footnote THE NEWSLETTER • Spring 2019
Diabetic foot initiatives around the world
From Berlin, Helsinki and Marrakesh to the Carribean Capacity building
Let’s put another man on the moon? Awards
D-Foot Board members recognised Another clinical picture quiz
What’s this non-diabetic foot doing here? Paper trail
Recent diabetic foot publications Abstracts galore
Your quarterly PubMed feast And more …
Dear Readers and diabetic foot friends Welcome to another edition of “Footnote�. We hope that this finds you all very well and you have had a good start to 2019. I was listening to a lecture at conference fairly recently, the title of which was recent advances in the management of the diabetic foot. It outlined the advances in the last 20 years from a clinical and scientific perspective. Several key messages were delivered some encouraging and others a little disappointing. One overarching message was that research, understanding, clinical guidelines and even the awareness in the diabetic foot has increased significantly. New technologies have been developed from
EDITOR’S NOTE Neil Baker
in patients’ homes, wound dressings and products. For me the exciting work in the use of amnion and chorion products in ulcer healing but more importantly preventing ulcer relapse by tissue regeneration and thus function restoration. The advances in surgical techniques is also encouraging, the evidence that foot ulcer and amputation mortality is worse than some cancers. This latter knowledge is very disturbing and sad but it is powerful data for us to move policymakers to bring about change. This of course all of this is very good news, however, there is still a long way to go as globally the number of lower extremity amputations appears to be rising not falling. How can we change this? Perhaps not by big interventions but cumulative small ones, particularly
in relation to service provision. Yes, I know in some parts of the world this is easy and others. Again, I think of the African saying “the best time to plant a tree is 30 years ago, the next best time is now”. Don’t forget “Together we are Stronger”……so may I urge you to network, collaborate and join with all your local, national and regional colleagues. Do get in touch with us and help us share your experiences. Neil
RD 3
THE NORDIC DIABETIC FOOT SYMPOSIUM: IMPRESSIONS FROM A PODIATRIST Anne Rasmussen Team Leader, Podiatrist MAH The 3rd Nordic Diabetic Foot Symposium was held in the beautiful capital city of Helsinki, Finland on 6th and 7th of November 2018. I was lucky again to have the possibility to participate in this very nice symposium, as it keeps me updated on the diabetic foot in Scandinavia and also participation gives me the chance to network with my colleagues from the other countries. The symposium is organized by the Nordic Diabetic Foot Task Force, which is a network of national and international healthcare clinicians, and its overall aim is to promote IWGDF guidance for the diabetic foot care in the Nordic countries (Denmark, Sweden, Norway, Finland and Iceland). The program was a mixture of plenary talks with speakers from primarily Nordic countries but also form other European countries, meet-theexperts sessions and hands-on workshops. Country specific sessions held in their national languages also attracted a lot of attention. Highlights from this year’s symposium included the latest updates in the field, e.g the new trends in vascular diagnostics, telemedicine, digital decision making and antimicrobial stewardship in the diabetic foot. Also, the workshops in Total Contact Casting, vascular assessment and external
Anna Trocha from Germany talked about the Diabetic Foot Study Group Project Initiative entitled “Prevention of the very first ulcer” fixation surgery were very popular. There were around 200 participants including podiatrists, nurses, doctors etc. The majority of participants were from Finland which is not surprising as it is always easier to participate if you live in the country and the travel costs are lower. As always, I got a lot out of the meeting academically, but as I see it, it is very difficult for the individual countries to implement guidelines in general, and there are deviations from country to country. Whether we have fully
The podiatrist Maureen Bates from the UK participated in the workshop Total Contact Casting
The Chair of the Nordic Symposium, Klaus Kirketerp-Mรถller summing up the Danish session for the future
implemented the most recent guidelines is questionable, but all countries agreed that we should work to do the best for the patients and the health professionals. In Denmark, we will focus on education of healthcare professionals who work with the diabetic foot. We will also try to improve communication and also political awareness and if we can make a national network, developments and research across the board may become possible, and this is certainly my dream.
Of course, I hope to see all the invited health professionals for the next symposium in 2 years.
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D-FOOT IMPLEMENTATION SUMMIT Kristien Van Acker President D-Foot International — Madrid, 16-18 November 2018 The D-Foot Implementation Summit was held at the Meliá Avenida América hotel in Madrid from 16-18 November 2018. The event was attended by 166 participants from 85 countries, including the D-Foot National Representatives, various stakeholder organisations, corporate partners and other industry representatives. From Forum to Summit … The primary objective of the D-Foot Implementation Summit was to bring together the global National Representatives of D-Foot to decide on the strategic direction of the association for the next one to two years, and beyond. The Summit was the culmination point of a series of related events started in early 2018. In a first phase, at its meeting in January 2018, the Board had developed an initial strategic plan. During the Implementation Forum in Brussels in April 2018, this plan was finetuned together with the Advisory
Committee, the Chairs of the working groups and selected Key Opinion Leaders. Industry was invited to participate in part of the sessions to obtain a better insight into D-Foot and to provide strategic and operational input. In a third phase, the plan was validated by the Regional Representatives and Full Members of D-Foot during the D-Foot Implementation Summit in November and solidified at the General Assembly. This process led to a focused and widely supported strategic plan for D-Foot. In addition, the Summit offered scientific sessions, information on guidance and implementation, provided a platform for Regional input and dialogue, and feature the D-Foot International General Assembly. The objectives of the Summit The Summit centre around four key areas. Science — The programme of the Summit included a number of academic sessions on diabetes footcare, as well as health economics and other topics.
Implementation — The implementation part gave clinicians the tools to translate the scientific evidence into daily practice, and adapt the theory to local clinical practice and culture. After the Summit, as leaders in their specialty, they were tasked to disseminate this information at all levels of integrated diabetic footcare in their region.
the nation’s goal of landing a man on the moon and D-Foot’s ambition to increase and strengthen the capacity we need to achieve our overarching goal to reduce the number of unnecessary amputations from diabetes worldwide and improve the quality of life of people with and at risk of diabetic foot. More details about this concept further on in this issue.
Regional input — The Summit offered the D-Foot Regional Representatives the opportunity to showcase their diabetic foot activities, share experiences and learn of best practice.
Implementation
General Assembly — In the framework of the Summit, D-Foot International held its first General Assembly attended by its National Representatives/ Full Members. Further interaction among the participants will help the understanding of the implications of recent scientific data. Man on the moon The opening set the scene by creating an analogy between US President John F. Kenndy announcing in the early 1960s
Josefien van Olmen of the Tropical Institute in Antwerp, Belgium, gave us an interesting perspective on how to develop and execute an implementation plan. She offered practical tips on strategy, how to avoid pitfalls and be street-smart in making good use of one’s network to make the plan happen. Telemedicine: reaching beyond Sergio Pillon of the Italian Telemedicine National Committee shared his confidence in the future of telemedicine. He presented convincing argument that the real possibilities of telemedicine have scarcely been scratched. He explained its driving forces and how experts, GPs and nurses could use the technology in healing diabetic foot.
