Scottish foot ulcer risk score predicts foot ulcer healing in a regional specialist foot clinic

How do patients and healthcare professionals experience foot examinations in diabetes care? - A randomised controlled study of digital foot examinations versus traditional foot examinations

BACKGROUND

Digital solutions in healthcare can facilitate and improve care. However, the experiences and the usefulness of using either digital foot examinations or traditional foot examinations need to be evaluated. The aims of the study were to evaluate: 1) The differences in patient experiences, having their foot examined supported by the Clinical Decision Support System as compared with having their foot examined in traditional practice, 2) How healthcare professionals, by using the digital tool, experienced the routine compared with performing the foot examination as in traditional practice.

METHODS

Of a total of 141 patients, 100 patients with diabetes were single-blind digitally randomised to one of two parallel arms: having their foot examined by a healthcare professional using a digital tool (n = 47) or having their foot examined as in traditional practice (n = 53) at the Department of Prosthetics and Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden. Patients filled in a modified version of the National Patient Survey and the Orthotics and Prosthetics Users' Survey at study end. Two healthcare professionals, working at a Department of Prosthetics and Orthotics, answered surveys regarding the interaction between the patient and the certified prosthetist and orthotist.

RESULTS

Patients, aged 66 ± 13 years, perceived a high level of satisfaction with the service at the department, regardless of the method used. No significant differences between groups were found when evaluated by 27 questions in the National Patient Survey or by the Orthotics and Prosthetics Users' Survey, with scores of 67.17 ± 12.18 vs. 66.35 ± 16.52 (p = 0.78) for the intervention and control group respectively. For the same patient that healthcare professionals foot examined, the risk class was fully obtained when the risk to develop foot ulcers was assessed by using the digital tool, whereas only 2% of the patients were classified when foot assessed in traditional practice.

CONCLUSIONS

Regardless of the method used for the foot examination, patients perceived a high level of satisfaction with the services at the Department of Prosthetics and Orthotics. All the patients were risk classified in the intervention group. The healthcare professionals found that, by using the Clinical Decision Support System, the foot examination was structured and followed clinical guidelines. Furthermore, the documentation in the electronic health record was thorough, even though further improvements, such as integration with co-existing health record systems, were requested.

TRIAL REGISTRATION

Clinical Trials NCT03088566 , Registered 23 March 2017.

Risk factors for diabetic foot ulcers: A systematic review and meta-analysis

OBJECTIVE

To systematically evaluate the risk factors for developing diabetic foot ulcers (DFU).

METHODS

The Cochrane Library, PubMed, Web of Science, SinoMed, CNKI, VIP, and Wanfang Data were searched for relevant studies on DFU risk factors, and the search time frame was from database creation to March 2022. Meta-analysis was performed using RevMan 5.3.

RESULTS

A total of 26 publications were included, including 3 cohort studies, 22 case-control studies, and one cross-sectional study. Meta-analysis showed that advanced age [MD = 6.04, 95% CI (3.92, 8.16)], male [OR = 1.84, 95% CI (1.48, 2.29)], elevated body mass index [MD = 1.58, 95% CI (0.47, 2.69)], prolonged duration of diabetes [MD = 2.72, 95% CI (2.33, 3.11)], comorbid nephropathy [OR = 3.15, 95% CI (2.68, 4.60)], comorbid neuropathy [OR = 4.80, 95% CI (2.79, 8.27)], comorbid retinopathy [OR = 3.37, 95% CI (2.26, 5.02)], elevated systolic blood pressure [OR = 8.19, 95% CI (6.33, 10.05)], elevated fasting glucose [MD = 1.60, 95% CI (0.21, 3.00)], elevated glycated hemoglobin [MD = 1.24, 95% CI (0.94, 1.54)], elevated triglycerides [MD = 0.44 (95% CI (0.15, 0.73)], elevated fibrinogen [MD = 1.35, 95% CI (0.62, 2.08)], elevated white blood cell count [MD = 2.56, 95% CI (2.24, 2.88)], elevated C-reactive protein [MD = 15.08, 95% CI (8.03, 22.13)], decreased ankle-brachial ratio [MD = -0.26, 95% CI (-0.36, -0.16)], and decreased total protein levels [MD = -4.58, 95% CI (-6.91, -2.25)] were risk factors for developing DFU (p < 0.05), and increased HDL cholesterol levels [MD = -0.22, 95% CI (-0.36, -0.08)] were protective factor for developing DFU (p < 0.05).

CONCLUSION

There are many risk factors for developing of ulcers in the diabetic feet, and early prevention and intervention should be performed as early as possible to assess the risk of developing diabetic foot patients.

Using Data to Improve the Management of Diabetes: The Tayside Experience

Tayside is a region in the East of Scotland and forms one of nine local government regions in the country. It is home to approximately 416,000 individuals who fall under the National Health Service (NHS) Tayside health board, which provides health care services to the population. In Tayside, Scotland, a comprehensive informatics network for diabetes care and research has been established for over 25 years. This has expanded more recently to a comprehensive Scotland-wide clinical care system, Scottish Care Information - Diabetes (SCI-Diabetes). This has enabled improved diabetes screening and integrated management of diabetic retinopathy, neuropathy, nephropathy, cardiovascular health, and other comorbidities. The regional health informatics network links all of these specialized services with comprehensive laboratory testing, prescribing records, general practitioner records, and hospitalization records. Not only do patients benefit from the seamless interconnectedness of these data, but also the Tayside bioresource has enabled considerable research opportunities and the creation of biobanks. In this article we describe how health informatics has been used to improve care of people with diabetes in Tayside and Scotland and, through anonymized data linkage, our understanding of the phenotypic and genotypic etiology of diabetes and associated complications and comorbidities.

Health Professionals' Opinions About Secondary Prevention of Diabetes-Related Foot Disease

PURPOSE

The purpose of this study was to explore the perceptions of health professionals regarding the ideal design of a remotely delivered diabetes-related foot disease (DFD) secondary prevention program.

METHODS

A qualitative study involving 33 semistructured phone interviews was conducted with health professionals with experience managing DFD. Interviews discussed the role of health professionals in managing DFD, their experience in using telehealth, perceived management priorities, preferences for a secondary prevention management program, and perceived barriers and facilitators for such a program. Interviews were audio-recorded and transcribed, and inductive thematic analysis was used to derive key themes.

