed with respect to their greatest diabetes-related fears including death, blindness, kidney failure, lower extremity infection and major amputation. Interestingly, patients with a history of diabetic foot disease reported major amputation as their greatest fear, even more than death! Studies such as this provide valuable insight into the day-to-day lives of our patients that expand beyond a brief office visit, and should help guide physicians with respect to the establishment of physicianpatient relationships, education and consent.
van Asten SAV, Mithani M, Peters EJG, La Fontaine J, Kim PJ, Lavery LA. Complications during the treatment of diabetic foot osteomyelitis. Diabetes Res Clin Pract. 2017 Jun 13; 135: 58-64. (Pubmed ID#: 28951333). In an objective example of the popular idiom “the cure is worse than the disease�, these authors provided evidence to quantify the incidence of complication during the medial treatment of osteomyelitis. Diabetic foot osteomyelitis is certainly a challenging diagnosis, and if complete surgical excision is not performed, then often a prolonged course of antibiotics is prescribed. In a series of 143 patients with confirmed osteomyelitis, 47 cases of acute kidney injury were observed. Some evidence of the development resistant bacterial strains was also observed, particularly in patient readmitted for infection. This information is important so that the benefits and potential risks of different treatment plans might be fully explained to patients before an educated decision of treatment course is made.
Q ui z CLINICAL PICTURE QUIZ Welcome to another basic picture quiz. Once again, I must stress that the aim of these are to stimulate thought for everyday clinical practice and can be used to help mentor/educate junior staff in the management of common diabetic foot pathologies. Please take a look at the photograph below. Similar to the clinical quiz in the last edition this may appear to be simple and in-reality it is. However, I would like you as always to use your eyes and build a case history upon what you see. and in essence it is not. Have fun and why not show this to your colleagues and see what they come up with. ☺ So as always . a few questions to get started … 1. 2. 3. 4.
What is the most striking feature that you see? Is there anything unusual about this? Are there any other general features worthy of note? How would you manage what you see?
Once again, the comments/ answers below are only the authors opinion. Please take time looking at the case and perhaps make some quick notes before reading below.
ANSWERS AND SUGGESTIONS 1. The most striking feature is clear as the photograph concentrates on it. You will clearly see a deformity of the 2nd toe. It is on the plantar aspect overlying the intermediate phalanx. The toe is clearly thickening in this region to the point that this area is now convex rather than concave as we would normally see (evident in 3rd and 4th toes). AddiConally, you can clearly see there has been a build up of callus in this area. Furthermore, the callus shows signs of extravasaCon (blood staining) in the centre of the callus. This would indicate a focus of applied force in this locaCon You will also noCce that the shape of the callus is circular but also there is almost a ring of extravasaCon in the outer borders of the callus. The burning questions are: Is the thickening in this area soft tissue or bone? What are the most likely causes and how would you determine these? 2. Yes, there is as mentioned above the plantar aspect of the interphalangeal joint area should be either concave or perhaps flat. In this case it is the reverse. As mentioned above why is this like this?
1. Are there any other features that are evident? Yes, there are several that are worth noting. Firstly, there is evidence of callus on the apex of the 2nd and 3rd toes that can be seen. Also, there is evidence of callus over the 3rd metatarsal head area but this appears to be light/ superficial. Of course, although obvious if you look at the shape of the callus it is circular. This gives a hint of the direction of forces applied in these areas. So why is there callus only in these areas. Again, this would point to abnormal biomechanical function of the foot and gait pattern. Although we cannot see the rest of the foot or the patient walking the shape of the callus and its position is informative. What is also striking is that the callus on the 3rd metatarsal head area is light and is right at the distal end of the 3rd toe. In contrast the callus is thicker on the second toe and is both at the deformity site and over most of the apex. This clearly indicates that the direction ad duration of force during the propulsive phase of gait are concentrated here. Please look at the condition of the skin in what would normally be the main weight-bearing area during this part of the gait cycle, i.e. the metatarsal heads…. what do you see?