Guidance and implementation This was followed by an extremely important part: D-Foot wanted to have an exchange of the clinical experts of all regions and representatives from the IWDGF Guidance group. The aim was to identify the gaps between guidance and recommendations. With this intervention D-Foot hoped that this open and constructive discussion would contribute to the guidance and recommendations of 2019, to be launched in The Hague in May 2019. The POINT Project: Podiatric Skills for International Diabetic Foot Teams This project is based on the ”Podiatry Capability Framework For Integrated Diabetic Foot Care: A User’s Guide” (TRIEPodD-UK, 2012). The international IWDGF Guidance states that podiatry care is central in diabetic foot care models. Unfortunately, the reality is than 80% of countries have no podiatry care. Pauline Wilson presented The POINT Project: a collaboration between D-Foot
International and the International Federation of Podiatrists. A panel discussed the relevant podiatric skills required to provided care in different healthcare systems and geographical locations, and identified and defined the skills multidisciplinary diabetic foot teams needed across 13 domains of care across 4 levels levels of practice. Such skills in many areas are provided by podiatrists where they exist. The POINT document allow teams to benchmark their care and identify areas where they need to improve. WHO-GATE & D-Foot International collaboration Gulapar Srisawasdi reported on assistive product specification for the procurement of therapeutic footwear: a collaboration of WHO-GATE and D-Foot International. The objective of this specification is to help organisations in procuring good quality therapeutic footwear that will be safe to use and which will solve the mobility-related practical problems in daily life for the majority of users.
AB(b)A - In search of excellence
DIAFI data collection tool
D-Foot encourages national expert diabetic foot units to become centres of excellence under the AB(b)A label, and recognised as national reference centres. The aim is to put in place dierent levels of foot care, integrated care pathways with fast-track referrals. Continuous Auditing, Benchmarking and Accreditation (ABbA) assures and controls the required standard of quality. The application and accreditation criteria were being updated.
To develop clinical practice, improve our programmes and lobby for support, gathering activity and outcome data are crucial. D-Foot worked with UNFM to set up the DIAbetes Foot Initiative (DIAFI), a data collection software housed on a memory stick. Clinicians can collect data quickly covering predetermined parameters. The software analyses the downloaded data immediately and allows for anonymous data export for further international statistical use. http://www.d-foot.org/d-foot/childpost/ diafi-data-collection-tool/
Diabetic Foot Atlas D-Foot wants to invest very strongly in well-defined and standardised data collection. The end objective for this is clearly to have once a quality global Diabetic Foot Atlas. For this reason the delegates received detailed information from Frances Game and other experts in the field about auditing techniques and using the best classification systems. SINBAD was to be the future tool for DFoot auditing, supported by a WHO document, to be published soon.
General Assembly At the end of the D-Foot Implementation Summit, the D-Foot National Representatives put on their Full Member hat and held their first in-person General Assembly. Kristien Van Acker, President, reported the events that had led to the establishment D-Foot International, its mission statement, goals and current action focus, and activities developed since its
establishment. José Luis Lázaro Martínez, President-Elect, outlined the intended strategic direction of the organisation in the near future and into the next biennium. The focus would be on continuity of governance, increased recognition among the wider diabetic foot and diabetes stakeholder community, further development and expansion of activities, recognition of podiatry at national, regional and global level, strengthening the active diabetic foot community through the network of National Representatives and Regional Councils, and building the capacity needed to achieve the organisation’s objectives. With the National Representatives now integrated into the governance and operations of the organisation, D-Foot is now ready to take on bigger challenges. As a first step, D-Foot has established itself as an open, democratic , inclusive international NGO of diabetic foot experts and those with a strong interest in diabetic foot. The next crucial step will be our first democratic elections for the next Board and Nominating Committee: a landmark event after 30 years of
diabetic foot care. We hope that, after the first step of our pioneers showing us the path, the next stage of development of D-Foot International will be one giant leap forward for diabetic foot.
DIABETIC FOOT STUDY ANNIVERSARY MEETING Nikolaos Papanas Vice Chairman DFSG
GROUP: 20-YEAR G IN 2018
The Diabetic Foot Study Group (DFSG) is one of the oldest study groups of the European Association for the Study of Diabetes (EASD). Professor Andrew Boulton was its founding Chairman. In September 2018, the DFSG held its annual scientific meeting in Berlin, Germany. This time, it was a 20-year anniversary meeting. It was a large and successful meeting with almost 300 participants from 37 countries both within and outside Europe. The programme was carefully chosen by the Executive Committee. As usual, it was based on oral and poster presentations of new research data pertinent to the diabetic foot. Indeed, the abundance of new research data, as evidenced by the ever-increasing number of submitted abstracts every year, testifies to the group’s long-standing tradition and the ongoing progress in the study and care of the diabetic foot. The room was always full of delegates actively participating in the discussion of results and interpretations. Like in previous years, the Paul Brand award was bestowed on the best study relating to repeated mechanical stress.
This year’s prize recipient was Dr. Caroline Abbott (UK) for her work entitled “Novel plantar pressure-sensing smart insoles reduce foot ulcer incidence in high risk diabetic patients: a longitudinal study”. Another interesting moment was the plenary session with the three top oral presentations, in which the audience voted the study “Data linkage and geospatial mapping exposes inequalities in outcomes for diabetic foot disease in Glasgow” by Dr. Joanne Hurst (UK) as the best (Picture 1). Like in previous meetings, a lifetime achievement award was bestowed in recognition of very important scientific contribution in the field of the diabetic foot: the awardee was Professor Ernst Chantelau (Germany). The highlight of this anniversary meeting was the “Rapid fire questions to the past chairmen” session. During this session, Professor Michael Edmonds (UK) gave some information on the beginning and history of the DFSG and contemplated on new achievements to come. Dr. Stephan Morbach (Germany), Professor Edward Jude (UK) and Professor Ralf Lobmann (Germany) spoke about their experience as Chairmen and suggested directions of further research along with other activities of the group. The audience had the opportunity to ask the past Chairmen many questions and seek advice (Picture 2). During the coffee break, the past Chairmen and the current Vice Chairman cut cakes shaped like feet, celebrating the group’s 20-year history and to deliver an important takehome message: cut the foot cakes, but do not amputate real feet! (Picture 3)
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Alphonso Richardson, Prosthetist and Orthotist; Simone McConnie, Podiatrist; Juanita James, President of the Antigua Diabetes Association, and Sharion Browne-Phillip, Wound care nurse Mount St John Medical Center.
