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http://ijl.sagepub.com/ Wounds The International Journal of Lower Extremity http://ijl.sagepub.com/content/12/1/71 The online version of this article can be found at: DOI: 10.1177/1534734613476519 2013 12: 71 originally published online 26 February 2013International Journal of Lower Extremity Wounds Peter Lamont, Kerryn Franklyn, Gerry Rayman and Andrew J. M. Boulton Update on the Diabetic Foot 2012: The 14th Biennial Malvern Diabetic Foot Conference, May 9-11, 2012 Published by: http://www.sagepublications.com can be found at:The International Journal of Lower Extremity WoundsAdditional services and information for http://ijl.sagepub.com/cgi/alertsEmail Alerts: http://ijl.sagepub.com/subscriptionsSubscriptions: http://www.sagepub.com/journalsReprints.navReprints: http://www.sagepub.com/journalsPermissions.navPermissions: What is This? - Feb 26, 2013OnlineFirst Version of Record - Mar 15, 2013Version of Record >> by guest on November 4, 2014ijl.sagepub.comDownloaded from by guest on November 4, 2014ijl.sagepub.comDownloaded from The International Journal of Lower Extremity Wounds 12(1) 71 –75 © The Author(s) 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734613476519 ijl.sagepub.com The 14th biennial Malvern Diabetic Foot Conference was held in May 2012. Since the first meeting in 1986, chaired by Dr Henry Connor and Professor A. J. M. Boulton, the conference has attracted increasing numbers of attendees and this year saw a record number of abstracts submitted albeit only one third could be accepted. Physicians, podia- trists, nurses, orthotists, surgeons, radiologists, and other professionals attended to reflect on the diabetic foot. There were delegates present from every continent except Antarc- tica, representing 25 different countries. The conference comprised interactive workshops, oral presentations of new research findings, and lectures from leading figures in the world of the diabetic foot. The conference was opened by Sir Michael Hirst, who is the incoming President of the International Diabetes Federation and the first nonmedical chairman of Diabetes UK. His interest in diabetes was sparked when his daughter was diagnosed with diabetes when she was 5 years old. He has been able to use his political career to influence policy changes, specifically ensuring that the UK drug tariff now includes disposable syringes. Sir Michael acknowledged that there is an inequality of care provided to diabetes patients across the world and wishes to raise awareness through edu- cation for patients and care professionals alike. He identified the importance of the influence that policy makers have when initiating change and highlighted the massive challenges that exist when dealing with chronic disease. Epidemiology/Health Economics Gerry Rayman (UK) introduced session 1, which was on Epidemiology and Health Economics. He discussed the uneven rates of amputation throughout England and noted that major amputation rates varied 10-fold across primary care trusts (PCTs) in the United Kingdom. This fact was highlighted in a discussion by Marion Kerr, Health Economist, who discussed the human and financial cost of amputation. A total of 61 000 people with diabetes in England will have a foot ulcer at any one time. The risk of lower extremity amputation is 23 times that of a nondia- betic individual. She noted that mortality rates are now at a similar level to some of the major cancers such as breast, prostate, colon, and lung. In 2010, 38 000 people had a first incidence of diabetic foot ulceration; only breast cancer has a higher incidence. The 5-year survival rate after a diabetic foot ulcer is 57%; however, after amputation the 2-year survival rate may be as low as 50%, although this rate is an association rather than an attribution. The discussion went 476519 IJL12110.1177/1534734613476519The International Journal of Lower Extremity WoundsLamont et al © The Author(s) 2011 Reprints and permission: http://www. sagepub.com/journalsPermissions.nav 1Manchester Foot Hospital, Manchester, UK 2Ipswich Hospital, Ipswich, UK 3Manchester Royal Infirmary, Manchester, UK Corresponding Author: Peter Lamont, The Foot Hospital, Rusholme, Manchester M14 5NP, UK. Email: peter.lamont@cmft.nhs.uk Update on the Diabetic Foot 2012: The 14th Biennial Malvern Diabetic Foot Conference, May 9-11, 2012 Peter Lamont, MSc, Hons, Podiatry1,Kerryn Franklyn, MSc, Hons, Podiatry1, Gerry Rayman, MD1, Andrew J. M. Boulton, MD2,3 Abstract The 14th biennial Malvern Diabetic Foot Conference was held in May 2012. Physicians, podiatrists, nurses, orthotists, surgeons, radiologists, and other professionals attended to reflect on the diabetic foot. The conference comprised interactive workshops, oral presentations of new research findings, and lectures from leading figures in the world of the diabetic foot. Over the 3 days, topics such as epidemiology, neuropathy, screening, vascular disease, prevention, and management among others were discussed. The conference has been an excellent platform from which to share new and ongoing research and it will without a doubt improve the treatment of the diabetic