RESULTS

Three themes were derived: (1) barriers in current model of DFD care, (2) facilitators and ideas for a remotely delivered secondary prevention program, and (3) potential challenges in implementation. DFD care remains acute-care focused, with variability in access to care and a lack of "clinical ownership." Patients were perceived as often having poor knowledge and competing priorities, meaning engagement in self-care remains poor. Participants felt a remote secondary prevention program should be simple to follow and individualized to patients' context, with embedded support from a case manager and local multidisciplinary service providers. Challenges to implementation included limited DFD awareness, poor patient motivation, patient-related issues with accessing and using technology, and the inability to accurately assess and treat the foot over telehealth.

CONCLUSIONS

Health professionals felt that an ideal remotely delivered secondary prevention program should be tailored to patients' needs with embedded support from a case manager and complemented with multidisciplinary collaboration with local service providers.

Multiple factors predict longer and shorter time-to-ulcer-free in people with diabetes-related foot ulcers: Survival analyses of a large prospective cohort followed-up for 24-months

AIMS

To investigate factors independently associated with time-to-(being)-ulcer-free, time-varying effects and predict adjusted ulcer-free probabilities, in a large prospective cohort with diabetes-related foot ulcers (DFU) followed-up for 24 months.

METHODS

Patients presenting with DFU(s) to 65 Diabetic Foot Services across Queensland, Australia, between July-2011 and December-2017 were included. Demographic, comorbidity, limb, ulcer, and treatment factors were captured at presentation. Patients were followed-up until ulcer-free (all DFU(s) healed), amputation, death or two years. Factors associated with time-to-ulcer-free were investigated using both Cox proportional hazards and flexible parametric survival models to explore time-varying effects and plot predicted adjusted ulcer-free probability graphs.

RESULTS

Of 4,709 included patients (median age 63 years, 69.5% male), median time-to-ulcer-free was 112 days (IQR:40->730), with 68.4% ulcer-free within two years. Factors independently associated with longer time-to-ulcer-free were each year of age younger than 60 years, living in a regional or remote area, smoking, neuropathy, peripheral artery disease (PAD), ulcer size >1 cm², deep ulcer and mild infection (all p < 0.05). Time-varying effects were found for PAD and ulcer size limiting their association to six months only. Shorter time-to-ulcer-free was associated with recent DFU treatment by a podiatrist and receiving knee-high offloading treatment (both p < 0.05). Predicted adjusted ulcer-free probability graphs reported largest differences in time-to-ulcer-free over 24-months for geographical remoteness and PAD factors.

CONCLUSIONS

Multiple factors predicted longer and shorter time-to-ulcer-free in people presenting with DFUs. Considering these factors, their time-varying effects and adjusted ulcer-free probability graphs, should aid the prediction of the likely time-to-(being)-ulcer-free for DFU patients.

Diabetic Foot Risk Classification at the Time of Type 2 Diabetes Diagnosis and Subsequent Risk of Mortality: A Population-Based Cohort Study

AIM

We aimed to compare the mortality of individuals at low, moderate, and high risk of diabetic foot disease (DFD) in the context of newly diagnosed type 2 diabetes, before developing active diabetic foot problem.

METHODS

This was a population-based cohort study of adults with newly diagnosed type 2 diabetes utilizing IQVIA Medical Research Data. The outcome was all-cause mortality among individuals with low, moderate, and high risk of DFD, and also in those with no record of foot assessment and those who declined foot examination.

RESULTS

Of 225,787 individuals with newly diagnosed type 2 diabetes, 34,061 (15.1%) died during the study period from January 1, 2000 to December 31, 2019. Moderate risk and high risk of DFD were associated with increased mortality risk compared to low risk of DFD (adjusted hazard ratio [aHR] 1.50, 95% CI 1.42, 1.58; aHR 2.01, 95% CI 1.84, 2.20, respectively). Individuals who declined foot examination or who had no record also had increased mortality risk of 75% and 25% vs. those at low risk of DFD, respectively (aHR 1.75, 95% CI 1.51, 2.04; aHR 1.25, 95% CI 1.20, 1.30).

CONCLUSION

Individuals with new-onset type 2 diabetes who had moderate to high risk of DFD were more likely to die compared to those at low risk of DFD. The associations between declined foot examination and absence of foot examinations, and increased risk of mortality further highlight the importance of assessing foot risk as it identifies not only patients at risk of diabetic foot ulceration but also mortality.

Independent Observational Analysis of Ulcer Outcomes for SINBAD and University of Texas Ulcer Scoring Systems

OBJECTIVE

The aim of this study was to compare the University of Texas (UT) and Site, Ischemia, Neuropathy, Bacterial Infection, and Depth (SINBAD) foot ulcer scores in predicting ulcer outcome within a routine diabetes foot clinic.

RESEARCH DESIGN AND METHODS

From 2006 to 2018, data were collected from all patients attending an outpatient diabetes foot clinic with an active ulcer not healed within 4 weeks. UT and SINBAD were compared in predicting ulcer outcome. A unified numerical score for UT was constructed and compared with UT grade (depth) and stage scores. Outcomes included death, a healed ulcer, or a nonhealed ulcer, which included major or minor amputation and nonhealing chronic ulcers.

RESULTS

Outcomes were available from 1,645 ulcer outcomes in 1,068 patients (mean [SD] age 65.4 [4] years, 72% male), of which 1,108 (67%) healed. With exclusion of death as an adverse outcome, the c-statistic (area under operator curve) was 0.67 (95% CI 0.65-0.71) for UT grade/depth and 0.64 (0.61-0.67) for UT stage. The new unified UT score had an improved c-statistic of 0.71 (0.68-0.74). The c-statistic was 0.72 (0.69-0.75) for SINBAD. There was a stepwise decrease in the proportion of ulcers healed for each increased score on ulcer grading for both grading schemes.

CONCLUSIONS

This large and independent observational comparison, in a real-world clinical setting, demonstrated that the UT and SINBAD diabetes foot ulcer grading schemes had similar prognostic ability for predicting foot ulcer outcomes. We have devised and validated a unified numerical scoring system for UT.

The Impact of Bariatric Surgery on Incident Microvascular Complications in Patients With Type 2 Diabetes: A Matched Controlled Population-Based Retrospective Cohort Study

OBJECTIVE

To assess the impact of bariatric surgery (BS) on incident microvascular complications of diabetes-related foot disease (DFD), sight-threatening diabetic retinopathy (STDR), and chronic kidney disease (CKD) in patients with type 2 diabetes and obesity.

