A Critical Evaluation of Existing Diabetic Foot Screening Guidelines.

NewsBot · Dec 25, 2016

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A Critical Evaluation of Existing Diabetic Foot Screening Guidelines.
Formosa C, Gatt A, Chockalingam N
Rev Diabet Stud. 2016 Summer-Fall;13(2-3):158-186

AIM:
To evaluate critically the current guidelines for foot screening in patients with diabetes, and to examine their relevance in terms of advancement in clinical practice, improvement in technology, and change in socio-cultural structure.
METHODS:
A structured literature search was conducted in Pubmed/Medline, CINAHL, Cochrane Register of Controlled Trials, and Google between January 2011 and January 2015 using the keywords '(Diabetes) AND (Foot Screening) AND (Guidelines)'.
RESULTS:
Ten complete diabetes foot screening guidelines were identified and selected for analysis. Six of them included the full-process guidelines recommended by the International Diabetes Federation. Evaluation of the existing diabetes foot screening guidelines showed substantial variability in terms of different evidence-based methods and grading systems to achieve targets, making it difficult to compare the guidelines. In some of the guidelines, it is unclear how the authors have derived the recommendations, i.e. on which study results they are based, making it difficult for the users to understand them.
CONCLUSIONS:
Limitations of currently available guidelines and lack of evidence on which the guidelines are based are responsible for the current gaps between guidelines, standard clinical practice, and development of complications. For the development of standard recommendations and everyday clinical practice, it will be necessary to pay more attention to both the limitations of guidelines and the underlying evidence.
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Admin2 · Dec 25, 2016

Related Threads:
60-Second Diabetic Foot Screen Tool
A 3-Minute Screening Exam for Diabetic Foot

NewsBot · May 29, 2019

Management of infected diabetic wound: a scoping review of guidelines
Huidi Tchero et al
F1000Research 2019, 8:737

Background: Various international guidelines and recommendations are available for management of diabetic foot infections. We present a review of the guidelines and recommendations for management of these infections.
Methods: A systematic literature search was conducted through MEDLINE, CENTRAL, EMBASE, LILACS, DARE, and national health bodies. Based on the review of fifteen documents, we present details on the importance of suspecting and diagnosing skin, superficial infections, and bone infections in diabetics.
Results: The guidelines recommend classifying the infections based on severity to guide the treatment. While antibiotics have shown the best results, other treatments like hyperbaric oxygen therapy and negative wound pressure have been debated. It is suggested that a team of specialists should be in-charge of managing the infected wounds. Infectious Diseases Society of America (IDSA) 2012 guidelines are widely followed world-over. All guidelines and reviews have consistent suggestions on the assessment of the severity of infection, diagnosis, start, selection, and duration of antibiotic therapy.
Conclusions: It is reasonable to conclude that the IDSA 2012 guidelines are commonly followed across the world. There is a consensus among the Australian guidelines, Canadian guidelines, IDSA 2012, National Institute for Health and Care Excellence (NICE) 2015, and International Working Group on the Diabetic Foot (IWGDF) 2016 guidelines on the management of infected wounds for patients with diabetes mellitus.
Keywords
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NewsBot · Aug 10, 2019

Evidence mapping of recommendations on diagnosis and therapeutic strategies for diabetes foot: an international review of 22 guidelines.
Sun Y et al
Metabolism. 2019 Aug 5:153956

To systematically review clinical practice guidelines (CPGs) on diabetes foot and assess the consistency of recommendations, quality of CPGs and to present an evidence-map for explicating research trends and gaps. We performed a literature search on PubMed, Embase, and Web of Science, guideline databases and websites of diabetes society to include the diabetic CPGs. The basic information, recommendations for the diabetic foot, methodological quality and reporting quality of diabetic CPGs were exacted by the Excel. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE II instrument and RIGHT checklist. R3.5.1 software was used to create all bubble plots. A total of 22 diabetic CPGs were included, eight CPGs were from different professional diabetes societies. Recommendations on diabetic foot complications involve Diabetic foot ulcer (DFU), Charcot neuropathy (CN) and Osteomyelitis (OM). Eight DFU diagnostic systems presented in 22 CPGs. According to the recommendations of diabetic CPGs, the treatment of DFU can be summarized in four major items; six recommendations on CN diagnosis and six recommendations on treatment of CN were consistent among studies. However, there were inconsistencies in three OM diagnosis recommendations and four OM treatment recommendations. Some recommendations in CPGs were not very specific and clear, and hence they were not reliable for OM diagnosis and treatment. Once these inconsistencies are resolved, validated, accurate and effective diagnosis and treatment of diabetes foot will lead to reduced costs and adverse complications. The results of this review add to our knowledge and promote the development of trustworthy CPGs on diabetes.
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NewsBot · Sep 1, 2019

Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines: A systematic review.
Pérez-Panero AJ, Ruiz-Muñoz M, Cuesta-Vargas AI, Gónzalez-Sánchez M
Medicine (Baltimore). 2019 Aug;98(35):e16877

AIM:
Diabetic foot complications are the main reason for hospitalization and amputation in people with diabetes and have a prevalence of up to 25%. Clinical practice guidelines are recommendations based on evidence with the aim of improving health care. The main aim of this study was to carry out a systematic review of the levels of the evaluation and treatment strategies that appear in the clinical practice guidelines focus on diabetic foot or diabetes with diabetic foot section. Another objective of this study was to perform an analysis of the levels of evidence in support of the recommendations made by the selected clinical practice guidelines.