foot across the world. Keywords diabetic foot, Malvern, amputation Regular Features by guest on November 4, 2014ijl.sagepub.comDownloaded from 72 The International Journal of Lower Extremity Wounds 12(1) on to describe the financial cost of diabetic foot care in the United Kingdom alone. In 2010/2011, the National Health Service (NHS) spent between £639 and £662 million, the majority of this in community, outpatient, and accident and emergency settings. In addition, £1 in every £150 of total NHS spending is required to treat the diabetic foot. Marion Kerr (UK) presented some key issues that were echoed during the rest of the conference. In the community setting, there appears to be discrepancies in collating infor- mation and foot screening. The point being made was whether patients who receive a foot screen and risk stratifi- cation really understand the meaning of the latter. In addi- tion, the question arose as to whether patients were receiving the correct care pathway following their risk categoriza- tion? There were also issues with inpatient care with three quarters of inpatients having no foot examination during their stay. This is despite the fact, based on the available data, that 2.2% of diabetes inpatient beds are occupied by someone who has developed a foot ulcer during their stay in hospital. It was alarming to note that over 18 sites, there was a variation of 0% to 27% for hospital admissions due to a diabetic foot ulcer. This emphasizes the many variations in data recording across the country. Multidisciplinary team care with community links has been shown to result in improved patient outcomes and savings. Two case studies, from Southampton and Middlesbrough, showed a reduction in annual amputations and an annual saving of 4 and 7 times the cost of the service, respectively. This highlights the need for quality and efficiency within services as the cost of dia- betic foot care is certain to rise substantially. William Jeffcoate (UK) supported much of the previous discussion in his talk on whether the diabetic foot is the cancer of diabetes. Data from Nottingham in 2003 found that diabetic patients with foot ulceration had a mortality rate of 16.7% at 12 months and 50% at 5 years. This is com- parable with colon cancer. It is surprising then that amputa- tion was perceived as a personal threat more than a mortality risk. He reiterated Rayman’s introduction by noting a 10-fold variation between PCTs inthe United Kingdom and questioned whether such a variation would be acceptable in cancer or heart disease? Is the diabetic foot the cancer of diabetes? Jeffcoate argued that it is now more important than cancer. Neuropathy: From Painless to Painful Professor Boulton (UK) provided an introduction to the dia- betic somatic sensory neuropathies by stating that they can present as pain, insensitivity, or a combination of the two. He pointed out that it is a length-dependent neuropathy, affecting the longest nerves, and that importantly height is a risk fac- tor. Neuropathy is twice as common in type 2 compared to type 1 diabetic patients, and the diagnosis depends on the exclusion of other causes. Electrophysiology will not inform the cause of the neuropathy, and the diagnosis cannot be made without a clinical examination. Clinical tests comprise monofilament, vibration, and pin-prick sensations together with reflexes, Neuropathy Disability Score, and Quantitative Sensory Testing such as Vibration Perception Threshold. There are also new quick chair-side tests available, such as the Vibratip and the Ipswich Touch Test. The latter is a quick, inexpensive, and reliable clinical test that will prove useful for situations where equipment is not readily available, such as on the ward or in developing countries. B. Nijafi (USA) presented the findings of an interesting gait variability (GV) study and discussed how this can be altered by neurodegenerative diseases. Aside from being a strong predictor of falls, GV may increase energy cost and shear force. Investigating methods to modify GV may have a practical application for foot care. To close the session, D. Ziegler (Germany) provided a comprehensive overview on the diagnosis and treatment of painful diabetic neuropathy. He reiterated the importance of bedside tests for large and small fiber function. The gold standard test is skin biopsy to detect any decrease in nerve fiber density; however, corneal confocal microscopy is also a newly developed technique. He provided a thorough over- view of treatment options, but in summary his recommen- dations for successful results consisted of initial treatment as soon as possible, taking into account pain relief and qual- ity of life, physical and emotional functioning, and sleep quality. Choice and dose of treatment should be made with consideration to other comorbidities such as renal and car- diovascular disease and therefore needs careful titrating. Most guidelines list Duloxetine or Pregabalin as first-line therapies for painful diabetic neuropathy. A drug should not be judged as ineffective until it has been administered for at least 2 to 4 weeks at an effective dose. Finally, analgesic combinations should be