Practical guidelines for the prevention and management of diabetic foot disease in China

Foot Care

Diabetic foot is one of the common and serious complications among the patients with diabetes mellitus. The major causes of amputation and/or death in the patients are foot deformities, ulcers, ischemia, and possible concurrent infections. To further standardize diabetic foot prevention and treatment in China, improve its diagnostic and therapeutic consistency, and promote the development of a specialized tiered care system, Chinese Burn Association, Yangtze River Delta Integrated Diabetic Foot Alliance, and Editorial Committee of Chinese Journal of Burns and Wounds organized a multidisciplinary expert team. The team determined clinical issues related to the diagnosis, treatment, and prevention of diabetic foot and evaluated the quality grades of relevant evidence using the grading of recommendations assessment, development, and evaluation system, and eventually developed the Practical guideline on the prevention and management of diabetic foot in China. There were 46 recommendations formed in the guideline, covering comprehensive medical assessment, internal medical treatments such as control of blood glucose, blood pressure, and blood lipid, antithrombotic and anti-infection therapy, perioperative risk assessment and management, surgical treatments such as debridement, vascular reconstruction, and tissue repair surgeries, as well as foot disease prevention, multidisciplinary team cooperation, and the construction of a tiered care system, aiming to provide guidance for the clinical practice of diabetic foot in China.

In May 2019, the International Diabetic Foot Working Group (IWGDF) updated and issued guidelines for the prevention and management of diabetic foot disease. This guide puts forward some suggestions for the diagnosis, treatment and effective prevention of diabetic foot: the prevention of diabetic foot should start with high-risk foot, early screening and treatment of diabetic foot infection, foot ulcer and peripheral vascular disease and early comprehensive treatment. Effective prevention and early treatment can reduce the incidence of cardiovascular and cerebrovascular events in patients with diabetes, reduce the amputation rate and mortality, and improve the prognosis and quality of life of patients. Key words: Diabetic foot; Foot ulcer; Peripheral vascular diseases

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.Registry number: IPGRP-2020cn124

Objective: To summarize the best evidence on exercise for the prevention and treatment of diabetic foot. Methods: A bibliometric approach was used. Systematic searches were carried out to retrieve all the publicly published evidences till July 2022 on exercise for the prevention and treatment of diabetic foot, including guidelines, evidence summary, recommended practices, expert consensus, systematic review, and original research, from foreign language databases including BMJ Best Practice, UpToDate, Joanna Briggs Institute Evidence-Based Practice Database, Cochrane Library, Embase, PubMed, Guideline International Network, National Guideline Clearinghouse, Chinese databases including China National Knowledge Infrastructure, Wanfang Database, VIP Database, China Biology Medicine disc, China Clinical Guidelines Library, and the official websites of relevant academic organizations including National Institute for Health and Care Excellence of the United Kingdom, Registered Nurses' Association of Ontario of Canada, the International Working Group on the Diabetic Foot, International Diabetes Federation, American College of Sports Medicine, American Diabetes Association, and Chinese Diabetes Society. The literature was screened and evaluated for the quality, from which the evidences were extracted and evaluated to summarize the best evidences. Results: Nine guidelines, three expert consensuses, one evidence summary (with two systematic reviews being traced), two systematic reviews, 6 randomized controlled trials were retrieved and included, with good quality of literature. Totally 33 pieces of best evidences on exercise for the prevention and treatment of diabetic foot were summarized from the aspects of appropriate exercise prevention of diabetic foot, exercise therapy of diabetic foot, precautions for exercise, health education, and establishment of a multidisciplinary limb salvage team. Conclusions: Totally 33 pieces of best evidences on exercise for the prevention and treatment of diabetic foot were summarized from 5 aspects, providing decision-making basis for clinical guidance on exercise practice for patients with diabetic foot.

Diabetic foot ulcers: treatment overview and cost considerations.