RESEARCH DESIGN AND METHODS

A retrospective matched, controlled population-based cohort study was conducted of adults with type 2 diabetes between 1 January 1990 and 31 January 2018 using IQVIA Medical Research Data (IMRD), a database of primary care electronic records. Each patient with type 2 diabetes who subsequently had BS (surgical group) was matched on the index date with up to two patients with type 2 diabetes who did not have BS (nonsurgical group) within the same general practice by age, sex, preindex BMI, and diabetes duration.

RESULTS

Included were 1,126 surgical and 2,219 nonsurgical participants. In the study population 2,261 (68%) were women. Mean (SD) age was 49.87 (9.3) years vs. 50.12 (9.3) years and BMI was 46.76 (7.96) kg/m2 vs. 46.14 (7.49) kg/m2 in the surgical versus nonsurgical group, respectively. In the surgical group, 22.1%, 22.7%, 52.2%, and 1.1% of patients had gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), and duodenal switch, respectively. Over a median follow-up of 3.9 years (interquartile range 1.8-6.4), BS was associated with reduction in incident combined microvascular complications (adjusted hazard ratio 0.53, 95% CI 0.43-0.66, P < 0.001), DFD (0.61, 0.50-0.75, P < 0.001), STDR (0.66, 0.44-1.00, P = 0.048), and CKD (0.63, 0.51-0.78, P < 0.001). Analysis based on the type of surgery showed that all types of surgery were associated with a favorable impact on the incidence of composite microvascular complications, with the greatest reduction for RYGB.

CONCLUSIONS

BS was associated with a significant reduction in incident diabetes-related microvascular complications.

Psychosocial and behavioural prognostic factors for diabetic foot ulcer development and healing: a systematic review

AIM

To investigate whether ulceration, amputation and healing of foot ulcers in people living with diabetes are associated with psychosocial and behavioural factors.

METHODS

We searched MEDLINE, Embase, PsychINFO, CINAHL and The Cochrane Library to March 2019 for longitudinal studies with multivariable analyses investigating independent associations. Two reviewers extracted data and assessed risk of bias.

RESULTS

We identified 15 eligible studies involving over 12 000 participants. Clinical and methodological heterogeneity precluded meta-analysis, so we summarize narratively. Risk of bias was moderate or high. For ulceration, we found significantly different results for people with and without an ulcer history. For those with no ulcer history, moderate quality evidence suggests depression increases ulcer risk [three studies; e.g. hazard ratio (HR) 1.68 (1.20, 2.35) per Hospital Anxiety and Depression Scale (HADS) standard unit]. Better foot self-care behaviour reduces ulcer risk [HR 0.61 (0.40, 0.93) per Summary of Diabetes Self-Care Activities scale standard unit; one study]. For people with diabetes and previous ulcers, low- or very low-quality evidence suggests little discernible association between ulcer recurrence and depression [e.g. HR 0.88 (0.61, 1.27) per HADS standard unit], foot self-care, footwear adherence or exercise. Low-quality evidence suggests incomplete clinic attendance is strongly associated with amputation [odds ratio (OR) 3.84 (1.54, 9.52); one study]. Evidence for the effects of other psychosocial or behavioural factors on ulcer healing and amputation is very low quality and inconclusive.

CONCLUSIONS

Psychosocial and behavioural factors may influence the development of first ulcers. More high quality research is needed on ulcer recurrence and healing. (Open Science Framework Registration: https://osf.io/ej689).

Diabetic foot ulcer classifications: A critical review

Classification and scoring systems can help both clinical management and audit outcomes of routine care. The aim of this study was to assess published systems of diabetic foot ulcers (DFUs) to determine which should be recommended for a given clinical purpose. Published classifications had to have been validated in populations of > 75% people with diabetes and a foot ulcer. Each study was assessed for internal and external validity and reliability. Eight key factors associated with failure to heal were identified from large clinical series and each classification was scored on the number of these key factors included. Classifications were then arranged according to their proposed purpose into one or more of four groups: (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) aid clinical management decision making for an individual case, and (d) audit to compare outcome in different populations. Thirty-seven classification systems were identified of which 18 were excluded for not being validated in a population of >75% DFUs. The included 19 classifications had different purposes and were derived from different populations. Only six were developed in multicentre studies, just 13 were externally validated, and very few had evaluated reliability.Classifications varied in the number (4 - 30), and definition of individual items and the diagnostic tools required. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalization, limb amputation, mortality, and cost. Despite the limitations, there was sufficient evidence to make recommendations on the use of particular classifications for the indications listed above.

Diabetic foot self-care and concordance of 3diabetic foot risk stratification systems in a basic health area of Gran Canaria

OBJECTIVE

To assess the level of self-care in the population with diabetes and determine the risk of diabetic foot lesions through the use of 3stratification systems as well as to establish the degree of concordance between these systems.

METHOD

Observational, cross-sectional and descriptive study carried out in the Basic Health Area of Santa Brígida (Gran Canaria-Canary Islands-Spain) in people diagnosed with diabetes (DM Type 1/DM Type 2) (n=182). Interview, physical examination, review of clinical history and completion of the Diabetic Foot Self-Care questionnaire of the University of Malaga were carried out. The risk stratification was then calculated using 3systems (System of the National Institute for Health Care Excellence, Classification of the International Working Group on the Diabetic Foot and High-Risk Diabetic Foot-60-Second Tool©-2012). The Kappa index was calculated to study the concordance between systems, the relative risk of negative screening of one method against another was estimated and the exact Fisher test to establish whether there were differences.

RESULTS

30.2% of diabetics had a low level of self-care, 45.1% a medium level and 24.7% a high level. The risk levels calculated were: National Institute for Health Care Excellence Classification (Negative Risk 71.4%-Positive Risk 28.6%), International Working Group on the Diabetic Foot Classification (Negative Risk 67.0%-Positive Risk 33.0%) and High-Risk Diabetic Foot-60-Second Tool© (Negative Risk 62.6%-Positive Risk 37.4%).

CONCLUSIONS

All 3systems have good concordance with each other. The High-Risk Diabetic Foot-60-Second Tool© only distinguishes 2levels of risk but detects a higher percentage of people at risk. The Diabetic Foot Self-Care questionnaire of the University of Malaga may be useful in the context of Primary Care to assess the level of self-care of people with diabetes.

Relationship of visual impairment and peripheral artery disease with the occurrence of diabetic foot ulcers in Dr. Moewardi Hospital

Objective

One of the diabetes mellitus (DM) complications is foot ulcers. Foot ulcers are influenced by many factors. DM puts patients at risk of injury because of visual impairment. Hyperglycemia can damage blood vessels, which results in peripheral artery disease (PAD). The purpose of this study was to find the relationship of visual impairment and PAD with diabetic foot ulcers.