From what we can see there is some loading over the 1st metatarsal head, although light, very little or none over the 2nd and 4th. The 1st toe does not appear to be loading as it should as the soft tissue does not show any evidence of loading. The soft tissue appears to be generally devitalised with perhaps impaired blood flow, or this is just a relatively elderly foot. This is evidenced by the extreme “wrinkling” or skin creasing seen over the image we have. One hint that this is merely an elderly foot is the subtle presence of hairs on the dorsal surface of the hallux if you look carefully! Obviously, we cannot tell from a photograph but the tissue must be dense in order to develop the callus in the way that it presents here. There is most likely bony involvement i.e. bony callus formation from either a previous fracture or osteomyelitis. It could be a dislocation at the interphalangeal joint but not likely. Most sinister causes could be a sarcoma or soft tissue tumour. If it is soft tissue then a fibrosed adventitious bursa, fibrous nodule, xanthoma on the long flexor tendon or a tumour. Certainly, the first invesCgaCon would be a plain x-ray to look for any bony pathologies as menConed above. I personally would ask for two main things; the view needs to be a true lateral from the medial side (hallux) with if
possible the 2nd toe pushed below the other toes. The other thing is to ask for mammograph quality film image. This is because it will pick up dense soft tissue more readily. Other imaging could be considered and a skilled Sonographer here would be very useful. How can this be managed? This would depend on the investigation results. If organised established bony callus is present then the management is to reduce the potential ulcer risk caused by the abnormal forces /pressure in this area. There would be 2 main courses of action: conservative and invasive. Conservative measures would include therapeutic footwear with a rocker sole unit, customised total contact insole with a sink in the aected area. Please remember if the latter is chosen the foot will move inside the shoe and so this needs to be accounted for when creating/ positioning a sink in an insole. A made to measure silicone orthodigital device moulded with a silicone putty material. Of course, regular podiatry /callus removal and inspection of this area. Another approach maybe to consider a surgical reduction of the bony prominence. This would be a quick and lasting procedure and can be very eective if undertaken carefully and with thought.
Any soft tissue mass should be referred for a second opinion or a biopsy taken to establish the histopathology. It is a given that a full patient assessment would have been undertaken before any of the above were undertaken. I hope that you have found this case, thought provoking. Sometimes simple things are often overlooked or dismissed, but this case is predominately about preventing an almost certain ulcer from occurring.
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ABSTRACTS GALORE Diabetic Foot Australia guideline on footwear for people with diabetes. Diabetic neuropathy and painful diabetic neuropathy: Cinderella complications in South East Asia. Prevalence of Chronic Diabetic Complications in Newly Diagnosed versus Known Type 2 Diabetic Subjects in a Sample of Alexandria Population, Egypt. Impact of Pedal Arch Patency on Tissue Loss and Time to Healing in Diabetic Patients with Foot Wounds Undergoing Infrainguinal Endovascular Revascularization. Eiciency of stem cell based therapy in the treatment of diabetic foot ulcer: a meta-analysis. Health Care Costs Associated With Incident Complications in Patients With Type 2 Diabetes in Germany. Eect of short- and long-term diabetes control on in-hospital and one year mortality rates in hospitalized patients with diabetic foot. Risk Factors and Frequency of Ingrown Nails in Adult Diabetic Patients. Annual Direct Medical Costs of Diabetic Foot Disease in Brazil: A Cost of Illness Study. Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene. Inter-observer agreement of the Wagner, University of Texas and PEDIS classification systems for the diabetic foot syndrome. Burden of disease from lower limb amputations attributable to diabetes mellitus in Santa Catarina State, Brazil, 2008-2013. CODIFI (Concordance in Diabetic Foot Ulcer Infection): a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England.
Improvement in Neuropathy Specific Quality of Life in Patients with Diabetes after Vitamin D Supplementation. Specific PKC β II Inhibitor: One Stone Two Birds in the Treatment of Diabetic Foot Ulcers. Limb- and Person-Level Risk Factors for Lower-Limb Amputation in the Prospective Seattle Diabetic Foot Study. Proinsulin-expressing dendritic cells in type 2 neuropathic diabetic patients with and without foot lesions. Topical 5% potassium permanganate solution accelerates the healing process in chronic diabetic foot ulcers. Smoking increases the risk of diabetic foot amputation: A meta-analysis. Collateral circulation between angiosomes in the feet of diabetic patients. Diabetic foot limb salvage - a series of 809 attempts and predictors for endovascular limb salvage failure. Calcium alginate-based antimicrobial film dressings for potential healing of infected foot ulcers. Self-efficacy of foot care behaviour of elderly patients with diabetes. Role of plasma growth factor in the healing of chronic ulcers of the lower legs and foot due to ischaemia in diabetic patients. How much do persons with diabetes in a rural area of South India know about diabetes management? A step toward person-centered care. Recent Advances and Future Opportunities to Address Challenges in Offloading Diabetic Feet: A Mini-Review. Minimally Invasive Plate Osteosynthesis for Treatment of Ankle Fractures in High-Risk Patients.