DIABETIC FOOT ACTION IN THE CARRIBEAN
Simone McConnie D-Foot International Regional Chair NAC
January is off to a big step for Antigua as The Antigua Diabetes Association met with Dr Bauer Sumpio from The Let them Walk charity (providing prosthetic limbs for those with amputations to enable them to get back to their lives) and Save our Soles Trust (an organisation geared towards educating those with diabetes on the need for prevention and management of their limbs to prevent amputations whilst providing support for those less fortunate in need of footwear, dressings or other to stave them away from amputations). This was hosted by Mr Alphonso Richardson from Mount St. John’s Medical Center. Mr Richardson has been a local champion working very closely with The let them walk program identifying those in need and providing training for local prosthetists. Mrs Simone McConnie Regional Chair for D-Foot International has been working in the region since 2008 assisting with the implementation of the step by step diabetic foot programs geared towards training health care professionals in prevention and management skills whilst building
capacity of teams for diabetic foot and limb salvage. Presentations facilitated by Dr Leslie Walwyn Associate Professor at American University of Antigua College of Medicine as part of their Community health program; and at Mount St John’s Medical Centre to medical staff. Lectures were on Wound care by Dr Adrian Wylie – Wound care specialist from Wounds Specialists LLc, Prof Bauer Sumpio Professor of Surgery, Radiology and Medicine at Yale Medicine, and Simone McConnie Podiatrist with specializing in the Diabetic foot and wound management. Further excitement was stimulated at the presentation of the POINT (Podiatric Skills for International Diabetic Foot Teams) document. It was presented to the Antigua Diabetes Association who have promised to have further discussions with the local Ministry of Health on reigniting the diabetic foot program to address the high amputations in Antigua.
TRAIN-THE-FOOT-TRAINER COURSE MARRAKESH, 4-9 DECEMBER 2018 Kristien Van Acker President D-Foot International
A remarkable and unforgettable Trainthe-Foot-Trainer course took place in Marrakesh from 4-5 December 2018. Previously, all of the other Train-theFoot-Trainer programmes had been delivered by the core developing team and in English. For this programme in Marrakesh several new barriers had to be overcome that we had not faced before. The main hurdles were that this time we needed a new teaching faculty as this programme had to be delivered in French. None of the new faculty had worked together before in Train-theFoot-Trainer. All of the documentation, lectures, workshops, etc had to be translated into French. Of course, as usual, financing the project proved difficult.
The first French edition with a total new faculty, instead of our regular team and our standard language of our courses, English. We also created a French axis from France via Maghreb to the French speaking African countries. Countries present: France, Belgium, Morocco, Algeria, Tunisia, Senegal, Mali, Guinée, Côte d’Ivoir, Congo, Togo, Abidjan, Cameroon, Mauritania and Tchad. Thanks to the dedicated effort of Université Numérique Francophone (UNFM) with Line Kleinebreil and Laurence Forlini we had a break-through. The event was supported by the Société
Francophone de Diabète (SFD) and our local partners Société Marocaine d’Endocrinologie, Diabétologie et Nutrition (SMEDIAN) who worked hard providing all the local organisation and logistics and they gave the whole team a big surprise at the end of the course with the most unforgettable event ever. They arranged a typical Maroc’outdoors activity in the evening with culminating in a fire-work display featuring the DFoot International logo. We had an opening ceremony and all delegates were immediately involved by giving a short introduction about
We had an opening ceremony and all delegates were immediately involved by giving a short introduction about themselves and their country followed by expressing their course expectations. All Train-the-Foot-Trainer courses are very interactive and have to be adapted to the region in which they are delivered. There are 3 main sections to the programme: Review of the basic course andadvanced “Step-by-Step“courses, followed by a quite intensive part with
implementation packages and workshops. In this last part data collection was a big part of it with the known D-Foot Tool (DIAFI). The hands-on practical sessions included live patient examination and education and as always o debridement training using oranges which nowanvestablished part of the training. The oranges from Morocco where delicious by the way! Let’s have a look to the immediate outcome of the course: • An enthusiastic faculty of France, who are keen to facilitate more robust
and progressive implementation of projects in France. • All delegates enjoyed in this shared experience and started immediately working on networking activities usingt apps and other tools. • It was the first time ever in our history of 6 years TtFT experience that people went home with a very advanced adapted action plans for their own countries. These plans are likely to start in approximately 2 months time. • Immediately after the course: - At the airport of Casablanca on transfer to Algeria, the Algerian team of 8 delegates created their national
working group and had their first oicial meeting. Today less then 2 months later, the Algerian diabetes association created a working group for D-Foot Algeria under their umbrella. From this group 3 people will be chosen to be our national representatives. - At the same place, same moment Tunisian participants created a WhatsApp group to start working together. - At least 3 teams came home and asked the chief of their department to make technical changes in their service to have a better wound-care service and directly changed their
daily clinical work to incorporate this. (Burkina Fasso, Mali, Senegal). - At the university hospital in Marrakesh a meeting took place 2 weeks after our training and they started to set up their first diabetic foot centre. • Last but not least: a more concrete and advanced cooperation started between the partners: SMEDIAN together with SFD and the other diabetes associations of Maghreb. SFD announced in the 12th Diabetes meeting of Oran in Algeria the important collaboration between SFD and D-Foot International. More to come‌
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
MAN ON THE MOON Luc Hendrickx D-Foot Chief Executive Officer Impossible! That was the immediate reaction when, on the 25th of May 1961, President John F. Kennedy addressed the United States Congress with the following prophetic words: "I believe that this nation should commit itself to achieving the goal, before this decade is out, of landing a man on the moon and returning him back safely to the earth.”
This crazy idea was greeted with words like “absurd”, “ludicrous”, “unfeasible” and “an impossible dream”. Today, we know what happened. In retrospect, it is an example of a political desire and determination to achieve a mission, and scientists pulling together resources and collaborating to complete a huge task far too big and ambitious to achieve for anyone or even a small group. On 20 July 1969, Neil Armstrong set foot on the moon.
Where there’s a will, there’s a way Against all odds, the ”impossible” can be done ... if only one wants it badly enough and builds enough capacity to do so. D-Foot International is a small organisation. We possess limited resources, particularly when measured against the challenges and critical issues that need to be addressed. True, D-Foot boasts a network of almost 200 volunteer National Representatives in more than 160 countries to help achieve our goals. But the focus of our National Representatives is mainly in their own respective countries, where they are mostly under-resourced themselves. Today, D-Foot centres around and relies upon a relatively small group of dedicated volunteer diabetic foot and other specialists. Not only do they lead the association as a Board and chair working groups and committees, but they are also actively engaged in the actual field work. A handful of volunteers wearing many hats and stretched to their limits makes the organisation fragile … Building capacity As new needs are identified, and as new paradigms for exchange and interaction
emerge, the organisation is continually challenged to devise ways to increase and strengthen its capacity. We must be selective in the projects that we can undertake, often against our better judgement The projects outlined in our strategic plan are those we feel should be our priority. Unfortunately, D-Foot does not have the necessary capacity as yet to execute even a significant number of them. Consequently, the Board is left with the tough decision to favour one urgent project at the expense of another equally urgent project, and postpone too many projects for lack of capacity to execute them. Essentially, this boils down to forcing the leadership, for lack of capacity, against our will and better judgement, to prioritise in an extreme way, producing trade-offs that may be detrimental to the short-term or long-term goals of the organisation. Effectively, insufficient capacity delays prevention, treatment and care that people with diabetes and diabetic foot deserve.
