A longitudinal study of foot ulceration and its risk factors in community-based patients with type 2 diabetes: the Fremantle Diabetes Study

Uncontrolled Diabetes is a Strong Predictor of Amputation in End Stage Renal Disease Patients on Hemodialysis

BACKGROUND

Diabetic nephropathy remains a strong risk factor for chronic kidney disease progression. Hemoglobin A1C (HBA1C) has historically been used as a marker for complications related to diabetes. The purpose of this study is to examine the relationship between HBA1C and clinical complications in a patient population with end stage renal disease.

METHODS

This was a prospective study performed using patients from multiple outpatient dialysis centers in Texas, United States. All patients included patients must have end stage renal disease and were receiving either hemodialysis or peritoneal dialysis. An HBA1C ≥ 6.5% was used as a cutoff to differentiate patients with well controlled versus uncontrolled diabetes in this population.

RESULTS

HBA1C ≥ 6.5% was strongly associated with both minor (P = 0.0014) and major (P = 0.006)amputation. Patients with HBA1C ≥ 6.5% was associated with lower mortality compared to patients with HBA1C < 6.5%, P = 0.007.

CONCLUSION

HBA1C remains a reliable marker for amputation in patients with end-stage renal disease; however, there is skepticism in using HBA1C as a marker for survival in these patients.

What characteristics are most important in stratifying patients into groups with different risk of diabetic foot ulceration?

AIMS/INTRODUCTION

This study aimed to assess if patients can be divided into different strata, and to explore if these correspond to the risk of diabetic foot complications.

MATERIALS AND METHODS

A set of 28 demographic, vascular, neurological and biomechanical measures from 2,284 (1,310 men, 974 women) patients were included in this study. A two-step cluster analysis technique  was utilised to divide the patients into groups, each with similar characteristics.

RESULTS

Only two distinct groups: group 1 (n = 1,199; 669 men, 530 women) and group 2 (n = 1,072; 636 men, 436 women) were identified. From continuous variables, the most important predictors of grouping were: ankle vibration perception threshold (16.9 ± 4.1 V vs 31.9 ± 7.4 V); hallux vibration perception threshold (16.1 ± 4.7 V vs 33.1 ± 7.9 V); knee vibration perception threshold (18.2 ± 5.1 V vs 30.1 ± 6.5 V); average temperature sensation threshold to cold (29.2 ± 1.1°C vs 26.7 ± 0.7°C) and hot (35.4 ± 1.8°C vs 39.5 ± 1.0°C) stimuli, and average temperature tolerance threshold to hot stimuli at the foot (43.4 ± 0.9°C vs 46.6 ± 1.3°C). From categorical variables, only impaired sensation to touch was found to have importance at the highest levels: 87.4% of those with normal sensation were in group 1; whereas group 2 comprised 95.1%, 99.3% and 90.5% of those with decreased, highly-decreased and absent sensation to touch, respectively. In addition, neuropathy (monofilament) was a moderately important predictor (importance level 0.52) of grouping with 26.2% of participants with neuropathy in group 1 versus 73.5% of participants with neuropathy in group 2. Ulceration during follow up was almost fivefold higher in group 2 versus group 1.

CONCLUSIONS

Impaired sensations to temperature, vibration and touch were shown to be the strongest factors in stratifying patients into two groups with one group having almost 5-fold risk of future foot ulceration compared to the other.

A Comprehensive Systematic Review of Data Linkage Publications on Diabetes in Australia

Aims

Our study aimed to identify the common themes, knowledge gaps and to evaluate the quality of data linkage research on diabetes in Australia.

Methods

This systematic review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement). Six biomedical databases and the Australian Population Health Research Network (PHRN) website were searched. A narrative synthesis was conducted to comprehensively identify the common themes and knowledge gaps. The guidelines for studies involving data linkage were used to appraise methodological quality of included studies.

Results

After screening and hand-searching, 118 studies were included in the final analysis. Data linkage publications confirmed negative health outcomes in people with diabetes, reported risk factors for diabetes and its complications, and found an inverse association between primary care use and hospitalization. Linked data were used to validate data sources and diabetes instruments. There were limited publications investigating healthcare expenditure and adverse drug reactions (ADRs) in people with diabetes. Regarding methodological assessment, important information about the linkage performed was under-reported in included studies.