Diabetic foot disease is a source of major patient suffering and societal costs. Investing in evidence-based international guidelines on diabetic foot disease is likely among the most cost-effective forms of health care expenditure, provided the guidelines are outcome focused, evidence based, and properly implemented. The International Working Group on the Diabetic Foot (IWGDF) has published and updated international guidelines since 1999. The 2019 updates are based on formulating relevant clinical questions and outcomes, rigorous systematic reviews of the literature, and recommendations that are specific, and unambiguous along with their transparent rationale, all using the Grading of Recommendations Assessment Development and Evaluation (GRADE) framework. We herein describe the development of the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease, which consists of six chapters, each prepared by a separate working group of international experts. These documents provide guidelines related to diabetic foot disease on prevention; offloading; peripheral artery disease; infection; wound healing interventions; and classification of diabetic foot ulcers. Based on these six chapters, the IWGDF Editorial Board also produced a set of practical guidelines. Each guideline underwent extensive review by the members of the IWGDF Editorial Board as well as independent international experts in each field. We believe that adoption and implementation of the 2019 IWGDF guidelines by health care providers, public health agencies, and policymakers will result in improved prevention and management of diabetic foot disease and a subsequent worldwide reduction in the patient and societal burden this disease causes.

Introduction: Diabetes mellitus is a significant cause of morbidity and mortality. Foot-related complications affect 2–2.5% of people with diabetes. There is significant variation in outcomes for patients with diabetic foot disease within the UK. The multidisciplinary approach to diabetic foot disease is well publicised and protocols, guidance and consensus approaches exist for most components of the management of diabetic foot disease. Antimicrobial therapy to treat diabetic foot infections based on microbiological sampling and culture is well documented, but no consensus exists on how these samples should be obtained, processed and reported. Methods: A literature review was undertaken to establish the reporting of techniques used in obtaining and processing microbiological samples in diabetic foot disease to establish if consensus exists in the methodologies used with a view to develop best practice guidelines. Results: Six out of 102 papers reported all processes in obtaining and processing microbiological samples. Conclusion: No gold standard consensus exists for microbiological sampling of diabetic foot infections, preventing optimisation of this aspect of management of diabetic foot disease and ultimately potentially adversely affecting the outcomes of this growing patient cohort.

Application of tele-podiatry in diabetic foot management: A series of illustrative cases

The 8th World International Symposium on the Diabetic Foot (ISDF) Conference which was sponsored by the International Working Group on Diabetic Foot (IWGDF) was held in the Hague between May 22nd and May 25th, 2019. The conference issued the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease. The update to the 2015 edition of the guidelines involves the following 6 chapters: prevention of foot ulcers in patients with diabetes; offloading foot ulcers in patients with diabetes; diagnosis, prognosis, and management of peripheral arterial disease in patients with a foot ulcer and diabetes; diagnosis and treatment of foot infection in patients with diabetes; interventions to enhance healing of foot ulcers in patients with diabetes; classification of diabetic foot ulcers. This guideline has been changed more than the previous edition. In this paper, the guidelines will be interpreted to provide cutting-edge information for domestic diabetic foot researchers.

Diabetic foot disease results in a major global burden for patients and the health care system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. In 2019, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification, and treatment of diabetic foot disease, based on the six IWGDF Guideline chapters. We also describe the organizational levels to successfully prevent and treat diabetic foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of health care professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes-related lower extremity amputations. We hope that these updated practical guidelines continue to serve as reference document to aid health care providers in reducing the global burden of diabetic foot disease.

ABSTRACTAims/IntroductionTo assess the association between vitamin D and diabetic foot (DF) in patients with type 2 diabetes mellitus (T2DM), in order to summarize clinical evidence in the prevention and treatment of DF.Materials and methodsBetween January 2012 and December 2019, a total of 1,721 hospitalized patients with type 2 diabetes mellitus were continuously enrolled in West China Hospital, Sichuan University, and divided into DF and non‐DF groups according to whether they had DF, and divided into four subgroups according to the admission season. The 25‐OH‐vitamin D levels were compared between groups and subgroups, and independent risk factors discussed for the occurrence of DF.ResultsThe vitamin D insufficiency and deficiency rate were higher in the DF group (77.51%) than in the non‐DF group (59.2%). The 25‐OH‐vitamin D levels were lower in the DF group (35.80 nmol/L) than in the non‐DF group (45.48 nmol/L) (P < 0.001). Patients with poor glycemic control had lower 25‐OH‐vitamin D levels (P = 0.01). The levels of 25‐OH‐vitamin D were lower in winter and spring. In the same season, the levels of 25‐OH‐vitamin D in patients with DF were still lower (P < 0.001). The 25‐OH‐vitamin D levels of patients with Wagner grades 0 to 5 showed a downward trend (P = 0.114). The 25‐OH‐vitamin D level was independently associated with diabetic foot (P < 0.001, OR = 0.986).ConclusionsThe low serum vitamin D level was significantly associated with a higher prevalence of DF among Chinese patients with type 2 diabetes mellitus. Although vitamin D levels vary seasonally, patients with DF were always at higher risk of having vitamin D insufficiency and deficiency.