METHODS:
A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and a quality assessment by the Appraisal of Guidelines for Research and Evaluation (AGREE II) were performed. The databases checked were "NICE", "Cinahl", "Health Guide", "RNAO", "Sign", "PubMed", "Scopus" and "NCG". The search terms included were "diabetic foot", "guideline(s)", "practice guideline(s)" and "diabetes."

RESULTS:
Twelve articles were selected after checked inclusion criteria and quality assessment. A summary and classification of the recommendations was completed.

CONCLUSIONS:
The heterogeneity of levels of evidence and grades of recommendation of the CPGs included regarding the management, approach and treatment of DF makes it difficult to interpret and assume them in clinical practice in order to select the most correct procedures. Despite this and according to the detailed study of the guidelines included in this work, it can be concluded that the highly recommendable interventions for DF management are debridement (very high level of evidence and strongly recommended), foot evaluation (moderate level of evidence and fairly recommended) and therapeutic footwear (moderate level of evidence and fairly recommended).
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NewsBot · Sep 25, 2019

The quality of guidelines for diabetic foot ulcers: A critical appraisal using the AGREE II instrument.
Zhang P et al
PLoS One. 2019 Sep 23;14(9)

This study aims to evaluate the quality of clinical practice guidelines(CPGs) for patients with diabetic foot worldwide. A search of guidelines websites, databases and academic institutions websites was performed from January 1st, 2010, until June 30th, 2018. Four assessors independently rated the quality of each CPG using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Twelve CPGs satisfied the inclusion criteria. The median scores for the 6 AGREE II domains (scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence) were 92.5%, 72.5%, 71.5%, 89%, 47%, and 77%, respectively. The overall quality of the CPGs was good since the majority of the CPGs reached an overall guideline quality between 5 and 7 points. Different CPGs had widely varying scores in the same area, ranging from 25 to 94 points.
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NewsBot · Jul 6, 2020

A Methodological Assessment of Diabetic Foot Syndrome Clinical Practice Guidelines
Matthew K.H.TanRichardGoodallWilliamHughesBenjaminLangridgeJosephShalhoubAlun H.Davies
European Journal of Vascular and Endovascular Surgery; 4 July 2020

Objective
Diabetic foot syndrome (DFS) contributes to significant morbidity in diabetic patients. Diagnostic and therapeutic approaches to DFS may be summarised in clinical practice guidelines (CPGs) to aid clinical practice but may only benefit patients if the CPG is of high quality. This study determines the methodological quality of DFS CPGs using a validated assessment tool to identify CPGs adequate for use in clinical practice.

Methods
Medline, EMBASE, and CPG databases were searched to 31 May 2019. Reference lists were also searched. Full text English evidence based DFS CPGs were included. CPGs based on expert consensus, guideline summaries, or those only available if purchased were excluded. Four reviewers independently assessed methodological quality using the Appraisal of Guidelines for Research and Evaluation II instrument. An overall guideline assessment scaled score of ≥80% was considered to be of adequate quality to recommend use.

Results
Sixteen CPGs were identified. Good inter-reviewer reliability (ICC 0.985, 95% CI 0.980–0.989) was achieved. Poor scores were noted in domains 2 (stakeholder involvement), 5 (applicability), and 6 (editorial independence). Significant methodological heterogeneity was observed in all domains with the most noted in domain 6 (mean scaled score 43.2 ± 32.1%). Four CPGs achieved overall assessment scores of ≥80%.

Conclusion
Four CPGs were considered to be adequate for clinical practice based on methodological quality. However, elements of methodological quality were still lacking, and all CPGs had areas for improvement, potentially through increased multidisciplinary team involvement and trial application of recommendations. Methodological rigour may be improved using structured approaches with validated CPG creation tools in the future. Future work should also assess recommendation accuracy using available validated assessment tools.
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NewsBot · Feb 23, 2021

The level of evidence of the publications on conservative surgery for the treatment of diabetic forefoot ulcers: A scoping review
KaissarYammine ChahineAssi
The Foot; 28 January 2021, 101784

Highlights
•The diabetic foot disease is one of the most serious complications of diabetes causing high rates of amputations, premature deaths and healthcare cost.
•Many reports demonstrated that conservative surgery particularly in the forefoot, compared better in terms of clinical outcomes with standard of care. Nevertheless, the quality of these surgical articles is thought to be average.
•Based on 90 included surgical papers, this systematic review showed that only 6 studies (6.7%) had a Level 1 level of evidence while the majority had a Level 4 of level of evidence with 70 studies (77.8%) being case-series.
•The findings should incite surgeons to get more involved in the treatment of forefoot diabetic wound and infection.
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Objective
The diabetic foot disease is one of the most serious complications of diabetes causing high rates of amputations, premature deaths and healthcare cost. While standard non-surgical care is the mainstay of treatment of diabetic foot ulcers (DFU), many reports demonstrated that conservative surgery particularly in the forefoot, compared better in terms of clinical outcomes. Nevertheless, the quality of surgical articles dealing with diabetic ulcers of the forefoot is thought to be average. This paper aimed to quantify the level of evidence of the DFU surgical papers published in the literature.