Conclusions

In the future, more up to date data linkage research addressing costs of diabetes and its complications in a contemporary Australian setting, as well as research assessing ADRs of recently approved antidiabetic medications, are required.

Prevalence and Burden of Diabetes-Related Foot Disease in New South Wales, Australia: Evidence from the 45 and Up Study Survey Data Linked with Health Services Data

Diabetes-related foot disease (DFD) is a major public health concern due to the higher risks of hospitalisation. However, estimates of the prevalence of DFD in the general population are not available in Australia. This study aims to estimate the prevalence of DFD and diabetes-related lower-extremity amputation (DLEA) among people aged 45 years and over in New South Wales (NSW), Australia. The NSW 45 and Up Study baseline survey data of 267,086 persons aged 45 years and over, linked with health services' administrative data from 2006 to 2012 were used in our study. Of these, 28,210 individuals had been diagnosed with diabetes, and our study identified 3035 individuals with DFD. The prevalence of DFD, diabetic foot ulcer (DFU), diabetic foot infection (DFI), diabetic gangrene (DG), and DLEA were 10.8% (95%CI: 10.3, 11.2), 5.4% (95% CI: 5.1, 5.8), 5.2% (95%CI: 4.9, 5.5), 0.4% (95%CI: 0.3, 0.5), and 0.9% (95%CI: 0.7, 1.0), respectively. DFD, DFU, DFI, DG, and DLEA were the most common among those who were older, born in Australia, from low-income households (<AUD 20,000), or were without private health insurance. Interventional messages to reduce all forms of DFD should target those who are from high-risk groups.

Development and validation of an incidence risk prediction model for early foot ulcer in diabetes based on a high evidence systematic review and meta-analysis

OBJECTIVES

To develop and validate a model for predicting the risk of early diabetic foot ulcer (DFU) based on systematic review and meta-analysis.

METHODS

Data were analyzed from the risk factors of DFU with their corresponding risk ratio (RR) by meta-analysis. The DFU prediction model included statistically significant risk factors from the meta-analysis, all of which were scored by its weightings, and the prediction model was externally validated using a validation cohort from China. The occurrence of early DFU was defined as patients with type 2 diabetes who were free of DFU at baseline and diagnosed with DFU at follow-up. Evaluation of model performance was based on the area under the discrimination receiver operating characteristic curve (ROC), with optimal cutoff point determined by calculation of sensitivity and specificity. Kaplan-Meier curve were performed tocompare the cumulative risk of different groups.

RESULTS

Our meta-analysis confirmed a cumulative incidence of approximately 6.0% in 46,521 patients with diabetes. The final risk prediction model included Sex, BMI, HbA1c, Smoker, DN, DR, DPN, Intermittent Claudication, Foot care, and their RRs were 1.87, 1.08, 1.21, 1.77, 2.97, 2.98, 2.76, 3.77, 0.38, respectively. The total score of all risk factors was 80 points according to their weightings. The prediction model showed good discrimination with AUC = 0.798 (95 %CI 0.738-0.858). At the optimal cut-off value of 46.5 points, the sensitivity, specificity and Youden index were 0.769, 0.798 and 0.567, respectively. The final model stratified the validation cohort into low, low-intermediate, high-intermediate and high-risk groups; Compared with low-risk group, the RR with 95 %CI of developing DFU in high-intermediate and high-risk group were 17.23 (5.12-58.02), p < 0.01 and 46.11 (5.16-91.74), p < 0.01, respectively.

CONCLUSION

We have developed a simple tool to facilitates early identification of patients with diabetes at high risk of developing DFU based on scores. This simple tool may improve clinical decision-making and potentially guide early intervention.

Risk factors for diabetic foot complications among patients with type 2 diabetes in Austria-A registry-based retrospective cohort study

Aims

Diabetic foot complications, a serious consequence of diabetes mellitus, are associated with a tremendous burden on both individual patients and health care systems. Since prevention strategies may reduce the incidence of this complication, identification of risk factors in large longitudinal studies is essential to optimize early detection and personalized screening of patients at increased risk.

Materials and methods

We conducted a registry‐based retrospective cohort study using data from 10,688 patients with type 2 diabetes mellitus aged ≥18 years. Cox regression models were used to identify risk factors for foot complications while adjusting for potential confounders.