This, in turn, snow-balls into even more people with diabetic foot. The tools we already have To build capacity, we have a number of capacity tools already. To halt the snow-ball effect of the increasing incidence and prevalence of diabetic foot, and to do what D-Foot must and wants to do, we must build our capacity on more than one front. We understand capacity and capacity building as �to have the ability and the means to fulfil our mission and goals in an effective manner�. Capacity has many faces: . motivational capacity . knowledge and skills capacity . governance capacity . human resources capacity . products and services capacity . financial capacity . networking capacity Some of these capacities we already possess, such as motivation, knowledge and skills, and a steadily expanding network of people and like-minded organisations. That’s already quite something. On the governance front, we built a governing structure designed and ready
priority. Unfortunately, D-Foot does not have the necessary capacity as yet to execute even a significant number of them. Consequently, the Board is left with the tough decision to favour one urgent project at the expense of another equally urgent project, and postpone too many projects for lack of capacity to execute them. Essentially, this boils down to forcing the leadership, for lack of capacity, against our will and better judgement, to prioritise in an extreme way, producing trade-offs that may be detrimental to the short-term or longterm goals of the organisation. Effectively, insufficient capacity delays prevention, treatment and care that people with diabetes and diabetic foot deserve. This, in turn, snow-balls into even more people with diabetic foot. Starting from tools we already have To building capacity, we have a number of capacity tools already To halt the snow-ball effect of the increasing incidence and prevalence of diabetic foot, and to do what D-Foot must and wants to do, we must build our capacity on more than one front. We understand capacity and capacity building as �to have the ability and the
to take on larger challenges. Still small but with a broad mission purpose clause in our Articles of Association, a professionally qualified Vice-President Finance as a mandatory position on the Board, an Audit and Risk Management Committee, the obligation to have our accounts and financial statements externally audited, the possibility to set up branch offices, and proper delegation of power to a CEO, we are punching slightly above our weight as a far our governing structures are concerned. But we have intentionally designed our governance in this way to be prepared for future growth.
The Train-the-Foot-Trainer course is the project flagship. Nearly all other projects relate to, or are a spin-off of the Train-the-Foot-Trainer course.
The tools we don’t have yet
For the D-Foot International Diabetic Foot Academy to be successful, we believe it must be managed professionally by a full-time senior and knowledgeable person, who can rely on proper marketing and administrative support. And the initiative must be properly funded, especially in the firstyear start-up phase when seed money is required until course participants generate sufficient income for the Academy to be self-sufficient.
To build capacity, we must address the capacity tools that we don’t have as yet. On the financial capacity front, we operate in a medical field that is not easily or heavily sponsored by industry and other funding partners. Let’s just face it. D-Foot is not a financially rich organisation by any standard. We are often struggling to make ends meet. Another crucial Achilles heel of our lack of capacity is our small core group of volunteers having to fulfil too many roles and take on too many managerial and operational tasks. To a large extent, we are our own bottle-neck.
A Diabetic Foot Academy Building human resources capacity to deliver more courses in more regions necessitates expanding the current core group of volunteer faculty. We can do this by setting up a professional D-Foot International Diabetic Foot Academy, which runs Train-the-Foot-Trainer courses and its derivatives all year long, either in a central location or off-site in the regions.
One outcome is more trained professionals, including trainers to run Train-the-Foot-Trainer courses—which means the Academy would also need to train Train-the-Foot-Trainer trainers.
Another outcome is trainers who are not also a member of the governing bodies of D-Foot; in other words: delegated capacity, multiplication and sustainability. The benefit is accelerated execution of projects, leading to accelerated rather than delayed referral of patients, which will eventually result in less amputations and better care and quality of life for people with diabetic for and those at risk. Aiming high Will it be easy? — No. Impossible? Definitely not! — Remember NASA’s space project. Ambitious? Yes, of course. But ... Isn’t it better to aim high and perhaps miss, than to aim low and hit? If our plan works out, isn’t significantly less unnecessary amputations where we would hit?
So … shall we put another man on the moon …?
WELL DESERVED RECOGNITION FROM THE ROYAL COLLEGE OF PHYSICIANS GLASGOW Neil Baker Editor-in-Chief Dr. Zulfiqarali G. Abbas received an honorary fellowship from the Royal College of Physicians Glasgow on 23rd November 2018 at the University of Glasgow, UK. The Fellowship award is an accolade held by some of the most exceptional and innovative physicians in the world. It is a mark of achievement and skill as a doctor and recognises ongoing contribution to the profession. They are awarded to physicians or surgeons who have made substantial contributions to their specialty, or are senior members of their profession. Dr Abbas was awarded this honour in recognition for his work in the diabetic foot in Africa, his extensive services to medicine and especially diabetes care in Tanzania. Additionally, as a pioneer in diabetic limb diseases within the Africa continent. Dr. Zulfiqarali G. Abbas is a Consultant Physician, Endocrinologist, and Diabetologist currently practicing in Tanzania. Over the last twenty seven years he has not only established and runs a diabetic foot centre but helped develop a diabetic foot clinics throughout Tanzainia, constantly raising the awareness within the country and throughout Africa. He has published
extensively both in scientific journals/ textbooks and delivers lectures at conferences around the world. He is the current chair of the Pan-Africa Diabetic Foot Study Group and a vice president of D-Foot International and a founder member of the Diabetic Foot study group. He is one of the founder members of the “Step by Step” foot project (2003) which is recognised as one of the most successful diabetic foot training projects worldwide having taking place in about 83 countries to date. Its’ impact has been enormous and includes significantly improvements in patient outcomes, reduction in rates of diabetic limb amputations. Dr Abbas is a mentor for undergraduate and post graduate students in Tanzania, has developed good coordinating working relationships with Ministries of Health in Tanzania and other African countries, IDF, WDF, and the IWGDF. Thus, in recognition of these and other achievement we would like to congratulate him on receiving this well deserve honour from the Royal College of Physicians Glasgow. Well done Abbas.
PRESTIGEOUS RECOGNITION FROM THE COLLEGE OF PODIATRY OF MADRID
On 9 March, Professor José Luis Lázaro Martínez, President-Elect of D-Foot International, received the recognition of Collegiate of Honour from the College of Podiatry of the City of Madrid. This award was granted by unanimous decision of the General Assembly of the College held on 28 February 2018. The award was given in relation to the professional and academic career of Professor Lázaro. According to the President of the College of Podiatry of Madrid, Professor Lázaro is a benchmark in the field of the diabetic foot at an international level, with numerous scientific publications and participation as a lecturer in more than 26 countries around the world. The award was presented by the Deputy Minister of Health of the Community in the presence of the Medical and Nursing Department of the San Carlos Clinical Hospital in Madrid. The College of Podiatry thus recognises the career of Professor Lázaro as a member of Honour, as a distinguished example of the development of the profession of podiatry in Spain and as a pioneer in the development of this profession in Spain and around the world.
r e p a P l i a r T Meric M, Ergun G, Meric C, Demirci I, Azal O. It is not diabetic foot: it is my foot. J Wound Care. 2019 Jan 2; 28(1): 30-37. (Pubmed ID#: 30625047). This is a very interesting subjective and qualitative report involving a semi-structured interview with 15 patients dealing with diabetic foot disease attempting to ascertain patient thoughts with respect to “developing diabetic foot”, “living with diabetic foot”, “coping with diabetic foot”, and “expectations”. As might be expected, patients related the day-to-day difficulty of living with this disease, and challenges encountered therein. It might be expected that articles such as this would help physicians better empathize with their patients, and provide a better avenue for physician-patient communication.