Methods

This research used observational analytic study with case–control methods. It used purposive sampling in 34 DM patients with foot ulcers and 34 DM patients without foot ulcers. The research instruments were an interview guide to assess visual impairment, physical examination to assess PAD, and documentation study, which was used to know the incidence of diabetic ulcers.

Results

The results showed that the respondents who experienced ulcers with visual impairment were 44.1% and the respondents who had foot ulcers with PAD were 73.5%. The results of statistical tests showed that there was no relationship between visual impairment and the incidence of ulcers (P = 0.166). The respondents with PAD will have a chance to suffer from foot ulcers 5.808 times higher than those who do not have PAD.

Conclusions

There is no relationship between visual impairment and the incidence of diabetic foot ulcers in Dr. Moewardi Hospital, but there is relationship between PAD and the incidence of diabetic foot ulcers in Dr. Moewardi Hospital. Suggestions of this study are to do foot screening and educate about the importance of foot care to prevent the occurrence of diabetic ulcers.

Amputation-free survival in 17,353 people at high risk for foot ulceration in diabetes: a national observational study

AIMS/HYPOTHESIS

Our aim was to investigate amputation-free survival in people at high risk for foot ulceration in diabetes ('high-risk foot'), and to compare different subcategories of high-risk foot.

METHODS

Overall, 17,353 people with diabetes and high-risk foot from January 2008 to December 2011 were identified from the Scotland-wide diabetes register (Scottish Care Information-Diabetes: N = 247,278). Participants were followed-up for up to 2 years from baseline and were categorised into three groups: (1) those with no previous ulcer, (2) those with an active ulcer or (3) those with a healed previous ulcer. Participants with prior minor or major amputation were excluded. Accelerated failure time models were used to compare amputation-free survival up to 2 years between the three exposure groups.

RESULTS

The 2 year amputation-free survival rate in all people with diabetes with high-risk foot was 84.5%. In this study group, 270 people (10.0%) had an amputation and 2424 (90.0%) died during the 2 year follow-up period. People who had active and healed previous ulcers at baseline had significantly lower 2 year amputation-free survival compared with those who had no previous ulcer (both p < 0.0001). The percentage of people who died within 2 years for those with healed ulcer, active ulcer or no baseline ulcer was 22.8%, 16% and 12.1%, respectively.

CONCLUSIONS/INTERPRETATION

In people judged to be at high risk of foot ulceration, the risk of death was up to nine times the risk of amputation. Death rates were higher for people with diabetes who had healed ulcers than for those with active ulcers. However, people with active ulcers had the highest risk of amputation.

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

INTRODUCTION

Long-term mortality of patients with diabetes who undergo lower extremity amputation (LEA) has not been reported in Spain.

METHODS

The retrospective cohort included all subjects who underwent LEAs from January 1, 2005 to December 31, 2015 in San Jorge Hospital, Huesca, Spain. Live status of every patient up to September 2017 and the date of death were retrieved using the national death index.

RESULTS

The series included 203 patients: 116 patients (57.1%) underwent a minor amputation and 87 patients (42.9%) underwent a major amputation. Twenty-five patients (12.3%) died in the perioperative period. Significant risk factors of perioperative mortality were undergoing an above-the-knee amputation, postoperative cardiac complications, age >74 years and acute renal failure. Survival rates at 1, 3, and 5 years were 90.6, 72.8, and 55.5% in patients who underwent a minor amputation compared with 70.8, 41.3, and 34.4% in patients who underwent a major amputation, respectively. Log-rank test between the two groups was χ² = 12.7 (p < 0.01).

CONCLUSIONS

Long-term survival was worse in patients who underwent a major amputation with a 5-year mortality of 65.6%. This mortality is worse than what has been reported for some types of common malignancies.

Prevention of diabetic foot complications

This paper discussed the importance of prevention of diabetic foot ulcers and our institution's protocol for prevention, reviewing the existing evidence in the literature regarding the effectiveness of the preventive approach. Diabetes mellitus is the second most significant cause of disease in Singapore after ischaemic heart disease. National University Hospital, Singapore, adopts a two-pronged strategy for the management of diabetic foot ulcers. The most important strategy is prevention, and education is key. Education should mainly be directed at patients and caregivers, but also professionals (general practitioners, allied health professionals and nurses) so that they can effectively educate patients and caregivers. Patient education includes care of diabetes mellitus, care of the foot and use of appropriate footwear. Patients also tend to have poor foot hygiene. Annual foot screening for diagnosed diabetics plays an important role. However, prolonged and sustained government intervention is necessary to provide education and screening on a national scale.

The prevalence of diabetic foot disease in the Waikato region

AIM

The aim of this study was to establish the prevalence of diabetic foot disease by utilising the retinal eye screening register in the Waikato region of New Zealand. Understanding both the prevalence and the degree of foot disease across the general diabetes population will help to determine what podiatry services are required for people with diabetes.

METHOD

2192 people aged 15years and over, who attended the Waikato Regional Diabetes Service mobile retinal photo screening service for the six-month period between May and November 2014, consented to a foot screen including testing for sensation and pedal pulses. A digital image was taken of the dorsal and plantar aspect of each foot for review by a registered Podiatrist.

RESULTS

Thirteen percent of the study sample was identified as having a high-risk foot including active foot complications. 65% were categorised as low risk and a further 22% at moderate risk of diabetic foot disease. Factors identified as significant included age, type of diabetes, duration of diabetes, and smoking. These factors placed people at greater risk of diabetic foot disease.

CONCLUSION

A significant number of people with diabetes are at risk of diabetic foot disease. This study has highlighted the need for targeted podiatry services to address diabetic foot disease.

A new diabetic foot risk assessment tool: DIAFORA

AIMS

This study aimed to derive a new model to classify subjects with diabetes and active diabetic foot ulcer by their risk of lower extremity amputation.

METHODS

A prospective cohort study was conducted that included all subjects with diabetic foot ulcer attending our Hospital Diabetic Foot Clinic from 2010 to 2013. Variables were collected at baseline. Subjects were followed up until healing, lower extremity amputation, death or for at least 3 months. Logistic regression was used to derive the new model, and the area under the receiver operating characteristic curve was assessed to propose the model with the greatest discrimination.