Literature survey
PubMed was searched from inception till Feb 2020. All study designs but case reports were accepted for inclusion. Two outcomes were searched for: a) study design and b) level of evidence. The level of evidence of the studies was based on the classification developed by the Oxford Center for Evidence-based Medicine.

Results
In total, 90 articles were included for analysis. Only 6 studies (6.7%) had a Level 1 level of evidence. One study had a Level 2 (1.1%) and 13 studies (14.4%) a Level 3. The majority of the included studies had a Level 4 of level of evidence with 70 studies (77.8%) being case-series.

Conclusion
It is surprising that a disease with such enormous health-related and financial burden did not generate enough interest among surgeons to invest more into high quality research. The findings should incite surgeons to get more involved in the treatment of forefoot diabetic wound and infection. Large comparative prospective high quality trials to assess the available surgical methods are needed.
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NewsBot · Apr 18, 2021

A literature review on intervention programs for diabetic foot care
Mohd Khairul Zul Hasymi Firdaus, Piyanuch Jittanoon
Enferm Clin. 2021 Apr;31 Suppl 2:S243-S246

This literature review conducted to explore the best available intervention for diabetic foot care. Online databases (ProQuest, CINAHL, Science Direct and Google Scholar) were searched to retrieve relevant articles. The keywords diabetic foot care, diabetic foot care program, diabetic foot care intervention, diabetic foot education were used for data retrieval and PICO analysis. After screening analysis was completed, only 15 (from 7423) articles, published within 2007-2017, were included in a qualitative synthesis of the data. The articles were categorized as: systematic review (n=1), randomized control trial (n=3), quasi-experimental (n=3), pre-test-post-test (n=4), cohort (n=2), cross-sectional (n=1) and surveys (n=1). Themes synthesized from the analysis were: effective approach (group or individual), project leader, specialized skills required and adaptation of technology. A combination of identified approaches would help design a technology-friendly program for managing diabetic foot care.
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NewsBot · Nov 9, 2021

Individualised screening of diabetic foot: creation of a prediction model based on penalised regression and assessment of theoretical efficacy
Iztok Štotl et al
Diabetologia. 2021 Nov 6

Aims/hypothesis: A large proportion of people with diabetes do not receive proper foot screening due to insufficiencies in healthcare systems. Introducing an effective risk prediction model into the screening protocol would potentially reduce the required screening frequency for those considered at low risk for diabetic foot complications. The main aim of the study was to investigate the value of individualised risk assignment for foot complications for optimisation of screening.

Methods: From 2015 to 2020, 11,878 routine follow-up foot investigations were performed in the tertiary diabetes clinic. From these, 4282 screening investigations with complete data containing all of 18 designated variables collected at regular clinical and foot screening visits were selected for the study sample. Penalised logistic regression models for the prediction of loss of protective sensation (LOPS) and loss of peripheral pulses (LPP) were developed and evaluated.

Results: Using leave-one-out cross validation (LOOCV), the penalised regression model showed an AUC of 0.84 (95% CI 0.82, 0.85) for prediction of LOPS and 0.80 (95% CI 0.78, 0.83) for prediction of LPP. Calibration analysis (based on LOOCV) presented consistent recall of probabilities, with a Brier score of 0.08 (intercept 0.01 [95% CI -0.09, 0.12], slope 1.00 [95% CI 0.92, 1.09]) for LOPS and a Brier score of 0.05 (intercept 0.01 [95% CI -0.12, 0.14], slope 1.09 [95% CI 0.95, 1.22]) for LPP. In a hypothetical follow-up period of 2 years, the regular screening interval was increased from 1 year to 2 years for individuals at low risk. In individuals with an International Working Group on the Diabetic Foot (IWGDF) risk 0, we could show a 40.5% reduction in the absolute number of screening examinations (3614 instead of 6074 screenings) when a 10% risk cut-off was used and a 26.5% reduction (4463 instead of 6074 screenings) when the risk cut-off was set to 5%.