tried and interactions should be considered. Symposium on Screening The screening of patients and allocation of risk stratifica- tion in Scotland has improved the treatment of the diabetic foot by focusing resources on the necessary areas, accord- ing to Graeme Leese (Scotland), who discussed the find- ings of a new traffic light system that is similar to that suggested by the International Working Group on the Diabetic Foot (IWGDF). They found that between 2007 and 2012, the number of diabetic patients who have been screened has risen from 25% to 86%. The development of some excellent leaflets and a new online training service has helped educate both patients and clinicians and infor- mation is available to all at www.diabetesframe.org. They have also focused on creating stronger links between com- munity services and specialist teams at the hospitals. by guest on November 4, 2014ijl.sagepub.comDownloaded from Lamont et al 73 Rodger Gadsby (UK) discussed the new Quality and Outcomes Framework (QoF) guidelines. QoF have increased foot care points from 6 to 7 with the emphasis on screening, which is an improvement; however, it is not at the level achieved in Scotland. The key drawback with this system is the referral pathway after screening. It has been noted that 20% of trusts do not have access to a multidisciplinary team and therefore there is no obvious pathway for these high-risk patients to be followed-up. Dr Gadsby concluded that, with the implementation of the commissioning act, these issues will be addressed because all trusts will have to have a mul- tidisciplinary team. This reiterated Sir Michael Hirst’s final point in his address that the policy makers are the key to initiating change to improve the service. G. Rayman (UK) summarized the recent diabetes inpa- tient audit. This was performed over 230 hospitals, repre- senting 96% of all acute hospitals in England. More than 12 000 patient’s care was audited and 56% of patients returned a patient experience questionnaire. The audit found that 15% of all inpatients had diabetes. Only 9% were admitted for a diabetes complication, the majority being admitted for another medical or surgical condition although diabetes invariably complicated their stay. Twelve percent of all dia- betes admissions had foot problems and half of these patients were admitted specifically for diabetic foot disease. As previously mentioned, only about a quarter of diabetes admissions had a foot inspection of any sort. A key problem when performing a foot screen is time and access to equip- ment. This led to the development of the Ipswich Touch Test, which was discussed in Prof Boulton’s talk. Dr Rayman found that use of the Touch Test and a heel check every day lead to a 63% reduction in foot lesions after admission over a 3-year period. The audit highlighted varia- tions in service availability across trusts, with 40% not hav- ing access to a multidisciplinary team, 7% not having access to a podiatrist or orthotist, and 12% without access to an interventional radiologist. Dr Rayman’s team has devel- oped an informative DVD to educate clinicians in primary care setting as to how diabetic patients can be screened for foot problems and risk stratification. Biomechanics and Vascular Disease N. Reeves (UK) presented on the biomechanics of the dia- betic foot and spoke in general about the mechanics of the whole lower limb during gait. He provided some back- ground into what is known about gait in people with diabe- tes. It has been demonstrated that a diabetic patient with peripheral neuropathy will perform a variable gait pattern with slower speed and a more cautious strategy, which leads to a higher number of falls compared to matched controls. Reeves presented some of his recent findings, which showed that diabetic patients with peripheral neu- ropathy appear to use a different muscle activation pattern compared to age-matched controls and diabetics without peripheral neuropathy. They appear to be slower to develop the required forces, which may indicate more difficulty in responding to unexpected events, which may suggest a higher likelihood to falls in this cohort. T. Richards (UK) discussed peripheral vascular disease diagnosis and management. He talked about advances in diagnostics and his use of the magnetic resonance scan, which produces similar results to the angiogram. Color duplex scanning is commonly used, but can be fraught with problems, particularly in the presence of calcified arteries. He recommended further investigations if pulses cannot be palpated, and not to rely solely on the hand-held Doppler. Identification of anastomoses and the formation of collater- als is necessary to find areas of impaired blood supply as this will indicate a limb has lost direct blood flow to the foot. A speedy referral of complex patients suffering from spreading cellulitis, deep tissue infection, abscess, whole toe gangrene, and sepsis is imperative. Richards expressed concern regarding variations across hospitalsand empha- sized the importance of data linkage and teamwork in this complex group of patients. Amputation is not a failure if there is a chance of rehabilitation and the