RESULTS

A total of 293 participants were included and followed for a median of 91 days. In 23.2% amputation was required, 5.1% died and 3.1% were lost. Our final model included the variables most commonly used in clinical practice for diabetic foot risk assessment (presence of neuropathy, foot deformity, peripheral arterial disease and previous foot complications) in addition to multiple diabetic foot ulcer, infection, gangrene and bone involvement. This model had an area under the receiver operating characteristic curve of 0.91 [95% confidence interval (CI) 0.87-0.95] and as classification of 0.89 (95% CI 0.84-0.93) for lower extremity amputation prediction. The high-risk group presented a positive likelihood ratio of 5 (95% CI 3-8) and predictive value of 58 (46-71). Only one minor lower extremity amputation occurred in the low-risk group.

CONCLUSIONS

We propose a new classification: diabetic foot risk assessment (DIAFORA). This classification was equally or more accurate for lower extremity amputation prediction in diabetic foot ulcer patients when compared with the existing ones.

Altered metabolic parameters in association with antipsychotic medication use in diabetes: A population based case-control study

AIMS

This study assess differences in clinical variables in diabetes patients prescribed antipsychotic medication and determines relative schizophrenia prevalence in the diabetes population.

METHODS

This population-based case-control study utilizing Scotland's national diabetes registry (SCI-diabetes) and linked psychiatric hospital discharge data (SMR04) established diabetes phenotypes in a patient cohort prescribed long term antipsychotic medication (n=2362) (cases). Cases were matched 1:10 to diabetes patients not prescribed antipsychotic medication (controls) for BMI, gender; diabetes type; birth year; diagnosis date; smoking status. Sub-groups with defined schizophrenia (n=196) or bipolar disorder (n=190) were further examined. Schizophrenia prevalence in the diabetes versus general population was compared.

RESULTS

During follow up, antipsychotic prescription was associated with lower HbA1c (55.1 (95% CI 54.5-55.8) or 7.2 (95% CI 7.1-7.3)% vs 58.2 (58.0-58.4) mmol or 7.5 (95% CI 7.5-7.5)% p<0.001) lower serum total cholesterol, 4.2 (4.1-4.2) vs 4.3 (4.2-4.3) mmol/l, p<0.001, lower blood pressure (systolic 130 (130.17-131.29) vs 134 (134.3-134.7) mmHg, p<0.001), higher prescription of oral hypoglycaemic medication (42% (40-45) vs 38% (37-39) p<0.001), similar statin prescriptions (85% (81-89) vs 85% (84-86), p=0.55), and lower retinopathy rates (28% (25.6-30.5) vs 32% (31.5-33.1), p<0.001). HbA1c at diagnosis was similar (p=0.27). Schizophrenia prevalence was higher in the diabetes versus general population with differences across age groups (Scottish population versus diabetic population rate of 522.2 (522.1-522.3) versus 717.4 (703.4-731.9) per 100,000).

CONCLUSIONS

We confirm higher diabetes rates in schizophrenia up to age 70, similar attendance rates and clinical measurements that are not worse in a large well-matched population-based Scottish sample prescribed antipsychotic medication versus matched general diabetes patients.

When and how to audit a diabetic foot service

Quality improvement depends on data collection and audit of clinical services to inform clinical improvements. Various steps in the care of the diabetic foot can be used to audit a service but need defined audit standards. A diabetes foot service should have risk stratification system in place that should compare to the population-based figures of 76% having low-risk feet, 17% moderate risk and 7% being at high risk of ulceration. Resources can then be directed towards those with high-risk feet. Prevalence of foot ulceration needs to be audited. Community-based studies give an audit standard of around 2%, with 2 to 9% having had an ulcer at some stage in the past. Amputation rates should be easier to measure, and the best results are reported to be around 1.5-3 per 1000 people with diabetes. This is a useful benchmark figure, and the rate has been shown to decrease by approximately a third over the last 15 years in some centres. Ulceration rates and ulcer healing rates are the ultimate outcome audit measure as they are always undesirable, whilst occasionally for defined individuals, an amputation can be a good outcome. In addition to clinical outcomes, processes of care can be audited such as provision of clinical services, time from new ulcer to be seen by health care professional, inpatient foot care or use of antibiotics. Measurement of clinical services can be a challenge in the diabetic foot, but it is essential if clinical services and patient outcomes are to be improved.

Diabetic Microangiopathy Is an Independent Predictor of Incident Diabetic Foot Ulcer

AIM

To determine the diabetic foot ulcer incidence and examine its association with microangiopathy complications, including diabetic retinopathy (DR) and albuminuria (Alb), in type 2 diabetes patients.

METHODS

This was a retrospective cohort study of 1,305 patients with type 2 diabetes who were assigned to the following groups: Category 1, normoalbuminuria without DR (n = 712); Category 2, Alb without DR (n = 195); Category 3, normoalbuminuria with DR (n = 185); and Category 4, Alb with DR (n = 213). Cox proportional hazard models were used to compare the risks of developing diabetic foot ulcers across the categories.

RESULTS

During 14,249 person-years of follow-up, 50 subjects developed diabetic foot ulcers, with incidence rates of 1.6/1,000, 1.5/1,000, 3.4/1,000, and 12.5/1,000 person-years in Categories 1, 2, 3, and 4, respectively. After adjusting for the presence of diabetic neuropathy and macroangiopathy, the hazard ratios and 95% confidence intervals (CIs) for the risk of diabetic foot ulcer development were 0.66 (95% CI, 0.18-2.36), 1.72 (95% CI, 0.67-4.42), and 3.17 (95% CI, 1.52-6.61) in Categories 2, 3, and 4, respectively, compared with Category 1.

CONCLUSION

The presence of DR and Alb significantly increases the risk of diabetic foot ulcer development.

Toward Big Data Analytics: Review of Predictive Models in Management of Diabetes and Its Complications

Diabetes is one of the top priorities in medical science and health care management, and an abundance of data and information is available on these patients. Whether data stem from statistical models or complex pattern recognition models, they may be fused into predictive models that combine patient information and prognostic outcome results. Such knowledge could be used in clinical decision support, disease surveillance, and public health management to improve patient care. Our aim was to review the literature and give an introduction to predictive models in screening for and the management of prevalent short- and long-term complications in diabetes. Predictive models have been developed for management of diabetes and its complications, and the number of publications on such models has been growing over the past decade. Often multiple logistic or a similar linear regression is used for prediction model development, possibly owing to its transparent functionality. Ultimately, for prediction models to prove useful, they must demonstrate impact, namely, their use must generate better patient outcomes. Although extensive effort has been put in to building these predictive models, there is a remarkable scarcity of impact studies.

Lower-limb amputation following foot ulcers in patients with diabetes: classification systems, external validation and comparative analysis

BACKGROUND

This study aimed to validate and compare the existing systems developed to stratify subjects with diabetic foot ulcers by risk of consequent lower extremity amputation.

