The diabetic foot constitutes a tremendous challenge for patients, care givers and the health care system. The International consensus document of 2007 is a mile stone in the recognition of the importance and consequences of the diabetic foot. There is now time to consider the present situation and future developement, since we now know that prevention and treatment of diabetic foot lesions can achieve a reduction in amputation rates as well as being cost effective. In a cost-utility analysis (Ragnarsson-Tennvall-2001). Including people with diabetes and different risk factors, optimal prevention with patient education, foot care and appropriate footwear according to international consensus recommendations, was compared with actual prevention and standard care in a Swedish population. The results from the study showed that providing all people at risk or high risk of diabetic foot ulcersand amputations with adequate prevention and a multidisciplinary management when ulcers present, that such a strategy would be highly cost-effective or even cost-saving. The conclusions from the previous study were confirmed if reduction of incidence of ulcer or amputation by 25-42% was achieved (Ortegon 2004, Rauner MS 2004). It was concluded that management of the diabetic foot according to present guidelines would result in improved survival and a reduced number of diabetic foot complications. In addition, it would be cost-effective or even cost saving compared to standard care. These and other studies also stated the importance and the influence of health care organization and reimbursement in prevention and management of the diabetic foot ulcer. (Boulton 2005, Ragnarsson-Tennvall-2004) The EURODIALE study (Prompers 2007-2008) and other large cohort studies have given us a deeper understanding regarding factors related to outcome of a diabetic foot ulcer (Jeffcoate 2006, Beckert 2006, Treece 2004, Apelqvist 1998, Margolis 2000). According to those results in mostly European cohorts, the severity of diabetic foot ulcers at presentation is greater than previously. However, the trend in all these studies and RCT’s is a successive improvement in healing rate (50-60% at 20 wks , >75% at one yr). Signs of peripheral arterial disease (PAD) can be found in more than half of the patients with a foot ulcer Prompers 2007). Given the uncertainties of history and clinical examination, more objective measurements of skin perfusion are frequently needed.
These non-invasive vascular tests can be used for predicting wound healing of a diabetic foot ulcer and need for revascularisation. (Norgren 2007) Studies performed in neuroischemic/ischemic ulcer show an improved/increased intervention rate as well healing rate and an increased awareness of angioplasty to achieve healing in a diabetic foot ulcer (Adam 2005, Faglia2002, Jacqueminet 2005). Infection is seldom the direct cause of an ulcer. Once an ulcer is complicated by an infection, the risk for subsequent amputation is greatly increased (Armstrong 1998). In the present EURODIALE study more 50% of patients with a foot ulcer received antibiotics at admission to a diabetic foot center/clinic and 25-75% of patients at various centers were considered to have a wound infection at time of admission. This finding is especially disturbing in a time of MRSA, multiresistent microbes and debate of “bioburden” and “biofilms”. There is a substantial amount of new information and knowledge waiting to be recognized and implemented in daily practice to achive a substantial reduction in diabetes related foot complications.
- Boulton AJM, Vileikyte L, Ragnarson-Tenvall, Apelqvist A: The global burden of diabetic foot disease. Lancet 366:1719-1724, 2005.
- Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A,Bakker K, Edmonds M, Holstein P, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, Van Acker K, van Baal J, van Merode F, Schaper N High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007 Jan;50(1):18-25
- Jeffcoate WJ, Chipchase SY, Ince P, Game FL: Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. Diab Care 29:1784-1787, 200
- Adam DJ, Beard JD, Cleveland T, Bell J, Bradbury AW, Forbes JF, Fowkes FG, Gillepsie I, Ruckley CV, Raab G, Storkey H; BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366:1925-34. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG; on behalf of the TASC II Working Group. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(1 Suppl):S5-S67
- Faglia E, Mantero M, Caminiti M, Caravaggi C, De Giglio R, Pritelli C, Clerici G, Fratino P, De Cata P, Dalla Paola L, Mariani G, Poli M, Settembrini PG, Sciangula L, Morabito A, Graziani L. Extensive use of peripheral angioplasty, particularly infrapopliteal, in the treatment of ischaemic diabetic foot ulcers: clinical results of a multicentric study of 221 consecutive diabetic subjects. J Intern Med. 2002;252:225-32.
- Treece KA, Macfarlane RM, Pound N, Game FL, Jeffcoate WJ: Validation of a system of foot ulcer classification in diabetes mellitus. Diabet Med 21:987-991, 2004
- Apelqvist J: Wound healing in diabetes. Outcome and costs. Clin Podiatr Med Surg 15:21-39, 1998
- Margolis DJ, Kantor J, Santanna J, Strom BL, Berlin JA: Risk factors for delayed healing of neuropathic diabetic foot ulcers: a pooled analysis. Arch Dermatol 136:1531-1535, 2000
- Marston WA: Risk factors associated with healing chronic diabetic foot ulcers: the importance of hyperglycaemia. Ostomy Wound Manage 52:26-28, 2006
- Ragnarson Tennvall G, Apelqvist J. Prevention of diabetes-related foot ulcers and amputations: a cost-utility analysis based on Markov model simulations. Diabetologia 2001; 44:2077-2087
- Ortegon MM, Redekop WK, Niessen LW. Cost-effectiveness of prevention and treatment of the diabetic foot. Diabetes Care 2004; 27:901-907.
- Rauner MS, Heidenberger K, Pesendorfer E-M. Using a Markov model to evaluate the cost-effectiveness of diabetic foot prevention strategies in Austria. Vol. 2004: SCS, The Society for Modeling Simulation International, 2004.
- Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis 2004; 39 (Suppl 2):S132-S139.
- Jacqueminet S, Hartemann-Heurtier A, Izzillo R, Cluzel P, Golmard JL, Ha Van G, Koskas F, Grimaldi A: Percutaneous transluminal angioplasty in severe diabetic foot ischemia: outcomes and prognostic factors. Diabetes Metab 31:370-375, 2005
- Armstrong DG, Lavery LA, Harkless LB: Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diab Care 21:855-859, 1998
- Beckert S, Witte M, Wicke C, Königsrainer A, Coerper S: A new wound-based severity score for diabetic foot ulcers. Diab Care 29: 988-992, 2006
Congratulations to Zena Moore on her appointment as President-elect of EWMA she will take up this post next year. This is a great honour for Zena, DWWMAI and Ireland. We are running a 4 week course on wound care in the education centre of Beaumont Hospital commencing with:
- Introduction to Wound Management on Tuesday 7th October
- Leg Ulcers on Tuesday 14th October
- Pressure Ulcers on Tuesday 21st October
- The Diabetic Foot on Tuesdat 4th November
Courses will run from 6pm to 9pm with workshops and refreshments included. This course is open to all health care workers with an interest in wound care.
The EWMA conference was held in Lisbon in May of this year. This year was one of the most successful to date as over 2,500 delegates attended. Members of the wound management association of Ireland were well represented as they delivered poster presentations and oral presentations. This was a great achievement and well done to all. Helen Strapp represented the organisation with her paper on "Staff nurses knowledge on Pressure Ulcer Prevention". We look forward to the conference next year in Helsinki and hope to increase our representation at this conference and have more posters and oral abstracts.
The third world union of wound healing societies conference was held in Toronto in June. Approximately 3000 delegates from 78 countries attended 5 days of conference. The standard and quality of the presentations was excellent. Again Ireland and the wound management association were represented. Members presented posters, oral abstracts and symposiums. This was a fantastic achievement and representation for a small country in such a high profile conference. The next world union conference will be held in Japan in 2012 so start planning!
Writing for the newsletter
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