Results

We observed 140 diabetic foot complications in our patient cohort. The multivariate Cox regression model revealed neuropathy, peripheral arterial disease and male gender as being positively associated with foot complications. The same effect was detected for nephropathy in the time >10 years after T2DM diagnosis. For higher age at diagnosis and use of insulin, however, a negative association was retrieved.

Conclusion

Male gender and several diabetes‐related comorbidities were identified as risk factors for subsequent initial foot complications in patients with type 2 diabetes mellitus. These findings suggest that personalized early detection of patients at increased risk might be feasible by using information on demographics, medical history and comorbidities.

[Development of a Diabetic Foot Ulceration Prediction Model and Nomogram]

PURPOSE

This study aimed to identify the risk factors for diabetic foot ulceration (DFU) to develop and evaluate the performance of a DFU prediction model and nomogram among people with diabetes mellitus (DM).

METHODS

This unmatched case-control study was conducted with 379 adult patients (118 patients with DM and 261 controls) from four general hospitals in South Korea. Data were collected through a structured questionnaire, foot examination, and review of patients' electronic health records. Multiple logistic regression analysis was performed to build the DFU prediction model and nomogram. Further, their performance was analyzed using the Lemeshow-Hosmer test, concordance statistic (C-statistic), and sensitivity/specificity analyses in training and test samples.

RESULTS

The prediction model was based on risk factors including previous foot ulcer or amputation, peripheral vascular disease, peripheral neuropathy, current smoking, and chronic kidney disease. The calibration of the DFU nomogram was appropriate (χ² = 5.85, p = .321). The C-statistic of the DFU nomogram was .95 (95% confidence interval .93~.97) for both the training and test samples. For clinical usefulness, the sensitivity and specificity obtained were 88.5% and 85.7%, respectively at 110 points in the training sample. The performance of the nomogram was better in male patients or those having DM for more than 10 years.

CONCLUSION

The nomogram of the DFU prediction model shows good performance, and is thereby recommended for monitoring the risk of DFU and preventing the occurrence of DFU in people with DM.

Diabetic foot complications-lessons learned from real-world data derived from a specialized Austrian hospital

BACKGROUND

Diabetic foot complications, one of the most severe late complications of type 2 diabetes mellitus, are associated with a tremendous personal and financial burden. In order to drive the prevention of diabetic foot complications forward and facilitate early detection and personalized screening of high-risk patients, longitudinal studies are needed to identify risk factors associated with diabetic foot complications in large patient datasets.

METHODS

This is a retrospective cohort study on 3002 patients with type 2 diabetes mellitus aged ≥ 18 years without prior foot complications. The data were collected between 2006 and 2017 in an Austrian hospital department specialized for diabetic patients. In addition to a univariate Cox regression analysis, multivariate Cox regression models were established to identify independent risk factors associated with diabetic foot complications and adjust for potential confounders.

RESULTS

We observed a total of 61 diabetic foot complications in 3002 patients. In the multivariate Cox regression model, significant risk factors (hazard ratio, 95% confidence interval) for foot complications were age at diagnosis > 70 years (3.39, 1.33-8.67), male gender (2.55, 1.42-4.55), neuropathy (3.03, 1.74-5.27), peripheral arterial disease (3.04, 1.61-5.74), hypertension > 10 years after diagnosis (2.32, 1.09-4.93) and HbA1c > 9% (2.44, 1.02-5.83).

CONCLUSION

The identified risk factors for diabetic foot complications suggest that personalized early detection of patients at high risk might be possible by taking the patient's clinical characteristics, medical history and comorbidities into account. Modifiable risk factors, such as hypertension and high levels of blood glucose might be tackled to reduce the risk for diabetic foot complications.

Diabetes-related foot disease in Australia: a systematic review of the prevalence and incidence of risk factors, disease and amputation in Australian populations

Background

Diabetes-related foot disease (DFD) is a leading cause of global hospitalisation, amputation and disability burdens; yet, the epidemiology of the DFD burden is unclear in Australia. We aimed to systematically review the literature reporting the prevalence and incidence of risk factors for DFD (e.g. neuropathy, peripheral artery disease), of DFD (ulcers and infection), and of diabetes-related amputation (total, minor and major amputation) in Australian populations.