patient’s quality of life will improve. He summarized his talk by highlight- ing 2 key treatment principles of sepsis drainage and improvement of blood flow. This talk was followed by J. Reekers (Netherlands), who spoke about both the diagnostic capabilities and the endo- vascular procedures that are performed by the interven- tional radiologist. The advantages of the small vessel percutaneous procedures are that they are minimally inva- sive requiring no general anesthetic and can be done in the outpatient setting, with results comparable to surgery. Moreover, they can be repeated if needed. Disadvantages are that they require a high level of skill, training, and expe- rience. The option to do either open or endo surgery is very much patient and wound specific; however, he feels that an interventional radiologist is a vital member of the multidis- ciplinary team. G. Andros (USA) followed with a talk on the manage- ment of the highest risk patient: who is the diabetic patient on dialysis with foot problems. He described 2 different types of vascular angiopathy, one being diabetes and the other caused by hypertension/tobacco. End-stage renal dis- ease (ESRD) is not widely recognized as an independent risk factor for diabetic foot ulceration. ESRD is 2.5 times greater than 10 years ago, with those with diabetes account- ing for 50% on hemodialysis. There is a relationship between the severity of renal disease and the risk of foot complications. It was noted that 1 in 5 diabetic patients with ESRD have a foot ulcer, and an amputation is usually required in those with ESRD suffering from a heel ulcer with exposed bone. In addition, mortality rates are poor in this cohort, with the cumulative survival postamputation by guest on November 4, 2014ijl.sagepub.comDownloaded from 74 The International Journal of Lower Extremity Wounds 12(1) being 50% at 2 years. As healing rates can be impaired in those patients with edema, he discussed the possible bene- fits of transferring a patient with an ulcer from peritoneal dialysis to hemodialysis. He noted that a primary below knee amputation is probably preferable to multiple open endovascular procedures, especially in the young, echoing the previous discussion by Mr Richards on rehabilitation and quality of life. Prevention and Management S. Morbach (Germany) discussed the “Step by Step” team exchange program introduced to developing countries to increase awareness, reduce amputations, and develop basic diabetes services. The program consists of a basic course covering screening and management of foot lesions. This is followed a year later by the advanced course, which involved case discussions and training in offloading. Pilot projects were undertaken in India and Tanzania. The pro- gram has now moved to Pakistan, Egypt, Congo, and the Caribbean, with future plans for the rest of the Caribbean Islands, Central America, and French-speaking Africa. This was followed by a discussion by Z. Abbas (Tanzania), who talked about the application of the “Step by Step” pro- gram to pan-African foot care. He mentioned that the true prevalence of amputations in Africa is unclear. Dr Abbas predicted that there will be a 93% increase in the next 15 years. Most of these will be identified through improve- ments in screening. He highlighted the problems associated with managing at-risk patients due to the use of herbal rem- edies and traditional medicines and the delay in presentation of acute problems. The aims of the project were to increase awareness and training and the education of staff and patients, with the overall target to reduce amputations. He also presented their education video. Small improvements are beginning to show, with the number of treatment centers increasing as well as the awareness of foot problems. R. Lobmann (Germany) then presented on the dysfunc- tion of wound healing in diabetic patients, in particular the disorganized processes of construction and destruction in the chronic wound. He gave a thorough overview of the role of matrix metalloproteinases (MMPs) in wound healing and noted that one of the characteristics of these patients is the high level of MMPs in normal skin. Wound healing begins at a cellular level, and in chronic diabetic wounds they tend to be stuck in the inflammatory stage, and this is where the use of cytokines and growth factors may play a role in treat- ment. The goal of wound treatment in these patients is to bring the wound back into balance by good wound bed preparation. Eighty percent of diabetic foot wounds will respond to offloading and debridement, with the remaining requiring the use of additional treatments, for example, growth factors and protease inhibitors. There are also high levels of infection in diabetic wounds. This infection is linked to inflammation with pro-inflammatory mediators upregulated by bacteria. Staphylococcus aureus releases MMPs and increases levels of interleukin-6 and tumor necrosis factor-α. B. Lipsky (USA) presented a concise update of the new guidelines for managing infection in the diabetic foot. These guidelines were the combinations of the IWGDF, the Infectious Disease Society USA, and NICE guidelines (UK). He advised anyone involved in the management of the diabetic foot to be aware of these guidelines and to remember that “guidelines are like a map—implementation is the journey.” D. Armstrong (USA) closed the morning session with an overview on negative pressure therapy. This device is evolving, becoming smaller and more easily portable, but still highly effective on large wounds. A new development is the intro- duction of therapies to the wound through the device such as MMP modulators, antibiotics, antibiofilms, and antiseptics. Another development is the transition from battery power to a smaller “spring” powered vacuum-assisted treatment device, with research indicating no significant difference between the traditional and newer devices. Management Challenges and the Future E. Jude (UK) began the final session of the conference on Osteomyelitis and Charcot. He presented the findings of a joint task force on Charcot neuroarthopathy available (Rogers L et al, The Charcot foot in diabetes. Diabetes Care. 2011;34(9):2123-2129). If presenting with a red, hot, swol- len foot, initial investigations in such a patient should include radiographs and bone scans; however, there is a time issue with both of these. A magnetic resonance imaging scan is helpful but a computed tomography scan is not recom- mended. Inflammatory markers and leukocyte scans are also used. First-line treatment is with offloading, ideally in an irremovable total contact cast or alternatively with a prefab- ricated removable walking cast. However, there is no ran- domized control trial of the air cast to recommend its use in Charcot. The mean casting time is 5 to 6 months. Once swelling has resolved and the temperature is within 2 degrees of the contra lateral foot, the patient may be transferred to a bespoke shoe. In summary, the diagnosis can be missed; hence, a high level of suspicion is required in the red, hot, swollen, neuropathic foot. Offloading is the initial treatment; however, surgical management is an option. Continuous follow-up in clinic is recommended to monitor for signs of recurrence or other diabetic foot complications. This was followed by F. Game (UK), discussing the med- ical versus surgical management of osteomyelitis. It would appear that both a medical and surgical approach is required. The IDSI guidelines are particularly helpful, and as in any management,patient preference should be considered. by guest on November 4, 2014ijl.sagepub.comDownloaded from Lamont et al 75 D. Wukich (USA) followed with a pragmatic overview of the surgical management of the diabetic Charcot foot although Charcot reconstruction is technically difficult. About 25% to 50% of patients will require some type of surgery, and 90% limb salvage is possible with good patient selection and good technique. The aim of surgery is to cre- ate a stable plantar grade foot that can fit in a shoe and avoid amputation. He presented the findings of a review of his ankle and hind foot surgeries in diabetes versus nondiabetic controls. In the diabetic group, there was a 3-fold increase in complications. For elective procedures, he suggests that the HBA1c is below 8%. He also found a high level of com- plications in tobacco users and therefore will not operate unless the patient has stopped smoking. There is no high- level evidence for surgical management and outcomes are based on expert anecdotal experience; however, he did note that a poor result from surgery is worse than a poor result from nonsurgery and that the best surgery is the one he never has to perform. The final talk at the conference was from C. Attinger (USA), who spoke on the Georgetown experience of major amputation in diabetes. Prevention is naturally better than cure; prophylactic care being the best and most cost-effec- tive treatment. He noted that, even when all of the treatment tools are available, only 79% of patients will achieve com- plete healing. In these cases, a frank and early discussion is required regarding the realistic expectations of limb salvage versus amputation. Their criteria for amputation are a leg not salvageable due to infection, pain due to peripheral arte- rial disease, and young patients whose quality of life is reduced due to a diseased leg. They also use the Ertl ampu- tation, which is a more distal amputation but found to be particularly good on young patients. Conclusions The key points resulting from the conference were that amputation is not always a failure if it is likely to improve the patient’s quality of life, reducing the inequalities in the treatment of the diabetic foot and continued improvement the foot screening and risk stratification of all our diabetic patients. The biennial Malvern Diabetic Foot Conference has been an excellent platform from which to share new and ongoing research. It will without a doubt improve the treatment of the diabetic foot across the world. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Funding The author(s) received no financial support for the research, authorship, and/or publication of this article. by guest on November 4, 2014ijl.sagepub.comDownloaded from
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