METHODS

We conducted a prospective cohort study on a consecutive series of patients (mean age of 68 years; 64% male) with active ulcer who were attending our Hospital Diabetic Foot Clinic (n = 293) from January 2010 to March 2013. At baseline, we collected information on the participants' characteristics and the relevant variables. Afterwards, we assessed the predictive value of each variable and each system's prognostic accuracy for amputation occurrence.

RESULTS

During a median follow-up of 91 days (interquartile range of 98), ulcers healed in 62% of the subjects. Major amputation occurred in 7% and minor occurred in 17%. Previous ulcer or amputation, ulcer area, and gangrene were associated with amputation occurrence. Nephropathy, pulses number, ulcer aetiology, depth, and number were associated with risk of amputation. Systems typically presented sensitivity values ≥80% and negative likelihood ratios ≤0.5 for the highest risk group; area under the receiver operating characteristic curve ranged from 0.56 to 0.83 and positive likelihood ratios from 1.0 to 5.9. If one chose only major amputation as an outcome, positive predictive values were lower, and negative predictive values tended to be higher.

CONCLUSIONS

System stages, grades, scores, and/or prognostics were generally associated with amputation, presenting overall substantial accuracy values. Nevertheless, great improvement is possible. A multicentre study validating and refining the existing systems is needed to improve clinical decision-making in this area.

Organization of wound healing services: The impact on lowering the diabetes foot amputation rate in a ten-year review and the importance of early debridement

Diabetes foot ulceration (DFU) has a negative impact on the quality of life and leads to disabling morbidity, such as lower extremity amputation (LEA). This study aimed to evaluate the LEA trend before and after the establishment of the diabetes foot team, an on-time debridement, on-site screening, and multidisciplinary integration with standardizing care, in Chang Gung Memorial Hospital, Chia Yi, Taiwan, starting in 2010. The study retrospectively investigated the non-traumatic LEA rate in diabetes foot (identified by using ICD-9-Clinical Modification (CM) codes, 250.70-250.83) and whole patients with diabetes (ICD-9 250.XX) yearly from 2004 to 2013. Patients were enrolled from hospitalization, emergency room (ER), or outpatient departments, respectively. Despite the overall incidence of diabetes foot in patients with diabetes remaining constant, from 3.47% in 2004 to 3.58% in 2013, the incidence of hospitalized diabetes foot from diabetes reduced, from 2.83% in 2004 to 1.51% in 2013. Introduction of integrated wound care also led to a reduction of the average LEA rate in hospitalized patients, from 15.27% (2004-2009) to 6.08% (2010-2013) (P<0.001). A similar decline of the LEA rate was observed for patients from hospitalization, ER and outpatient departments together with an average LEA rate from 7.99% (2004-2009) down to 3.02% (2010-2013) (P<0.001). In trend analysis, the curve estimation revealed a quadratic trend in the relationship between LEA rate and time (R-square=0.869, P=0.001) for hospitalized patients as well as a linear (R-square=0.819, P<0.001) and quadratic (R-square=0.845, P=0.001) trend in the relationship between LEA rate and time for hospitalization, ER, and outpatient departments together. The LEA rate for DM patients declined from 372.72/100,000 in 2004 to 61.74/100,000 in 2013. With establishment of an organizing, standardized wound care protocol and integrated multidisciplinary team, we demonstrated a significant decline in the LEA rate both in diabetes foot patients and all patients with diabetes. These improvements can be attributed to introducing an efficient pathway with on-time debridement and early intervention of diabetes foot ulcers.

Foot deformities, function in the lower extremities, and plantar pressure in patients with diabetes at high risk to develop foot ulcers

Objective

Foot deformities, neuropathy, and dysfunction in the lower extremities are known risk factors that increase plantar peak pressure (PP) and, as a result, the risk of developing foot ulcers in patients with diabetes. However, knowledge about the prevalence of these factors is still limited. The aim of the present study was to describe the prevalence of risk factors observed in patients with diabetes without foot ulcers and to explore possible connections between the risk factors and high plantar pressure.

Patients and methods

Patients diagnosed with type 1 (n=27) or type 2 (n=47) diabetes (mean age 60.0±15.0 years) were included in this cross-sectional study. Assessments included the registration of foot deformities; test of gross function at the hip, knee, and ankle joints; a stratification of the risk of developing foot ulcers according to the Swedish National Diabetes Register; a walking test; and self-reported questionnaires including the SF-36 health survey. In-shoe PP was measured in seven regions of interests on the sole of the foot using F-Scan^®. An exploratory analysis of the association of risk factors with PP was performed.

Results

Neuropathy was present in 28 (38%), and 39 (53%) had callosities in the heel region. Low forefoot arch was present in 57 (77%). Gait-related parameters, such as the ability to walk on the forefoot or heel, were normal in all patients. Eighty percent had normal function at the hip and ankle joints. Gait velocity was 1.2±0.2 m/s. All patients were stratified to risk group 3. Hallux valgus and hallux rigidus were associated with an increase in the PP in the medial forefoot. A higher body mass index (BMI) was found to increase the PP at metatarsal heads 4 and 5. Pes planus was associated with a decrease in PP at metatarsal head 1. Neuropathy did not have a high association with PP.

Conclusions

This study identified several potential risk factors for the onset of diabetic foot ulcers (DFU). Hallux valgus and hallux rigidus appeared to increase the PP under the medial forefoot and a high BMI appeared to increase the PP under the lateral forefoot. There is a need to construct a simple, valid, and reliable assessment routine to detect potential risk factors for the onset of DFU.

Comparing the Meggitt-Wagner and the University of Texas wound classification systems for diabetic foot ulcers: inter-observer analyses

Accurate classification of diabetic foot ulcers is essential for inter-clinician communication, assessment of healing tendency and determination of treatment options. The aim of this study was to assess the inter-observer agreement (IOA) of the most commonly used classification systems for diabetic foot ulcers; the Meggitt-Wagner (MW) and the University of Texas (UT) systems. In this study, 95 clinicians judged digital photographs of diabetic foot ulcers in various stages of healing. Wound depth was classified along the grades of the MW and the UT systems. IOA of the MW and UT systems was only moderate among the clinicians. This moderate agreement demonstrates that the MW and the UT systems appear not to be useful as single instrument and should always be used in combination with additional clinical information to avoid erroneous interpretations.