Methods

We systematically searched PubMed and EMBASE databases for peer-reviewed articles published until December 31, 2019. We used search strings combining key terms for prevalence or incidence, DFD or amputation, and Australia. Search results were independently screened for eligibility by two investigators. Publications that reported prevalence or incidence of outcomes of interest in geographically defined Australian populations were eligible for inclusion. Included studies were independently assessed for methodological quality and key data were extracted by two investigators.

Results

Twenty publications met eligibility and were included. There was high heterogeneity for populations investigated and methods used to identify outcomes. We found within diabetes populations, the prevalence of risk factors ranged from 10.0–58.8%, of DFD from 1.2–1.5%, and the incidence of diabetes-related amputation ranged from 5.2–7.2 per 1000 person-years. Additionally, the incidence of DFD-related hospitalisation ranged from 5.2–36.6 per 1000 person-years within diabetes populations. Furthermore, within inpatients with diabetes, we found the prevalence of risk factors ranged from 35.3–43.3%, DFD from 7.0–15.1% and amputation during hospitalisation from 1.4–5.8%.

Conclusions

Our review suggests a similar risk factor prevalence, low but uncertain DFD prevalence, and high DFD-related hospitalisation and amputation incidence in Australia compared to international populations. These findings may suggest that a low proportion of people with risk factors develop DFD, however, it is also possible that there is an underestimation of DFD prevalence in Australia in the few limited studies, given the high incidence of hospitalisation and amputation because of DFD. Either way, studies of nationally representative populations using valid outcome measures are needed to verify these DFD-related findings and interpretations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-021-00447-x.

Risk factors for diabetic foot complications in type 2 diabetes-A systematic review

Aims

With increasing numbers of patients with type 2 diabetes mellitus (T2DM) worldwide, the number of associated diabetic foot complications might also increase. This systematic review was performed to summarize published data about risk factors for the diabetic foot (DF) syndrome in order to improve the identification of high-risk patients.

Materials and methods

Six electronic databases were searched for publications up to August 2019 using predefined stringent inclusion and exclusion criteria.

Results

Of 9,476 identified articles, 31 articles from 28 different study populations fulfilled the criteria for our evaluation. The overall quality of the studies was good, and the risk of bias was low. There was large heterogeneity among the studies concerning study protocols and patient populations analysed. A total of 79 risk factors were analysed within this review. The majority of studies described a consistently positive association with different outcomes of interest related to DF for gender, peripheral neuropathy, retinopathy, nephropathy, poor glycaemic control, insulin use, duration of diabetes, smoking and height. For age, hypertension, dyslipidaemia and body mass index, the results remain inconsistent.

Conclusion

A most up-to-date literature review resulted in glycaemic control and smoking as the only amenable risk factors with a consistently positive association for DF. Due to the high personal and financial burden associated with DF and the large heterogeneity among included studies, additional longitudinal studies in large patient populations are necessary to identify more modifiable risk factors that can be used in the prediction and prevention of DF complications.

The role of amputative and non-amputative foot deformities severity in the risk for diabetic ulceration classification systems building: a cross-sectional and case-control pilot investigation

Introduction

Foot deformities and amputations are parameters that have been studied as risk factors for diabetic foot ulceration (DFU). However, inclusion of "foot deformities" and "amputations" in a single, broad variable and with reference to the severity of these deformities, may better characterize subjects who are prone to develop DFU.

Methods

The objective of the study was the examination of amputative and non-amputative foot deformities severity as risk factor for DFU in relation with the other established risk factors. A cross-sectional and case-control study was conducted from October 2005 to November 2016. One hundred and thirty-four subjects with type 1 and 2 diabetes, with and without active foot ulcers, participated. A structured quantitative interview guide was used. Univariate logistic regression analysis for the literature's established risk factors was performed, as well as for two versions of the "amputative and non-amputative foot deformities severity" variable. Subsequently, multivariate logistic regression analysis (MLRA) for three models and receiver operating characteristic (ROC) curve analysis were carried out.

Results

From the MLRA, only PAD (peripheral arterial disease) was significant (OR 3.56, 95% CI 1.17-10.82, P=0.025 and OR 3.33, 95% CI 1.02-10.08, P=0.033). Concerning the ROC curve analysis of the models, the one with the three categories amputative and non-amputative foot deformities severity variable, had the greatest area under the ROC curve (0.763, P<0.001).