Conclusions/interpretation: Enhancement of the protocol for diabetic foot screening by inclusion of a prediction model allows differentiation of individuals with diabetes based on the likelihood of complications. This could potentially reduce the number of screenings needed in those considered at low risk of diabetic foot complications. The proposed model requires further refinement and external validation, but it shows the potential for improving compliance with screening guidelines.
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NewsBot · Feb 1, 2022

Australian guideline on wound classification of diabetes-related foot ulcers: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease
Emma J. Hamilton, Joanna Scheepers, Hayley Ryan, Byron M. Perrin, James Charles, Jane Cheney & Stephen M. Twigg on behalf of the Australian Diabetes-related Foot Disease Guidelines & Pathways Project
Journal of Foot and Ankle Research volume 14, Article number: 60 (2021)

Background
Wound classification systems are useful tools to characterise diabetes-related foot ulcers (DFU) and are utilised for the purpose of clinical assessment, to promote effective communication between health professionals, and to support clinical audit and benchmarking. Australian guidelines regarding wound classification in patients with DFU are outdated. We aimed to adapt existing international guidelines for wound classification to develop new evidence-based Australian guidelines for wound classification in people with diabetes and DFU.

Methods
Recommended NHRMC procedures were followed to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines on wound classification to the Australian health context. Five IWGDF wound classification recommendations were evaluated and assessed according to the ADAPTE and GRADE systems. We compared our judgements with IWGDF judgements to decide if recommendations should be adopted, adapted or excluded in an Australian context. We re-evaluated the quality of evidence and strength of recommendation ratings, provided justifications for the recommendation and outlined any special considerations for implementation, subgroups, monitoring and future research in an Australian setting.

Results
After the five recommendations from the IWGDF 2019 guidelines on the classification of DFUs were evaluated by the panel, two were adopted and three were adapted to be more suitable for Australia. The main reasons for adapting, were to align the recommendations to existing Australian standards of care, especially in specialist settings, to maintain consistency with existing recommendations for documentation, audit and benchmarking and to be more appropriate, acceptable and applicable to an Australian context. In Australia, we recommend the use of the SINBAD system as a minimum standard to document the characteristics of a DFU for the purposes of communication among health professionals and for regional/national/international audit. In contrast to the IWGDF who recommend against usage, in Australia we recommend caution in the use of existing wound classification systems to provide an individual prognosis for a person with diabetes and a foot ulcer.

Conclusions
We have developed new guidelines for wound classification for people with diabetes and a foot ulcer that are appropriate and applicable for use across diverse care settings and geographical locations in Australia.
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NewsBot · Mar 29, 2022

Screening for identification of patients at high risk for diabetes-related foot ulcers: a cross-sectional study
Mohammed Al-Mohaithef et al
J Int Med Res. 2022 Mar;50(3)

Objective: Diabetes affected 463 million people globally in 2019, and this number is anticipated to reach 700 million by 2045. Diabetes results in lower limb amputation every 30 seconds. Egypt has a high prevalence of diabetic foot disease among patients with type 2 diabetes mellitus (T2DM). We aimed to identify high-risk patients for diabetic foot ulcers (DFUs) in Egypt.

Methods: We designed a cross-sectional study among adult patients with diabetes at Asyut University Hospital. Inlow's 60-second diabetic foot screening tool was used to assess the risk of DFU. Neuropathy was assessed using the 10g monofilament test, and laboratory testing was performed to assess glycosylated hemoglobin (HbA1c) and diabetes control levels.

Results: Participants were aged 46.11 ± 9.18 years; 56% had T2DM and HbA1c levels >7%. In total, 47.9% of participants were at risk for DFUs. This risk was higher in patients who were older, male, widowed, working, illiterate, living in rural areas, and patients with diabetes duration >10 years, body mass index >32 kg/m2, uncontrolled blood glucose levels, on an insulin regimen, and smokers.

Conclusions: Increasing health care providers' awareness and ability to identify high-risk patients is critical to prevent DFUs and reduce the risk of amputation.
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NewsBot · Apr 7, 2022

Evidence map of recommendations on diabetic foot ulcers care：A systematic review of 22 guidelines
Yue Sun et al
J Tissue Viability. 2022 Mar 21

Background: Diabetic foot ulcers (DFUs) are one of the major complications of diabetes, representing a leading cause of hospitalization and non-traumatic lower limb amputations. Clinical practice guidelines (CPGs) are statements that include recommendations intended to improve patients' outcomes by providing recommendations for key clinical issues with alternative care options. The aim of this study is to systematically review CPGs on DFUs care and generate an evidence-map for visualizing research trends and gaps in the CPGs.

Methods: A search of the PubMed, Embase, and Web of Science, guideline databases and website of diabetes society was performed to include the diabetic CPGs. We exacted the basic information, methodological quality and reporting quality of CPGs, recommendations for DFUs care by the Excel 2016. Four researchers evaluated the methodological and reporting quality of diabetic foot CPGs by AGREE Ⅱ instrument and RIGHT checklist. The bubble plot format of evidence map was reduced by R (3.5.1) software.

Results: 22 CPGs proved eligible, which included 10 diabetic foot guidelines and 12 comprehensive diabetes guidelines. According to the recommendations of diabetic CPGs, current standard of care for DFUs care mainly involves offloading of pressure, wound care, choice of shoes and adjunctive treatment. Recommendations on offloading of pressure and wound care were consistent in 22 CPGs. However, there were some conflicts on adjunctive treatment recommendations and recommendations for choice of shoes were not accurate.