Classification systems for lower extremity amputation prediction in subjects with active diabetic foot ulcer: a systematic review and meta-analysis

AIM

We systematically review the available systems used to classify diabetic foot ulcers in order to synthesize their methodological qualitative issues and accuracy to predict lower extremity amputation, as this may represent a critical point in these patients' care.

MATERIAL AND METHODS

Two investigators searched, in EBSCO, ISI, PubMed and SCOPUS databases, and independently selected studies published until May 2013 and reporting prognostic accuracy and/or reliability of specific systems for patients with diabetic foot ulcer in order to predict lower extremity amputation.

RESULTS

We included 25 studies reporting a prevalence of lower extremity amputation between 6% and 78%. Eight different diabetic foot ulcer descriptions and seven prognostic stratification classification systems were addressed with a variable (1-9) number of factors included, specially peripheral arterial disease (n = 12) or infection at the ulcer site (n = 10) or ulcer depth (n = 10). The Meggitt-Wagner, S(AD)SAD and Texas University Classification systems were the most extensively validated, whereas ten classifications were derived or validated only once. Reliability was reported in a single study, and accuracy measures were reported in five studies with another eight allowing their calculation. Pooled accuracy ranged from 0.65 (for gangrene) to 0.74 (for infection).

CONCLUSION

There are numerous classification systems for diabetic foot ulcer outcome prediction, but only few studies evaluated their reliability or external validity. Studies rarely validated several systems simultaneously and only a few reported accuracy measures. Further studies assessing reliability and accuracy of the available systems and their composing variables are needed.

Risk factors for foot ulcers--a cross sectional survey from a primary care setting in Brazil

AIMS

To identify the prevalence of higher risk of foot ulceration and associated factors among patients with diabetes mellitus (DM) at primary health care services.

METHODS

Individuals with DM, registered at primary health care services in a municipality in southern Brazil, were interviewed and underwent foot examinations. Their risk of ulceration was classified in accordance with the recommendations of the International Working Group on the Diabetic Foot. Poisson bivariate and multivariate analyses were performed and adjusted prevalence ratios (PR) and 95% confidence intervals (CI) were calculated.

RESULTS

The prevalence of higher risk of foot ulceration among the 337 interviewees was 27.9% (95% CI 23.1-32.9). The following factors were associated with this risk: having been diagnosed with DM for more than 10 years (Adjusted-PR 1.669; 95% CI 1.175-2.373; p=0.004); having had previous diagnoses of acute myocardial infarction (Adjusted-PR 1.873; 95% CI 1.330-2.638; p<0.001) and stroke (Adjusted-PR 1.684; 95% CI 1.089-2.604; p=0.019); presenting interdigital mycosis (Adjusted-PR 1.539; 95% CI 1.030-2.300; p=0.035) and calluses (Adjusted-PR 1.654; 95% CI 1.117-2.451; p=0.012).

CONCLUSIONS

The prevalence of higher risk of ulceration was high, which reinforces the importance of continued education for health care professionals in order to prevent complications in the feet of these patients.

Preventing the first or recurrent ulcers

Prevention is overlooked and underused, even in very high-risk patients. Prevention is best achieved within a multispecialty group of providers that have a common objective. Ideally, the team approach should include educators; physical therapists; nurses; internist; pedorthists; and vascular, orthopedic, and podiatric surgeons. The basic elements involve education, foot examination, risk classification, therapeutic shoes and insoles, and regular foot care. High-risk patients need additional assessment for vascular disease and intensive disease management, and corrective vascular and foot surgery when necessary. Basic interventions can reduce the incidence of foot ulcers by more than 50%.

Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team

A longitudinal observational study on a convenience sample was conducted between 4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management of diabetes-related foot ulcers (DFUs) in patients living in a small urban community in Ontario, Canada. Eighty-three patients presented to the IPDFUT with 114 DFUs of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and 90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of 7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led to healing in three patients (4%) and one patient required a below-knee amputation. Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to work together resulted in improved healing outcomes. The rate of healing, proportion of wounds closed and complication rate were similar if not better than the results published previously in Canada and around the world. The IPDFUT appears to be a successful model of care and could be used as a template to provide effective community care to the patients with DFU in Ontario, Canada.

The Investigation of Demographic Characteristics and the Health-Related Quality of Life in Patients With Diabetic Foot Ulcers at First Presentation

To investigate the characteristics of diabetic patients with foot ulcers, their health-related quality of life (HRQoL), and the link between them. The study population included 131 consecutive patients presenting in a diabetic foot clinic with a new foot ulcer between December 1, 2011, and May 1, 2012. The authors collected sociodemographic data, foot and ulcer characteristics using the Wagner Grade, and HRQoL (using the SF-36 Scale) information; 54.2% of the patients were in Wagner 2 or Wagner 3 categories. In all the 8 SF-36 subscales and in the SF-36 summary scales, the patients with diabetic foot ulcer had significantly poorer HRQoL than the general population in China ( P < .01). Their Wagner Grade had negative correlation with all the SF-36 subscales and the summary scales ( P < .05). In conclusion, new diabetic foot ulcers were already in poor condition when patients first visited the diabetic foot clinic. Concomitantly, patients had worse HRQoL compared with the general population. More effective interventions are needed to improve their self-care level and HRQoL.

A national approach to diabetes foot risk stratification and foot care

The Scottish Diabetes Foot Action Group (SDG) has developed and introduced a national strategy plan for diabetic foot care across Scotland. This has involved the implementation of an evidence-based national foot screening and risk stratification programme that has already covered 61% of the population in just the first two years. Nationally agreed patient information foot leaflets and professional education material have been introduced, and a consensus for antibiotic use in the diabetic foot has been published. Information on multidisciplinary specialist foot services has been collected, indicating that 58% of Health Board areas have consultants with dedicated sessions in their job plan to a foot clinic, and 42% had integrated orthotic involvement. The SDG aims to increase these figures. Work has been undertaken to support local podiatry networks and improve communication between the specialist centre and the community. At a national level the SDG is working with Foot in Diabetes UK (FDUK) to recognize key podiatry skills by developing core competencies and a competency framework for the diabetes podiatrist and diabetes orthotist. The annual Scottish Diabetes Survey indicates some improvement in amputation rates with prevalence decreasing from 0.8% to 0.5%, and improved recording of foot ulceration at a national level. This national strategy has helped highlight the importance and difficulties facing diabetes foot care and should help to continue to improve the quality of care of people with diabetes who have foot-related problems.

Measuring the accuracy of different ways to identify the 'at-risk' foot in routine clinical practice

AIMS

We aimed to identify which individual risk factors best predict foot ulceration in routine clinical practice and whether an integrated clinical tool is a better screening tool for future foot ulceration.