Zha ML, Cai JY, Chen HL. A bibliometric analysis of global research production pertaining to diabetic foot ulcers in the past ten years. J Foot Ankle Surg. 2019 Jan 15. (Pubmed ID#: 30658958). This study provides a birds-eye view of the literature relating to the diabetic foot over the decade spanning 2007-2018. In an analysis of the published investigations, the authors found that the largest volume of diabetic foot literature was produced by the US, followed by the UK, China, Germany, Italy, Netherlands, India, France, Australia and Canada. Although the largest quantity of literature was related to surgery, other common topics included dermatology, endocrinology, orthopedics, internal medicine, cell biology, engineering, cardiology and pharmacology. The authors identified “complications”, “amputation” and “infection” as contemporary hot spots within the literature, and identified “infection”, “wound management” and prediction studies as frontiers to be explored in the future. As there is such a large volume of literature published on this topic, and such a variety to the journals it is published in, a broad view like presented in this article is able to provide a unique perspective.
Shi E, Jex M, Patel S, Garg J. Outcomes of wound healing and limb loss after transmetatarsal amputation in the presence of peripheral vascular disease. J Foot Ankle Surg. 2019 Jan; 58(1): 47-51. (Pubmed ID#: 30583781). There has been an appropriate contemporary momentum developed for diabetic foot surgeons to recommend and perform relatively definitive partial foot amputations in order to decrease recidivism. So for example, a transmetatarsal amputation might be performed as opposed to a biomechanically unstable foot with multiple partial ray resections. One might argue that this even seems intuitive to some degree, although it might not always match up with clinical practice. This study, however, highlights that even these more “definitive� procedures are not necessarily associated with overwhelmingly successful long-term outcomes. In fact, in this series of 153 patient undergoing a transmetatarsal amputation with a history of peripheral arterial disease, a 44% rate of major amputation was reported at 3 years. Although procedure selection and long-term thinking are certainly beneficial to patient care, this underscores that the appropriate procedure is only effective when matched to the appropriate patient.
Dayama A, Tsilimparis N, Kolakowski S, Matolo NM, Humphries MD. Clinical outcomes of bypass-first versus endovascular-first strategy in patients with chronic limbthreatening ischemia due to infrageniculate arterial disease. J Vasc Surg. 2019 Jan; 69(1): 156-163. (Pubmed ID#: 30579443). This retrospective review of the NSQIP database adds to the body of evidence with respect to treatment intervention options for chronic limb-threatening ischemia. Both open bypass and endovascular interventions might be effective in this challenging patient cohort, and obviously come with a different set of expectations and sequela. Patients who underwent a bypass-first approach has a lower rate of 30-day amputation (4.3% vs. 7.4%), but also had a higher rate of major adverse cardiac event (6.9% vs. 2.6%) and 30-day mortality (3.23% vs. 1.8%). Interestingly, the benefit of lower 30-day amputation rate was not observed when dialysis patients were excluded from the data analysis. As with most things in life, an individual assessment of potential benefits and risks is usually necessary as opposed to having clear-cut and black/white choices.
Boulton AJM. The 2017 Banting Memorial Lecture. The diabetic lower limb – a forty year journey: from clinical observation to clinical science. Diabet Med. 2019 Jan 19. (Pubmed ID#: 30659650). And finally who could resist reading a lecture by the esteemed Dr. Boulton recounting his professional experience with the lower limb affected by diabetes? Specific topics addressed include his clinical and scientific experience with necrobiosis lipoidica diabeticorum, symptomatic diabetic sensorimotor neuropathy, autonomic neuropathy, and the pathogenesis/evaluation of the high-risk foot.
Q ui z CLINICAL PICTURE QUIZ In this edition’s clinical picture quiz, I have chosen a case that again is the type of patient that may be seen every day clinical practice. Yes I know that many of you will say …..why this condition, but bear with me please. So, we will adopt the same format as before. Try to have a good look at the picture and imagine the patient in front of you. Yes, I know you can’t ask any questions or physically examine the patient but your eyes will tell you most things. Questions 1. What is the most obvious presenting clinical feature? 2. Is this related to diabetes? 3. What other foot pathologies do you see? 4. Do you think this patient is at increased risk for foot ulceration? 5. 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.
THOUGHTS, COMMENTS AND ANSWERS
What is the most obvious presenting clinical feature? There are several striking features but perhaps the most obvious are the extensive skin plaques and areas of plantar callus. As you can see the skin plaques are orange/ brown in colour and are more evident on the lateral aspect of the heel extending distally along the lateral border. You will notice that the skin is slightly red in all the areas where the plaques or callus are. It is very noticeable when you compare the 1st,3rd,4th and 5th toes with the second toe. There is a diuse area of callus on the plantar surface of the 2nd and 3rd metatarsal heads, localised callus over the medial aspects of the 1st metatarso-phalangeal joint and the interphalangeal joint area of the great toe. However, the appearance of the callus is not typical, it looks to have a friable almost flaky surface and is white in appearance. In the medial longitudinal arch, there are some small reddened lesions that look like a vesicular eruption, this is also seen more subtly in other areas of the foot for example just proximal to the 1st metatarsal head area, the great toe and shaft of 4th metatarsal.