Conclusion: There is mixed quality evidence of CPGs for DFUs care, and some recommendations are inconsistent. This evidence map could provide new perspectives in presentation of evidence and help us know the need for future research to address the current gaps, as well as areas of opportunity for CPG development.
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NewsBot · Apr 20, 2022

Guidelines development protocol and findings: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease
Peter A. Lazzarini, Anita Raspovic, Jenny Prentice, Robert J. Commons, Robert A. Fitridge, James Charles, Jane Cheney, Nytasha Purcell & Stephen M. Twigg on behalf of the Australian Diabetes-related Foot Disease Guidelines & Pathways Project
Journal of Foot and Ankle Research volume 15, Article number: 28 (2022)

Background
Diabetes-related foot disease (DFD) is a leading cause of the Australian disease burden. The 2011 Australian DFD guidelines were outdated. We aimed to develop methodology for systematically adapting suitable international guidelines to the Australian context to become the new Australian evidence-based guidelines for DFD.

Methods
We followed the Australian National Health Medical Research Council (NHMRC) guidelines for adapting guidelines. We systematically searched for all international DFD guideline records. All identified records were independently screened and assessed for eligibility. Those deemed eligible were further assessed and included if scoring at least moderate quality, suitability and currency using AGREE II and NHMRC instruments. The included international guidelines had all recommendations extracted into six sub-fields: prevention, wound classification, peripheral artery disease, infection, offloading and wound healing. Six national panels, each comprising 6–8 multidisciplinary national experts, screened all recommendations within their sub-field for acceptability and applicability in Australia using an ADAPTE form. Where panels were unsure of any acceptability and applicability items, full assessments were undertaken using a GRADE Evidence to Decision tool. Recommendations were adopted, adapted, or excluded, based on the agreement between the panel’s and international guideline’s judgements. Each panel drafted a guideline that included all their recommendations, rationale, justifications, and implementation considerations. All underwent public consultation, final revision, and approval by national peak bodies.

Results
We screened 182 identified records, assessed 24 full text records, and after further quality, suitability, and currency assessment, one record was deemed a suitable international guideline, the International Working Group Diabetic Foot Guidelines (IWGDF guidelines). The six panels collectively assessed 100 IWGDF recommendations, with 71 being adopted, 27 adapted, and two excluded for the Australian context. We received 47 public consultation responses with > 80% (strongly) agreeing that the guidelines should be approved, and ten national peak bodies endorsed the final six guidelines. The six guidelines and this protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/

Conclusion
New Australian evidence-based guidelines for DFD have been developed for the first time in a decade by adapting suitable international guidelines. The methodology developed for adaptation may be useful for other foot-related conditions. These new guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia.
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NewsBot · May 12, 2022

Results from a community based diabetic foot screening campaign
Léonie Chinet et al
Rev Med Suisse. 2022 May 4;18(780):909-913

A community-based diabetic foot screening campaign was introduced during one week in the French-speaking part of Switzerland to emphasize the preventive impact of systematic foot inspections. Of 494 screened people, 46 % never had their feet checked - and as many as 63% if only standardized examinations according to the recommendations are considered. The risk of diabetic foot complications may appear as early as a few years after diagnosis, underlining the importance of a systematic annual check-up.
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NewsBot · Jun 3, 2022

A Scoping Review of Foot Screening in Adults With Diabetes Mellitus Across Canada
Janhavi Patel et al
Can J Diabetes. 2022 Jan 31;S1499-2671(22)00004-1

Objectives: Regular foot screening by a knowledgeable health provider is the cornerstone of ulcer and amputation prevention in people with diabetes. However, information on foot screening practices among Canadians with diabetes remains sparse. Therefore, we sought to synthesize available data on the frequency and approach to diabetic foot screening across Canada.

Methods: We conducted a scoping review by searching MEDLINE and Embase databases, alongside a grey literature search, for both English- and French-language reports. Data on patients' demographics, setting as well as the frequency and approach to foot screening were abstracted. Title and abstract screening, full-text review and data abstraction were conducted in duplicate, with discrepancies resolved by a third reviewer.

Results: The search yielded 21 reports including information on diabetic foot screening practices in Canada. In a consolidated study sample of 13,388 Canadians with diabetes, 7,277 (53%) reported receiving a foot examination by a health-care provider at least once in the past year. The majority of reports did not provide information on the demographics of patients being screened or details on the approach to foot screening. No report mentioned the use of a triage algorithm applied to the results of foot screening.