Conclusion

A united variable for lower extremity amputations and other foot deformities with reference to their severity, could be more helpful to the clinicians in identifying patients with diabetes at risk for foot ulceration.

Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes?

AIMS

The aim of this study was to identify the biomechanical, neurological and clinical parameters along with other demographics and lifestyle risk factors that could explain the presence of foot ulcer in patients with diabetes in Africa.

METHODS

A total of 1270 (M/F:696/574) patients; 77(M/F:53/24) with ulcerated vs 1193 (M/F: 643/550) with non-ulcerated feet; participated in this study. A set of 28 parameters were collected and compared between the participants with and without active foot ulcers. Multivariate logistic regression was utilised to develop an explanatory model for foot ulceration.

RESULTS

Foot swelling (χ2(1,n = 1270) = 265.9,P = 0.000,Phi = 0.464) and impaired sensation to monofilament (χ2(2,n = 1270) = 114.2,P = 0.000,Cramer'sV = 0.300) showed strong association with presence of ulceration. A lower Temperature sensitivity to cold stimuli and limited ankle joint mobility were observed to be significant (P < 0.05) contributors to ulceration. The logistic regression model can justify the presence of foot ulceration with 95.3% diagnostic accuracy, 99.1% specificity and 37.3% sensitivity.

CONCLUSION

Participants with ulcerated foot show distinct characteristics in few foot related parameters. Swollen foot, limited ankle mobility, and peripheral sensory neuropathy were significant characteristics of patients with diabetic foot ulcer. One out of three patients with ulcerated foot showed common characteristics that could be justified by the model.

Association between diabetic eye disease and other complications of diabetes: Implications for care. A systematic review

The aim of this systematic review was to examine the associations between diabetic retinopathy (DR) and the common micro- and macrovascular complications of diabetes mellitus, and how these could potentially affect clinical practice. A structured search of the PubMed database identified studies of patients with diabetes that assessed the presence or development of DR in conjunction with other vascular complications of diabetes. From 70 included studies, we found that DR is consistently associated with other complications of diabetes, with the severity of DR linked to a higher risk of the presence of, or of developing, other micro- and macrovascular complications. In particular, DR increases the likelihood of having or developing nephropathy and is also a strong predictor of stroke and cardiovascular disease, and progression of DR significantly increases this risk. Proliferative DR is a strong risk factor for peripheral arterial disease, which carries a risk of lower extremity ulceration and amputation. Additionally, our findings suggest that a patient with DR has an overall worse prognosis than a patient without DR. In conclusion, this analysis highlights the need for a coordinated and collaborative approach to patient management. Given the widespread use of DR screening programmes that can be performed outside of an ophthalmology office, and the overall cost-effectiveness of DR screening, the presence and severity of DR can be a means of identifying patients at increased risk for micro- and macrovascular complications, enabling earlier detection, referral and intervention with the aim of reducing morbidity and mortality among patients with diabetes. Healthcare professionals involved in the management of diabetes should encourage regular DR screening.

Chronic wounds in Australia: A systematic review of key epidemiological and clinical parameters

Chronic wounds are a significant problem in Australia. The health care-related costs of chronic wounds in Australia are considerable, equivalent to more than AUD $3.5 billion, approximately 2% of national health care expenditure. Chronic wounds can also have a significant negative impact on the health-related quality of life of affected individuals. Studies have demonstrated that evidence-based care for chronic wounds improves clinical outcomes. Decision analytical modelling is important in confirming and applying these findings in the Australian context. Epidemiological and clinical data on chronic wounds are required to populate decision analytical models. Although epidemiological and clinical data on chronic wounds in Australia are available, these data have yet to be systematically summarised. To address these omissions and clarify the state of existing evidence, we conducted a systematic review of the literature on key epidemiological and clinical parameters of chronic wounds in Australia. A total of 90 studies were selected for inclusion. This paper presents a synthesis of the evidence on the prevalence and incidence of chronic wounds in Australia, as well as rates of infection, hospitalisation, amputation, healing, and recurrence.

Assessment of chronic wounds in adults: an integrative review

OBJECTIVE

To identify the main aspects that should be assessed in adults with chronic wounds.