The presenting condition is Psoriasis, which is s a long-lasting autoimmune disease characterized by patches of abnormal skin. These skin patches are typically red, dry, itchy, and scaly. There here are five main types of psoriasis: plaque, guttate, inverse, pustular, and erythrodermic. Plaque psoriasis, also known as psoriasis vulgaris, makes up about 90 percent of cases. It typically presents as red patches with white scales on top. Is this diabetes related? No, this condition is not related to diabetes… So why is this case being used in our footnote? I wanted to highlight that other non-diabetes related conditions can have an impact on the diabetic foot. I am sure you are all more aware of this me but sometimes it’s good to not lose sight or trivialise other pathologies because they are not diabetes related. Forgive me if this sounds obvious or condescending. It’s not meant to be at all. What other pathologies are present? There are several foot pathologies present some obvious others perhaps less so. Let’s start proximally and move distally. The rearfoot - there is what appears to be extensive callus on the medial border of the heel. The distribution is unequal being
thicker more distally with the heaviest concentration at the most distal weightbearing end. Again, the callus looks very dry and white. This is a slightly unusual place to have the thickest area of callus. It is difficult to tell exactly why the callus is so dense here but it is also quite thick along the whole medial border. There are deep skin creases just anterior to this in the medial arch and there is slight bulging of the soft tissue in the dorsal aspect of the arch. This gives a very strong indication that this patient has over or hyper-pronation on stance and walking (flat feet). This would certainly result in a high medio lateral linear and rotational shear force at the end of midstance through to the propulsive phase of gait. This would be sufficient to cause the callus formation and its location. I have just mentioned the pronounced skin creases in the medial arch. I would not be surprised if this was due to an abnormal range of motion in both the longitudinal and obliques axis of the mid -tarsal joint. This would lead to the overpronation is mentioned above and commonly is the cause of the deep or pronounced skin creases you see here. Moving distally the next obvious feature is the great toe. Here you can see Hallux Abducto-valgus …bunion. The 1st metatarsophalangeal joint is deviated in the common
“bunionâ€? position and you can also see a very rounded edged to the medial aspect of the joint. This is also slightly darker red in colour indicating there may be an overlying adventitious bursa present. There is also callus present on the plantar aspect of this joint and again you san see the evidence of psoriasis extending up to the great toe. Once again, the callus appears to be very dry and white. Moving across to the metatarsal head area there is a duuse almost circular area of callus over the 2nd an 3rd metatarsal head area, that almost extends up to the base of the toes. The shape of this callus indicates a couple of things very clearly. Firstly, that this appears to be the main or longest weightbearing area during forefoot loading and propulsion. And secondly that the direction of force during loading is both rotational and linear anteriorly. The callus indicated an abductory twist type motion during propulsion which is not static to the metatarsal head area but is shifting anteriorly during the end of propulsion. This is evidenced by the amount of callus formation in the area of callus. With regard to the toes, the hallux is deviated laterally and is slightly rotated with a heavy build up of callus on the medial
aspect of the plantar interphalangeal joint area. Again, this is indicative of abnormal abduction and plantar flexion during propulsion. Once again you can see that that the plantar soft tissue of the pulp of the hallux is red with evidence of parakeratotic activity due to Psoriasis. The Second toe is non-weight-bearing and almost dorsally displaced being clawed like the other lesser toes. Due to this deformity the second metatarsal head will certainly be in a plantar- flexed position giving rise to some of its’ callus formation. The second toe is a healthy pink colour. The other lesser toes all appear to have a clawed toe type deformity with medial rotation and burrowing of the 5th toe. The 3rd and 4th toe appear to have slight flattening of the soft tissue on the pulp of the toes suggesting they are weightbearing. The inflammatory state of the skin is again seen here as the skin is red and you can see the flaking /desquamation of the epidermal tissue so characteristic of active Psoriasis.
Do you think this patient is at increased risk for foot ulceration?
The evident toenails are long and thickened and friable again this most likely due to Psoriasis but enhanced by trauma. Due to the poor integrity of the nail plate there is also a possibility that mycotic infection could also be present.
Psoriasis is a condition that is very difficult to treat effectively and required the expertise of a dermatologist. So, within the remit of this picture quiz I will not venture to discuss the different treatment options for this condition.
This depends upon several criteria for determining Foot ulcer risk stratification. Clearly if the patient has a loss of protective sensation then this would put the patient in a high-risk category because they also have callus formation. Additionally, they also have deformity present this together with loss of protective sensation would place them at increased risk. Some risk stratification work would place the patient at moderate risk if the patient has deformity alone with intact protective sensation. The risk of subungual ulceration is not well documented in the literature but clinical experience would suggest that this area if left untreated can lead to ulceration even in those with intact sensation and good blood flow. How would you manage what you see?
As usual I will make some suggestion for the management of the other pathologies we see. Firstly, the removal of the plantar callus is something that is essential particularly if the patient has a loss of protective sensation. This is generally undertaken by sharp debridement using a scalpel, it can also be performed by using a mild abrasive such as an emery board. Please note that psoriasis causes a parakeratosis which is incomplete keratinisation of the epidermis this means that the skin is very flaky and is subject to pinpoint haemorrhaging when the flakes of skin are removed. The skin is prone to almost crumbling as it is removed thus a very good and precise cutting action is required in order remove the callus safely and prevent blunting of the scalpel blade. Removing the callus is one thing but it will return and so needs to be done regularly with the use of urea -based moisturisers applied daily after its’ removal. Having said this, it is also very important to try to address the underlying cause of the callus formation. In this case it is mostly likely-due to excessive mid-tarsal joint pronation thus the use of foot orthoses would be useful. Whether these would be functional, semifunctional or accommodative would depend on other clinical feature and findings.
The toe nails would need reducing in thickness regularly and again care is needed as the nail plate is also friable and similar to the status of the skin. It may be worthwhile considering a nail culture for mycotic infection. Accommodating the hallux abducto-valgus and lesser toe deformities in appropriate footwear is also important to help prevent ulceration over these areas. Care must be taken with closed in shoes to ensure that the front of the shoes is deep and wide enough. Also, equally important is the method of fastening, slip on style or loose fastening shoes must be avoided. The fastening should ideally be lace or strap and as close to the front of the ankle as possible. The fastenings should checked and refastened a couple of times a day as any oedema in the foot will be lessened by the confines of the shoe making it loose. If persistent problems arise over any of the deformities despite optimal footwear then surgical correction of the deformities could be considered provided proper assessment and risks were accounted for.