METHODS

Routinely collected clinical information on foot and general diabetes indicators were recorded on the regional diabetes electronic register. Follow-up data on foot ulceration were collected from the same electronic record, the local multidisciplinary foot clinic and community and hospital podiatry paper records. Data were electronically linked to see which criteria best predicted future foot ulceration.

RESULTS

Foot risk scores were recorded on 3719 patients (44% female, mean age 59±15years) across community and hospital clinics. Overall, 851 (22.9%) had insensitivity to monofilaments, in 629 (17.2%) both pulses were absent and 184 (4.9%) had a prior ulcer. In multivariate analysis, the strongest predictors of foot ulceration were prior ulcer, insulin treatment, absent monofilaments, structural abnormality and proteinuria and retinopathy. The sensitivity of predicting foot ulceration was 52% for prior ulcer, 61% for absent monofilaments, 75% for 'high risk' on an integrated risk score and 91% for high and moderate risk combined. The corresponding specificities were 99, 81, 89 and 61%. Positive likelihood ratio was 52 for prior ulcer and 6.8 for foot risk, with negative likelihood ratios of 0.48 and 0.15, respectively.

CONCLUSIONS

Integrated foot risk scores are more sensitive than individual clinical criteria in predicting future foot ulceration and are likely to be better screening tools, where excluding false negative results is of paramount importance.

A national strategic approach to diabetic foot disease in Scotland: changing a culture

A diabetes foot action plan was introduced to Scotland in 2006. This has included developing a foot-screening programme with foot risk stratification. Currently 140,000 people (61% of all patients with diabetes) have undergone foot risk stratification, with 69% categorised as low risk, 20% as moderate risk and 11% as being at high risk of foot ulceration. This has helped support the introduction of needs-related care pathways. Schemes to support community-based podiatrists and strengthen links and referral pathways to specialist foot services have been introduced. Identifying key competencies for podiatrists and orthotists working for patients with diabetes has underpinned the development of a competency framework for each profession. Nationally agreed and utilised patient education leaflets and staff education programmes, including online training programmes have been introduced. Surveys of multidisciplinary foot services, have shown amongst other things, a low level of consultant involvement in such clinics (58% of Health Boards). Overall, national data indicated that across Scotland in 2009 the prevalence of foot ulceration was 2.5% in December 2010 and amputation was 0.5% in 2009, the latter having declined from 0.8% in 2003.

Risk stratification systems for diabetic foot ulcers: a systematic review

AIMS/HYPOTHESIS

Several risk stratification systems have been proposed for predicting development of diabetic foot ulcer. However, little has been published that assesses their similarities and disparities, diagnostic accuracy and evidence level. Consequently, we conducted a systematic review of the existing stratification systems.

METHODS

We searched the MEDLINE database for studies (published until April 2010) describing the creation and validation of risk stratification systems for prediction of diabetic foot ulcer development.

RESULTS

We included 13 studies describing or evaluating the following different risk degree stratification systems: University of Texas; International Working Group on Diabetic Foot; Scottish Intercollegiate Guideline Network (SIGN); American Diabetes Association; and Boyko and colleagues. We confirmed that five variables were included in almost all the systems: diabetic neuropathy, peripheral vascular disease, foot deformity, and previous foot ulcer and amputation. The number of variables included ranged from four to eight and the number of risk groups from two to six. Only four studies reported or allowed the calculation of diagnostic accuracy measures. The SIGN system showed some higher diagnostic accuracy values, particularly positive likelihood ratio, while predictive ability was confirmed through external validation only in the system of Boyko et al.

CONCLUSIONS/INTERPRETATION

Foot ulcer risk stratification systems are a much needed tool for screening patients with diabetes. The core variables of various systems are very similar, but the number of included variables in each model and risk groups varied greatly. Overall, the quality of evidence for these systems is low, as little validation of their predictive ability has been done.

Review: The varied attractions of the diabetic foot

Various advances have been seen in the management of the diabetic foot. In some areas the rate of diabetes-related major amputations is declining. Duloxetine, pregabalin, venlafaxine and oxycodone are all well proven to help alleviate the pain of diabetic neuropathy. Negative pressure wound therapy has been shown to accelerate the healing of foot ulcers. New antibiotic policies designed to reduce Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) infections focus on narrow spectrum short duration antibiotics, and 80% of osteomyelitis can be successfully treated without surgery. Foot screening identifies patients who will ulcerate, with high-risk patients being up to 83 times more likely to ulcerate than low-risk patients. The ‘holiday foot’ and distal peripheral vascular disease remain as major risk factors for foot ulcer development and non-healing. The diabetic foot provides many interesting and varied challenges for the interested clinician.

Br J Diabetes Vasc Dis 2009;9:155—159

Risk factors and healing impact of multidrug-resistant bacteria in diabetic foot ulcers

AIM

To determine the risk factors for acquiring multidrug-resistant organisms (MDRO) and their impact on outcome in infected diabetic foot ulcers.

METHODS

Patients hospitalized in our diabetic foot unit for an episode of infected foot ulcer were prospectively included. Diagnosis of infection was based on clinical findings using the International Working Group on the Diabetic Foot-Infectious Diseases Society of America (IWGDF-ISDA) system, and wound specimens were obtained for bacterial cultures. Each patient was followed-up for 1 year. Univariate analysis was performed to compare infected ulcers according to the presence or absence of MDRO; logistic regression was used to identify explanatory variables for MDRO presence. Factors related to healing time were evaluated by univariate and multivariate survival analyses.

RESULTS

MDRO were isolated in 45 (23.9%) of the 188 patients studied. Deep and recurrent ulcer, previous hospitalization, HbA(1c) level, nephropathy and retinopathy were significantly associated with MDRO-infected ulceration. By multivariate analysis, previous hospitalization (OR=99.6, 95% CI=[19.9-499.0]) and proliferative retinopathy (OR=7.4, 95% CI=[1.6-33.7]) significantly increased the risk of MDRO infection. Superficial ulcers were associated with a significant decrease in healing time, whereas neuroischaemic ulcer, proliferative retinopathy and high HbA(1c) level were associated with an increased healing time. In the multivariate analysis, presence of MDRO had no significant influence on healing time.

CONCLUSION

MDRO are pathogens frequently isolated from diabetic foot infection in our foot clinic. Nevertheless, their presence appears to have no significant impact on healing time if early aggressive treatment, as in the present study, is given, including empirical broad-spectrum antibiotic treatment, later adjusted according to microbiological findings.