Conclusions: In this work, we identified the limited frequency and uncertain quality of diabetic foot screening across Canada. Further research should focus on better understanding disparities and barriers to regular diabetic foot screening.
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NewsBot · Jun 12, 2022

Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease
Robert J. Commons, James Charles, Jane Cheney, Sarah A. Lynar, Matthew Malone & Edward Raby on behalf of the Australian Diabetes-related Foot Disease Guidelines & Pathways Project
Journal of Foot and Ankle Research volume 15, Article number: 47 (2022)

Background
Diabetes-related foot infections cause substantial morbidity and mortality, both globally and in Australia. There is a need for up-to-date evidence-based guidelines to ensure optimal management of patients with diabetes-related foot infections. We aimed to identify and adapt high quality international guidelines to the Australian context to become the new Australian evidence-based guideline for people with a diabetes-related foot infection.

Methods
Following Australian National Health and Medical Research Council (NHMRC) procedures we identified the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines as suitable for adaptation to the Australian context. Guidelines were screened, assessed and judged by an expert panel for the Australian context using the guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Judgements led to recommendations being adopted, adapted or excluded, with additional consideration regarding their implementation, monitoring and future research for the Australian context. Clinical pathways were then developed to assist implementation.

Results
Of 36 original diabetes-related foot infection IWGDF sub-recommendations, 31 were adopted, four were adapted and one was excluded. Adaption was primarily undertaken due to differences or clarification of the sub-recommendations’ intended population. One sub-recommendation was excluded due to substantial differences in judgements between the panel and IWGDF and unacceptable heterogeneity of the target population. Therefore, we developed 35 evidence-based sub-recommendations for the Australian context that should guide best practice diagnosis and management of people with diabetes-related foot infection in Australia. Additionally, we incorporated these sub-recommendations into two clinical pathways to assist Australian health professionals to implement these evidence-based sub-recommendations into clinical practice. The six guidelines and the full protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/.

Conclusions
A new national guideline for the diagnosis and management of people with diabetes-related foot infections were successfully developed for the Australian context. In combination with simplified clinical pathway tools they provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections across Australia and highlight considerations for implementation and monitoring.
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NewsBot · Jun 13, 2022

Heterogeneity in the guidelines for the management of diabetic foot disease in the Caribbean
S. McConnie et al
VOLUME 186, SUPPLEMENT 1, 109433, APRIL 01, 2022

Background: In 2019, diabetes mellitus was thought to affect over 463 million individuals globally, with worldwide prevalence rates reaching nearly 9.3%. Amongst the ‘triumvirate’ of microvascular complications which include retinopathy and nephropathy, diabetic neuropathy is the most common, ultimately affecting more than 50% those with diabetes and the most common cause of diabetic foot (DF) ulceration which precedes a leg amputation. This is a major global public health problem and it is estimated that a major amputation occurs every 20 secs world-wide.
The prevalence of diabetes and DF disease is high in the Caribbean and unfortunately, some countries have been labeled as “amputation capitals of the world”. Despite public health and care-giver DF initiatives, there does not appear to be any significant improvement in the number of lower limb amputations in most of the Caribbean.
Given the historical accounts of the dire state of DF disease in the Caribbean, this study aimed to determine whether the Caribbean countries have protocols in place to monitor and manage DF disease consistent with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. We specifically queried whether there were responsible institutions or individuals in the country that were designated with this responsibility.
Aim: This study was undertaken to determine whether Caribbean countries have designated individuals that monitor DF disease and whether there are DF protocols consistent with the International Working Group on the Diabetic Foot (IWGDF) guidance documents available in the country.
Method: Relevant DF health care personnel(s) from the CARICOM and Dutch Caribbean countries were called or sent questionnaires regarding the presence of structured programs to monitor and manage DF problems in the population.
Results: All 25 countries (100%) responded. 81% of respondents could not identify any Ministry, Hospital or individual initiatives that monitored the DF. Only 9 (36%) countries had any guidelines in place. Only 3 countries with guidelines in place utilized IWGDF guidelines. Only 6 (24%) countries had podiatrists and 10 (40%) had vascular surgery availability. 7 (28%) countries had the components for a multidisciplinary team.
Discussion: The presence or the appointment of a designated individual and/or a multidisciplinary approach within the countries for DF disease was absent in the majority of respondent countries. Only a minority of countries implemented DF guidelines or had expertise available to organize a DF multidisciplinary team. Vascular surgery and podiatric care were noticeably deficient. These may be critical factors in the variability and reduced success in implementation of strategies for managing DF problems and subsequent amputations amongst these Caribbean countries.
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NewsBot · Jul 7, 2022

Australian guideline on diagnosis and management of peripheral artery disease: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease
Vivienne Chuter et al
J Foot Ankle Res. 2022 Jul 5;15(1):51

Background: Peripheral artery disease (PAD) is implicated in up to 50% of diabetes-related foot ulcers (DFU) and significantly contributes to morbidity and mortality in this population. An evidence-based guideline that is relevant to the national context including consideration of the unique geographical and health care system differences between Australia and other countries, and delivery of culturally safe care to First Nations people, is urgently required to improve outcomes for patients with PAD and DFU in Australia. We aimed to identify and adapt current international guidelines for diagnosis and management of patients with PAD and DFU to develop an updated Australian guideline.