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Extended Islanded Reverse Sural Artery flap for Staged Reconstruction of Foot Defects Proximal to Toes. Eicacy of Cellular Therapy for Diabetic Foot Ulcer: A Meta-Analysis of Randomized Controlled Clinical Trials. eNOS Uncoupling, A Therapeutic Target For Ischemic Foot of Diabetic Rat. Foot Kinetics and Kinematics Profile in Type 2 Diabetes Mellitus with Peripheral Neuropathy: A Hospital Based Study from South India. Association between QTc interval prolongation and outcomes of diabetic foot ulcers: Data from a 4-year follow-up study in China. Incidence of diabetic foot ulcer in Japanese patients with type 2 diabetes mellitus: The Fukuoka diabetes registry. Association between biofilm and multi/extensive drug resistance in diabetic foot infection. The current role of glycopeptides in the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in not neutropenic adults: the viewpoint of a group of Italian experts. Corneal confocal microscopy detects severe small fibre neuropathy in diabetes patients with charcot neuroarthropathy. Update on management of diabetic foot ulcers. Prevalence of Chronic Diabetic Complications in Newly Diagnosed versus Known Type 2 Diabetic Subjects in a Sample of Alexandria Population, Egypt. Precise Retrograde Supera Stenting of the Ostium (PRESTO) of the Superficial Femoral Artery for Complex Femoropopliteal Occlusions: The PRESTO Technique. Impact of Pedal Arch Patency on Tissue Loss and Time to Healing in Diabetic Patients with Foot Wounds Undergoing Infrainguinal Endovascular Revascularization.
Efficiency of stem cell based therapy in the treatment of diabetic foot ulcer: a meta-analysis. Development and validation of a brief diabetic foot ulceration risk checklist among diabetic patients: a multicenter longitudinal study in China. Efficacy of Aloe vera/ Plantago major gel in Diabetic Foot Ulcer: a randomized double-blind clinical trial. Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene. Cost-Utility Analysis of Heberprot-P as an Add-on Therapy to Good Wound Care for Patients in Slovakia with Advanced Diabetic Foot Ulcer. Noninvasive Vascular Assessment of Lower Extremity Wounds in Diabetics: Are We Able to Predict Perfusion Deficits? An Economic Evaluation of the Impact, Cost, and Medicare Policy Implications of Chronic Nonhealing Wounds. Assessing the Effect of Piperacillin/Tazobactam on Hematological Parameters in Patients Admitted with Moderate or Severe Foot Infections. Knowledge, attitude, and practice of foot care in patients with diabetes at central rural India. Clinical Guidelines for the Antibiotic Treatment for Community-Acquired Skin and Soft Tissue Infection. Medical Imaging and Laboratory Analysis of Diagnostic Accuracy in 107 Consecutive Hospitalized Patients With Diabetic Foot Osteomyelitis and Partial Foot Amputations. Effectiveness of Diabetes Foot Screening in Primary Care in Preventing Lower Extremity Amputations. Advantages of early diagnosis of diabetic neuropathy in the prevention of diabetic foot ulcers.
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Adherence Over Time: The Course of Adherence to Customized Diabetic Insoles as Objectively Assessed by a Temperature Sensor. Single stage treatment of diabetic calcaneal osteomyelitis with an absorbable gentamicin-loaded calcium sulphate/hydroxyapatite biocomposite: The Silo technique. A Cyclical Approach to Continuum Modeling: A Conceptual Model of Diabetic Foot Care. Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial. Staphylococcus Aureus Triggers Induction of MIR-15B-5P to Diminish DNA Repair and De-Regulate inflammatory Response in Diabetic Foot Ulcers. EUREKA study - the evaluation of real-life use of a biophotonic system in chronic wound management: an interim analysis. Does First Ray Amputation in Diabetic Patients Influence Gait and Quality of Life? Endovascular Distal Plantar Vein Arterialization in Dialysis Patients With NoOption Critical Limb Ischemia and Posterior Tibial Artery Occlusion: A Technique for Limb Salvage in a Challenging Patient Subset. Assessment of Risk Factors Associated With Hospital-Acquired Pressure Injuries and Impact on Health Care Utilization and Cost Outcomes in US Hospitals. The Eect of Foot Exercises on Wound Healing in Type 2 Diabetic Patients With a Foot Ulcer. Prevalence of diabetic foot syndrome amongst population with type 2 diabetes in Pakistan in primary care settings. Risk Factors for Infection with Pseudomonas aeruginosa in Diabetic Foot Infections.