ABSTRACTS GALORE https://goo.gl/5ipDhL Ulcer-risk classification and plantar pressure distribution in patients with diabetic polyneuropathy: exploring the factors that can lead to foot ulceration. 7 Diabetic Neuropathy Prevalence and Its Associated Risk Factors in Two Representative Groups of Type 1 and Type 2 Diabetes Mellitus Patients from Bihor County. 7 Association between hospitalization stay and diabetic foot: an analytical cross-sectional study in three Peruvian hospitals. 8 Evaluate the Effect of Education Interventions in the Prevention of Diabetic Foot Ulcers through Knowledge of the Disease and Self-Care Practices in Saudi Arabia. 9 Can we link foot ulcer with risk factors in diabetics? A study in a tertiary care hospital. 10 Corneal Subbasal Nerve Plexus Changes in Severe Diabetic Charcot Foot Deformity: A Pilot Study in Search for a DNOAP Biomarker. 11 Diabetes foot screening: Challenges and future strategies. 12 Innocuous "foot lump" in patient with diabetes mellitus: A manifestation of phaeohyphomycosis. 13 Bacteriologic analysis of bone biopsy from diabetic foot infections within a VA patient population. 14 Effects of nursing care on patients in an educational program for prevention of diabetic foot. 14 Degree of risk for foot ulcer due to diabetes: nursing assessment. 15 Efficacy of negative pressure wound therapy using vacuum-assisted closure combined with photon therapy for management of diabetic foot ulcers. 15 Extracorporeal Shockwave Therapy for Diabetic FootUlcers: A Systematic Review and Meta-analysis. 17
Performance of the automated multiplex PCR Unyvero implant and tissue infections system in the management of diabetic foot osteomyelitis. 18 Prevalence of Extended Spectrum β-Lactamases in Multi-drug Resistant Pseudomonas aeruginosa from Diabetic Foot Patients. 18 Evaluating the potential of kit-based 68Ga-ubiquicidin formulation in diagnosis of infection: a pilot study68Ga. 19 0.075% capsaicin lotion for the treatment of painful diabetic neuropathy: A randomized, double-blind, crossover, placebo-controlled trial. 20 Differences between national and international guidelines for the management of diabetic foot disease. 21 Application of a paste-type acellular dermal matrix for coverage of chronic ulcerative wounds. 22 Reasonable Glycemic Control Would Help Wound Healing During the Treatment of Diabetic Foot Ulcers. 23 An exploration of the relationship between foot skin temperature and blood flow in type 2 diabetes mellitus patients: a cross-sectional study. 24 Association Between Cigarette Smoking and Diabetic Foot Healing: A Systematic Review and Meta-Analysis. 25 Acute Cardiac Events in Patients With Severe Limb Infection. 25 Using a muscle pump activator device to stimulate healing for non-healing lower leg wounds in long-term care residents. 26 Intravenous contrast-free standardized exercise perfusion imaging in diabetic feet with ulcers. 27 The association of diabetic microvascular and macrovascular disease with cutaneous circulation in patients with type 2 diabetes mellitus. 28 Hemodialysis Impact on Motor Function beyond Aging and DiabetesObjectively Assessing Gait and Balance by Wearable Technology.29
Temperature as a Causative Factor in Diabetic Foot Ulceration: A Call to Revisit Ulcer Pathomechanics. 30 A case report of brain abscess caused by Nocardia cyriacigeorgica in a diabetic patient. 31 Redefined clinical spectra of diabetic foot syndrome. 32 A Novel Method for the Determination of Vancomycin in Serum by HighPerformance Liquid Chromatography-Tandem Mass Spectrometry and Its Application in Patients with Diabetic Foot Infections. 33 Neuromuscular electrostimulation on lower limb wounds. 34 A systematic review of local antibiotic devices used to improve wound healing following the surgical management of foot infections in diabetics. 34 Differences in skin blood flow oscillations between the plantar and dorsal foot in people with diabetes mellitus and peripheral neuropathy. 35 Wound Fluid Matrix Metalloproteinase-9 as a Potential Predictive Marker for the Poor Healing Outcome in Diabetic Foot Ulcers. 36 Effect of lifestyle interventions on diabetic peripheral neuropathy in patients with type 2 diabetes, result of a randomized clinical trial. 37 Epidemiology of Diabetic Foot Infection in the Metro-Detroit Area With a Focus on Independent Predictors for Pathogens Resistant to Recommended Empiric Antimicrobial Therapy. 38 Traditional Chinese Medicine Injections in the Treatment of Diabetic Foot: A Systematic Review and Meta-Analysis. 39 Evaluation of fluorescence biomodulation in the real-life management of chronic wounds: the EUREKA trial. 40 Preliminary experience of an expert panel using Triangle Wound Assessment for the evaluation of chronic wounds. 41
POINT: podiatry for international diabetic foot teams. 42 Improving comprehensive care for patients with diabetes. 44 Perceptions and experiences of diabetic foot ulceration and foot care in people with diabetes: A qualitative meta-synthesis. 44 The influence of population characteristics and measurement system on barefoot plantar pressures: A systematic review and meta-regression analysis. 45 How do type 2 diabetes mellitus (T2DM)-related complications and socioeconomic factors impact direct medical costs? A cross-sectional study in rural Southeast China. 46 Perception of social support in individuals living with a diabetic foot: A qualitative study. 47 Novel insole design for diabetic foot ulcer management. 48 Advancements in improving health-related quality of life in patients living with diabetic foot ulcers. 49 Artificial, Triple-Layered, Nanomembranous Wound Patch for Potential Diabetic Foot Ulcer Intervention. 50 Validity of diagnostic codes and estimation of prevalence of diabetic foot ulcers using a large electronic medical record database. 51 Clinical Outcomes for Diabetic Foot Ulcers Treated with Clostridial Collagenase Ointment or with a Product Containing Silver. 52 Transverse tibial bone movement for the treatment of diabetic foot ulcers 52 Topical application of platelet-rich plasma for diabetic foot ulcers: A systematic review. 53
Evaluation of health utility values for diabetic complications, treatment regimens, glycemic control and other subjective symptoms in diabetic patients using the EQ-5D-5L. 54 Coadministration of DPP-4 inhibitor and insulin therapy does not further reduce the risk of cardiovascular events compared with DPP-4 inhibitor therapy in diabetic foot patients: a nationwide population-based study. 55 Efficacy of high intensity laser therapy in the management of foot ulcers: a systematic review. 57 Hydrogen sulfide primes diabetic wound to close through inhibition of NETosis. 57 Co-delivery of deferoxamine and hydroxysafflor yellow A to accelerate diabetic wound healing via enhanced angiogenesis. 58 Cost-effectiveness of telemonitoring screening for diabetic foot ulcer: a mathematical model. 59 A Tale of Two Eras: Mining Big Data from Electronic Health Records to Determine Limb Salvage Rates with Podiatry.60 Use of Local Flaps for Soft-Tissue Closure in Diabetic FootWounds: A Systematic Review. 61 Mechanical Noise Improves the Vibration Perception Threshold of the Foot in People With Diabetic Neuropathy. 62 Effect of N-acyl-dopamines on beta cell differentiation and wound healing in diabetic mice. 63 Quality Measures in Foot and Ankle Care. 64 Comparative efficacy of nine different dressings in healing diabetic foot ulcer: A Bayesian network analysis. 64 Impact of the pay-for-performance program on lower extremity amputations in patients with diabetes in Taiwan. 65