Methods: Using a panel of national content experts and the National Health and Medical Research Council procedures, the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines were adapted to the Australian context. The guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were applied to the IWGDF guideline for PAD by the expert panel. Recommendations were then adopted, adapted or excluded, and specific considerations for implementation, population subgroups, monitoring and future research in Australia were developed with accompanying clinical pathways provided to support guideline implementation.

Results: Of the 17 recommendations from the IWGDF Guideline on diagnosis, prognosis and management of PAD in patients with diabetes with and without foot ulcers, 16 were adopted for the Australian guideline and one recommendation was adapted due to the original recommendation lacking feasibility in the Australian context. In Australia we recommend all people with diabetes and DFU undergo clinical assessment for PAD with accompanying bedside testing. Further vascular imaging and possible need for revascularisation should be considered for all patients with non-healing DFU irrespective of bedside results. All centres treating DFU should have expertise in, and/or rapid access to facilities necessary to diagnose and treat PAD, and should provide multidisciplinary care post-operatively, including implementation of intensive cardiovascular risk management.

Conclusions: A guideline containing 17 recommendations for the diagnosis and management of PAD for Australian patients with DFU was developed with accompanying clinical pathways. As part of the adaptation of the IWGDF guideline to the Australian context, recommendations are supported by considerations for implementation, monitoring, and future research priorities, and in relation to specific subgroups including Aboriginal and Torres Strait Islander people, and geographically remote people. This manuscript has been published online in full with the authorisation of Diabetes Feet Australia and can be found on the Diabetes Feet Australia website: https://www.diabetesfeetaustralia.org/new-guidelines/ .
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NewsBot · Jul 8, 2022

Accuracy and Cost-effectiveness of the Diabetic Foot Screen Proforma in Detection of Diabetic Peripheral Neuropathy in Myanmar
Mya Win Hnit et al
J ASEAN Fed Endocr Soc. 2022;37(1):31-37

Objective: Proper foot assessment is important for early detection and treatment of diabetic peripheral neuropathy (DPN), the main cause of diabetic foot ulcers (DFUs). This study aimed to determine the accuracy and cost-effectiveness of the locally developed Diabetic Foot Screen (DFS) proforma in detecting DPN among diabetic patients at 10 selected clinics in Yangon, Myanmar.

Methodology: The study included 625 type 2 diabetics from 10 primary care clinics who participated in the diagnostic accuracy and cost-effectiveness analysis. They were assessed with DFS proforma and biothesiometry by two examiners independently. The cost-effectiveness analysis was conducted based on available data in the local primary care setting.

Results: The overall accuracy of the DFS proforma assessment was 74.76% (95% CI: 70.46%- 79.06%). The optimal cut-off DFS score was ≥1.5 (sensitivity 62%; specificity 76%) in detecting DPN. Compared to biothesiometry, the cost-effectiveness of DFS proforma assessment in DPN detection was 41.79 USD per DPN case detected.

Conclusion: This study supported the use of DFS proforma for DPN detection in primary care clinics. It also provided new information on the estimated costs per patient with DPN detected in Myanmar.
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NewsBot · Sep 26, 2022

Cost-effectiveness of guideline-based care provision for patients with diabetes-related foot ulcers: A modelled analysis using discrete-event simulation
Yuqi Zhang et al
Diabet Med. 2022 Sep 22;e14961

Aims: The provision of guideline-based care for patients with diabetes-related foot ulcers (DFU) in clinical practice is sub-optimal. We estimated the cost-effectiveness of higher rates of guideline-based care, compared with current practice.

Methods: The costs and quality-adjusted life-years (QALYs) associated with current practice (30% of patients receiving guideline-based care) were compared with seven hypothetical scenarios with increasing proportion of guideline-based care (40%, 50%, 60%, 70%, 80%, 90%, 100%). Comparisons were made using discrete-event simulations reflecting the natural history of DFU over a three-year time horizon from the Australian healthcare perspective. Incremental cost-effectiveness ratios were calculated for each scenario and compared to a willingness-to-pay of AUD 28,000 per QALY. Probabilistic sensitivity analyses were conducted to incorporate joint parameter uncertainty.

Results: All seven scenarios with higher rates of guideline-based care were likely cheaper and more effective than current practice. Increased proportions compared with current practice resulted in between AUD 0.28 to 1.84 million in cost savings and 11 to 56 additional QALYs per 1,000 patients. Probabilistic sensitivity analyses indicated that the finding is robust to parameter uncertainty.

Conclusions: Higher proportions of patients receiving guideline-based care are less costly and improve patient outcomes. Strategies to increase the proportion of patients receiving guideline-based care are warranted.
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NewsBot · Oct 21, 2022

Reliability of the evidence to guide decision-making in foot ulcer prevention in diabetes: an overview of systematic reviews
Fay Crawford et al
BMC Med Res Methodol. 2022 Oct 20;22(1):274

Background: Reliable evidence on the effectiveness of interventions to prevent diabetes-related foot ulceration is essential to inform clinical practice. Well-conducted systematic reviews that synthesise evidence from all relevant trials offer the most robust evidence for decision-making. We conducted an overview to assess the comprehensiveness and utility of the available secondary evidence as a reliable source of robust estimates of effect with the aim of informing a cost-effective care pathway using an economic model. Here we report the details of the overview. [PROSPERO Database (CRD42016052324)].