ImageJ: A Free, Easy, and Reliable Method to Measure Leg Ulcers Using Digital Pictures. The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system correlates with cost of care for diabetic foot ulcers treated in a multidisciplinary setting. Management of chronic diabetic foot ulcers using platelet-rich plasma. Diabetic foot ulcer management in clinical practice in the UK: costs and outcomes. Reclaiming Autologous Amputated Tissue for Limb Salvage of a Diabetic Foot Burn with Underlying Critical Limb Ischemia. Knowledge of the Warning Signs of Foot Ulcer Deterioration Among Patients With Diabetes. Modern management of diabetic foot osteomyelitis. The when, how and why of conservative approaches. Novel Semiquantitative Bone Marrow Oedema Score and Fracture Score for the Magnetic Resonance Imaging Assessment of the Active Charcot Foot in Diabetes. Podiatry Ankle Duplex Scan: Readily Learned and Accurate in Diabetes. Mobile phone generated vibrations used to detect diabetic peripheral neuropathy. Development and Evaluation of Patient Information Leaflet for Diabetic Foot Ulcer Patients. The beneficial eects of probiotic administration on wound healing and metabolic status in patients with diabetic foot ulcer: A randomized, doubleblind, placebo-controlled trial. Tissue Augmentation with Allograft Adipose Matrix For the Diabetic Foot in Remission.
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All-cause mortality among diabetic foot patients and related risk factors in Saudi Arabia. Tibio-calcaneal fusion by retrograde intramedullary nailing in charcot neuroarthropathy. Relationship between person's health beliefs and diabetes self-care management regimen. Intralesional epidermal growth factor therapy fordiabetic foot ulcers: an evaluation of 15 cases Enhanced antibacterial eects of green synthesized ZnO NPs using Aristolochia indica against Multi-drug resistant bacterial pathogens from Diabetic Foot Ulcer. Predictive Laboratory Findings of Lower Extremity Amputation in Diabetic Patients: Meta-analysis. Norwegian trends in numbers of lower extremity revascularisations and amputations including regional trends in endovascular treatments for peripheral arterial disease: a retrospective cross-sectional registry study from 2001 to 2014. Ciprofloxacin-loaded calcium alginate wafers prepared by freeze-drying technique for potential healing of chronic diabetic foot ulcers. Diabetes-related amputations create considerable public health burden in the UK. Topical oxygen therapy promotes the healing of chronic diabetic foot ulcers: a pilot study. Tibiotalocalcaneal Arthrodesis With the Hindfoot Arthrodesis Nail: A Prospective Consecutive Series From a Single Institution. Factors Associated with a Prolonged Length of Hospital Stay in Patients with Diabetic Foot: A Single-Center Retrospective Study.
Antibiotic Resistance in Diabetic Foot Soft Tissue Infections: A Series From Greece. Improved limb salvage for patients with vascular disease and tissue loss associated with new model of provision targeted at the diabetic foot. Risk of lower limb amputation in a national prevalent cohort of patients with diabetes. Three-question set from Michigan Neuropathy Screening Instrument adds independent prognostic information on cardiovascular outcomes: analysis of ALTITUDE trial. Prognosis of the infected diabetic foot ulcer: a 12-month prospective observational study.
INFOGRAPHIC FACTS AND FIGURES Dear Readers Here is a little taster of something that the editorial board are considering becoming a regular feature entitled “Know your Country/ Region”. Instead of just giving you a list of facts we will try to make it more graphic. We have used infographic displays of some of the data regarding the USA. Why are we doing this? We felt that it would be useful to use infographics to show diabetic foot data from different parts of the world. Using this type of data presentation is very helpful when approaching organisations, government bodies to try to obtain support, strategic development and funding for the diabetic foot. It also may be useful in promoting more engagement from our colleagues in our own or other specialities. Of course we would love to have your views.
Click into the infographic to go to the larger, responsive version
Closing wounds. Together.
What makes my nurse so special?
Her quality of care and her care for quality.
THE NEW CUTIMED SILTEC RANGE ®
DESIGNED TO WORK FOR YOU Exceptional exudate management – even viscous exudate is no problem1 Soft and reliable adherence to the skin2
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Contoured shape with rounded corners for high wearing comfort 1
BSN medical data on file report. JB4 40025962; JB4 40026441 – fluid handling, viscous exudate; JB4 40025969 – retention † Source: S.M.T.L. Report No: 16/5219/1
2
BSN medical data on file report. JB4 40025961 – adherence/pain
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