Prevalence of ankle equinus and correlation with foot plantar pressures in people with diabetes. 66 Decompression nerve surgery for diabetic neuropathy: a structured review of published clinical trials.68 Baseline characteristics of infected foot ulcers in patients with diabetes at a tertiary care hospital in Pakistan. 69 Promoting Self-Care of Diabetic Foot Ulcers Through a Mobile Phone App: User-Centered Design and Evaluation. 70 Mortality and complications after treatment of acute diabetic Charcot foot. 71 An exercise program for people with severe peripheral neuropathy and diabetic foot ulcers - a case series on feasibility and safety.72 Clinical outcomes among morbidly obese patients hospitalized with diabetic foot complications. 73 Does reconstruction preserving the first or first two rays benefit over full transmetatarsal amputation in diabetic foot? 74 Clinical Outcomes and Complications of Midfoot Charcot Reconstruction With Intramedullary Beaming. 75 Malnutrition in type 2 diabetic patients does not affect healing of foot ulcers. 76 The Use of a Novel Super-Oxidized Solution on Top of Standard Treatment in the Home Care Management of Postsurgical Lesions of the Diabetic Foot Reduces Reinfections and Shortens Healing Time. 77 Tracking Anti-Staphylococcus aureus Antibodies Produced In Vivo and Ex Vivo during Foot Salvage Therapy for Diabetic Foot Infections Reveals Prognostic Insights and Evidence of Diversified Humoral Immunity. 77 Spectrum of disease and outcome of primary amputation for diabetic foot sepsis in rural KwaZulu-Natal. 78
The use of ankle brachial pressure indices in a cohort of black African diabetic patients. 79 Charcot neuroarthropathy patient education among podiatrists in Scotland: a modified Delphi approach. 80 A Systematic Review to Compare the Effect of Low-frequency Ultrasonic Versus Nonsurgical Sharp Debridement on the Healing Rate of Chronic Diabetes-related Foot Ulcers. 81 Open-label Extension Phase of a Chronic Diabetic FootUlcer Multicenter, Controlled, Randomized Clinical Trial Using Cryopreserved Placental Membrane. 82 A multicentre prospective randomised controlled comparative parallel study of dehydrated human umbilical cord (EpiCord) allograft for the treatment of diabetic footulcers. 83 LeucoPatch system for the management of hard-to-heal diabetic foot ulcers in the UK, Denmark, and Sweden: an observer-masked, randomised controlled trial. 84 Bacterial distribution, changes of drug susceptibility and clinical characteristics in patients with diabetic foot infection. 85 Continuous diffusion of oxygen improves diabetic foot ulcer healing when compared with a placebo control: a randomised, double-blind, multicentre study. 86 Use of local intrinsic muscle flaps for diabetic foot and ankle reconstruction: a systematic review. 87 Role of platelet-rich plasma in healing diabetic foot ulcers: a prospective study. 88 Diabetes-related foot disorders among adult Ghanaians. 89 Agreement of clinical tests for the diagnosis of peripheral arterial disease. 90
Neuropathy and Other Risk Factors for Lower Extremity Amputation in People with Diabetes Using a Clinical Data Repository System. 91 Autologous platelet-rich gel treatment for diabetic chronic cutaneous ulcers: A meta-analysis of randomized controlled trials. 92 Level of Agreement With a Multi-Test Approach to the Diagnosis of Diabetic Foot Osteomyelitis. 93 The significance of neutrophil-lymphocyte ratio, platelet-lymphocyte ratio and lymphocyte-monocyte ratio in predicting peripheral arterial disease, peripheral neuropathy, osteomyelitis and amputation in diabetic footinfection. 94 Risk factors associated with diabetic foot ulcer-free survival in patients with diabetes. 95 Hallux plantar flexor strength in people with diabetic neuropathy: Validation of a simple clinical test. 96 Validity of the Tinel Sign and Prevalence of Tibial Nerve Entrapment at the Tarsal Tunnel in Both Diabetic and Nondiabetic Subjects: A Cross-Sectional Study.97 Prevalence of Foot Complications in People With Type 2 Diabetes Mellitus: A Community-Based Survey in Rural Udupi. 98 Short-term foot complications in Charcot neuroarthropathy: A retrospective study in tertiary care centres in Spain. 98 Antibiotic therapy of diabetic foot infections: A systematic review of randomized controlled trials.99 Fungal Osteomyelitis in Diabetic Foot Infections: A Case Series and Comparative Analysis. 100 Association of hypoxia inducible factor-1 alpha exon 12 mutation in diabetic patients with and without diabetic footulcer. 101
The Impact of Liraglutide on Diabetes-Related Foot Ulceration and Associated Complications in Patients With Type 2 Diabetes at High Risk for Cardiovascular Events: Results From the LEADER Trial. 102 Peripheral Blood Mononuclear Cells Therapy for Treatment of Lower Limb Ischemia in Diabetic Patients: A Single-Center Experience. 103 Grading the loss of sensation in diabetic patients: A psychometric evaluation of the rotterdam diabetic foot study test battery. 103 Elevated obstructive sleep apnoea risk score is associated with poor healing of diabetic foot ulcers: a prospective cohort study. 104 Efficacy of low-level light therapy for treatment of diabetic foot ulcer: A systematic review and meta-analysis of randomized controlled trials. 105 Single nucleotide polymorphisms in cytokine/chemokine genes are associated with severe infection, ulcer grade and amputation in diabetic foot ulcer. 106 Effects of Non-thermal, Non-cavitational Ultrasound Exposure on Human Diabetic Ulcer Healing and Inflammatory Gene Expression in a Pilot Study.107 Analysis of recurrent ulcerations at a multidisciplinary diabetic Foot unit after implementation of a comprehensive Foot care program. 108 Differentially expressed circulating microRNAs in the development of acute diabetic Charcot foot. 109 Difference in Serum Endostatin Levels in Diabetic Patients with Critical Limb Ischemia Treated by Autologous Cell Therapy or Percutaneous Transluminal Angioplasty. 109 International Variations in Amputation Practice: A VASCUNET Report. 110 Comparison of peripheral nerve blockade characteristics between nondiabetic patients and patients suffering from diabetic neuropathy: a prospective cohort study. 111
The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing better than direct angiosome perfusion in diabetic foot wounds. 112 Associations of health literacy with diabetic foot outcomes: a systematic review and meta-analysis. 114 Short-term predictors of amputation in patients with diabetic foot ulcers.114 Increasing SBP variability is associated with an increased risk of developing incident diabetic foot ulcers. 115 Presence of chronic diabetic foot ulcers is associated with more frequent and more advanced retinopathy. 116 BAD transmission and SAD distribution: a new scenario for critical limb ischemia. 117 Empowerment of type 2 diabetic patients visiting Fuladshahr diabetes clinics for prevention of diabetic foot. 118 Diabetic foot syndrome in patients with diabetes. A multicenter German/ Austrian DPV analysis on 33 870 patients. 119 An aseptically processed, acellular, reticular, allogenic human dermis improves healing in diabetic foot ulcers: A prospective, randomised, controlled, multicentre follow-up trial. 120 Dynamic contrast-enhanced magnetic resonance imaging for differentiating osteomyelitis from acute neuropathic arthropathy in the complicated diabetic foot. 121 The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification independently predicts wound healing in diabetic foot ulcers. 122 Risks of diabetic foot syndrome and amputation associated with sodium glucose co-transporter 2 inhibitors: A Meta-analysis of Randomized Controlled Trials. 123
Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps.124 Correction of ankle and hind foot deformity in Charcot neuroarthropathy using a retrograde hind foot nail-The Kings' Experience. 125 Corneal confocal microscopy detects severe small fiber neuropathy in diabetic patients with Charcot neuroarthropathy. 126 Medical Imaging and Laboratory Analysis of Diagnostic Accuracy in 107 Consecutive Hospitalized Patients With Diabetic Foot Osteomyelitis and Partial Foot Amputations. 127 Depth and combined infection is important predictor of lower extremity amputations in hospitalized diabetic footulcer patients. 127
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