Methods: Medline (Ovid), Embase (Ovid), Epistomonikos, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), and the Health Technology Assessment Journals Library were searched to 17th May 2021, without restrictions, for systematic reviews of randomised controlled trials (RCTs) of preventive interventions in people with diabetes. The primary outcomes of interest were new primary or recurrent foot ulcers. Two reviewers independently extracted data and assessed the risk of bias in the included reviews.

Findings: The overview identified 30 systematic reviews of patient education, footwear and off-loading, complex and other interventions. Many are poorly reported and have fundamental methodological shortcomings associated with increased risk of bias. Most concerns relate to vague inclusion criteria (60%), weak search or selection strategies (70%) and quality appraisal methods (53%) and inexpert conduct and interpretation of quantitative and narrative evidence syntheses (57%). The 30 reviews have collectively assessed 26 largely poor-quality RCTs with substantial overlap.

Interpretation: The majority of these systematic reviews of the effectiveness of interventions to prevent diabetic foot ulceration are at high risk of bias and fail to provide reliable evidence for decision-making. Adherence to the core principles of conducting and reporting systematic reviews is needed to improve the reliability of the evidence generated to inform clinical practice.
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NewsBot · Nov 22, 2022

Artificial Intelligence Methodologies Applied to Technologies for Screening, Diagnosis and Care of the Diabetic Foot: A Narrative Review
Gaetano Chemello et al
Biosensors (Basel). 2022 Nov 8;12(11):985

Diabetic foot syndrome is a multifactorial pathology with at least three main etiological factors, i.e., peripheral neuropathy, peripheral arterial disease, and infection. In addition to complexity, another distinctive trait of diabetic foot syndrome is its insidiousness, due to a frequent lack of early symptoms. In recent years, it has become clear that the prevalence of diabetic foot syndrome is increasing, and it is among the diabetes complications with a stronger impact on patient's quality of life. Considering the complex nature of this syndrome, artificial intelligence (AI) methodologies appear adequate to address aspects such as timely screening for the identification of the risk for foot ulcers (or, even worse, for amputation), based on appropriate sensor technologies. In this review, we summarize the main findings of the pertinent studies in the field, paying attention to both the AI-based methodological aspects and the main physiological/clinical study outcomes. The analyzed studies show that AI application to data derived by different technologies provides promising results, but in our opinion future studies may benefit from inclusion of quantitative measures based on simple sensors, which are still scarcely exploited.
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NewsBot · Mar 30, 2023

Heterogeneity in the guidelines for the management of diabetic foot disease in the Caribbean
Bauer E Sumpio et al
PLOS Glob Public Health. 2022 May 13;2(5):e0000446

The prevalence of diabetes mellitus, diabetic foot (DF) disease and, as a result, lower extremity amputation rates remain high in the Caribbean. This study was undertaken to determine whether Caribbean countries have designated individuals that monitor DF disease and whether there are DF protocols consistent with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. Relevant DF health care personnel(s) from the CARICOM and Dutch Caribbean countries were called or sent questionnaires regarding the presence of structured programs to monitor and manage DF problems in the population. All 25 countries (100%) responded. 81% of respondents could not identify any Ministry, Hospital or individual initiatives that monitored the DF. Only 9 (36%) countries had any guidelines in place. Only 3 countries with guidelines in place utilized IWGDF guidelines. Only 6 (24%) countries had podiatrists and 10 (40%) had vascular surgery availability. 7 (28%) countries had the components for a multidisciplinary team. The presence or the appointment of a designated individual and/or a multidisciplinary approach within the countries for DF disease was absent in the majority of respondent countries. Only a minority of countries implemented DF guidelines or had expertise available to organize a DF multidisciplinary team. Vascular surgery and podiatric care were noticeably deficient. These may be critical factors in the variability and reduced success in implementation of strategies for managing DF problems and subsequent amputations amongst these Caribbean countries.
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A Critical Evaluation of Existing Diabetic Foot Screening Guidelines.

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Critical Thinking

Iatrogenic injury and critical limb iscahemia

“Switch” Critical to Wound Healing

Critical limb ischemia

Critical limb ischemia criteria are not applicable to diabetic foot

'Time critical' rapid amputation using fire service hydraulic cutting equipment

Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis--critical appr

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A Critical Evaluation of Existing Diabetic Foot Screening Guidelines.

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Critical Thinking

Iatrogenic injury and critical limb iscahemia

“Switch” Critical to Wound Healing

Critical limb ischemia

Critical limb ischemia criteria are not applicable to diabetic foot

'Time critical' rapid amputation using fire service hydraulic cutting equipment

Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis--critical appr

Share This Page

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