METHOD

This was an integrative review of the scientific literature published between 2010 and early 2015 in the PubMed and Web of Science databases.

RESULTS

Few studies exclusively address wound assessment. However, the review found many aspects to consider when assessing individuals with ulcers, grouped as follows: factors that significantly affect healing or the development of new wounds (age, nutritional status, functional capacity, or comorbidities), pyschosocial factors, and wound characteristics (location, size, depth, type of tissue, time of evolution).

CONCLUSION

The literature search did not result in any one aspect that must be considered when assessing chronic wounds, but a complex interaction of factors that include both physiological and social and psychological elements. Professionals should be aware of this multifactorial approach to achieve early detection of the development and evolution of ulcers and to intervene accordingly.

Empirical Antibiotic Treatment in Diabetic Foot Infection: A Study Focusing on the Culture and Antibiotic Sensitivity in a Population From Southern China

Diabetic foot and subsequent diabetic ulcer infections are the most devastating complication of diabetes. This study was conducted to explore the bacterial spectrum, sensitivity of microbials, and analysis of the empirical antibiotic regimens in our health center. The study included patients with diabetic foot ulcer infection (DFI) seen from 2009 to 2014. The patients included had all information covering the physical examination, laboratory tests, and image examinations. We sent appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all participants. A total of 312 patients were included: 52, 112, 95 and 53 patients within uninfected, mild, moderate, and severe infection groups. The total percentages of Gram-positive cocci (GPCs) and Gram-negative rods (GNRs) were 54% and 48.8% ( P = 0.63). The most common GPC was Staphylococcus aureus (22.4%) and GNR was Pseudomonas aeruginosa (11.9%). Methicillin-resistant Staphylococcus aureus was isolated from 21 patients (6.7%). Even in the mild infection group, there was no significant difference between GPC and GNR infection, irrespective of recent antibiotic use ( P = 0.053). The most frequently used empirical antibiotics in our center were second-/third-generation cephalosporin ± clindamycin, both in the mild and moderate/severe infection groups. In our center, the amoxicillin/clavulanate or ampicillin/sulbactam (β-L-ase 1) and second-/third-generation cephalosporins were highly resistant to the common GNR (30%-60%). The ticarcillin/clavulanate, piperacillin/tazuobactam (β-L-ase 2), fluoroquinolone, and group 2 carbapenem had good sensitivity. This study presents a comprehensive microbiological survey of diabetic foot ulcers in inpatients and provides reliable evidence of the local microbial epidemiology and sensitivity of antibiotics, which may help us improve clinical outcomes in DFI patients.

Temporal changes in the prevalence and associates of foot ulceration in type 2 diabetes: the Fremantle Diabetes Study

AIMS

To assess temporal changes in foot ulceration and its risk factors in community-based people with type 2 diabetes.

METHODS

Baseline data from the longitudinal observational Fremantle Diabetes Study collected from 1993 to 1996 (Phase I) and 2008 to 2011 (Phase II) were analyzed. Generalized linear modeling was used to examine changes in foot ulcer prevalence and its associates between phases. Multiple logistic regression was used to determine associates of prevalent foot ulceration in individual and pooled phases.

RESULTS

There were 16 foot ulcers among 1296 patients in Phase I (1.2%) and 23 in 1509 Phase II patients (1.5%; P=0.86 after age, sex and race/ethnicity adjustment). Glycemic and non-glycemic cardiovascular risk factors were better in Phase II, but diabetes duration was longer, peripheral sensory neuropathy (PSN) was more prevalent and more patients were Aboriginal (P<0.001) than in Phase I. In multivariable analysis of both phases and pooled data, diabetes duration and peripheral sensory neuropathy (PSN) were independent associates of foot ulceration (P≤0.026). Prior hospitalization for ulcer, intermittent claudication, any absent pedal pulse and Aboriginality were also significant in the pooled model (P≤0.009).

CONCLUSIONS

Strong associations between foot ulcer and diabetes duration, PSN, symptomatic and clinically-detectable peripheral vascular disease were observed. Aboriginality also proved an independent risk factor. Since all these risk factors apart from intermittent claudication and impalpable foot pulses were more prevalent in Phase II, improved community- and hospital-based foot care between phases are likely to have attenuated the risk of foot ulcers in Phase II patients.