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient-intervention-comparison-outcome (PICO) format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.

A review of the literature on the use of hydrocolloids in the management of diabetic foot disease.

Diabetic foot disease is a debilitating complication of diabetes mellitus, ultimately affecting up to 50% of patients with both type 1 and 2 diabetes. Currently, this complication is still leading to significant loss of quality and years of life of the affected patient [1, 2]. Furthermore, it represents at least 12–15% of the overall cost associated with diabetes and up to 40% in developing countries [2, 3]. Additionally, current available treatments for diabetic foot disease are usually not as effective as they should be [4]. This is mainly explained by the insufficient knowledge of its underlying mechanisms and treatment tools because of the insufficient interest and research resources allocated to the study of this complication worldwide. All, except one, of the papers included in this special issue are dealing with clinical and epidemiological aspects of diabetic foot disease with an observational design. One paper is devoted to the investigation of a novel therapeutic approach in an experimental animal model. The content of this issue mirrors the current clinical and research background of this diabetic complication; that is, there is ample room for improvement in all aspects of its prevention and treatment. In one of the papers, using a retrospective study design, N. K. Chammas et al. assessed mortality and its causes in a large sample of patients from a single foot clinic in the UK and confirmed that death occurred 5 years earlier in patients with a diabetic foot ulcer. As for the general diabetic population, cardiovascular mortality was the main cause of death in the cohort, and the same was observed in patients with neuropathic foot ulcers where ischemic heart disease was the main cause of death. As found in previous studies, these results confirm the close link between diabetic microangiopathic disease and atherosclerotic cardiovascular disease. As for retinopathy and diabetic kidney disease, the results point again to neuropathic foot disease as a cardiovascular risk condition. In a very large cohort of patients from Japan, a retrospective study by M. Tomita et al. aimed at assessing the incidence of diabetic foot ulcers according to the presence and severity of microvascular disease, that is, retinopathy and albuminuria. During a long follow-up period, after adjusting for other potential major contributing factors, the authors showed that the presence of concomitant retinopathy and albuminuria greatly increased the risk of developing diabetic foot disease. Thus, these findings should be taken into account in terms of preventative measures in patients with diabetic microangiopathic complications. In the field of epidemiology, C. I. Bondor et al. performed a post hoc analysis using the data from a previous study of quality of life in a cross-sectional survey done in Romania in 2012. Although the study was based on self-reported data, they showed a very high frequency of foot ulcers and amputations in this large cohort of more than 21,000 diabetic patients. These results confirm the great burden created by diabetic foot disease and highlight the importance of epidemiological studies to raise the awareness of this important health care problem around the globe. M. T. V. Quilici et al. performed a cross-sectional study in patients admitted to a Brazilian hospital because of diabetic foot infections. The findings of the study showed a high rate of amputations in this study cohort in which most patients had neuroischemic feet. Additionally, the study underlines the importance of early referral of patients with diabetic foot infections. An interesting paper by M. May et al. showed the data on amputations from a large insurance company delivering health care to some 2.9 million people from 2 regions in Germany before and after the implementation of 6 networks for specialized care of the diabetic foot. They found that there was a decrease of overall amputations. However, the amputation rates were still high and indicate the need for further improvement in specialized care of the diabetic foot. Finally, in the field of experimental research, X. Zhang et al. conducted an experimental study using Tuo-Li-Xiao-Du-San, a traditional Chinese medicine formula, to treat wounds in a rat model of diabetes. They were able to show that this treatment was able to enhance the healing of ulcers through several mechanisms: reduction of inflammatory cell mediators and increase in angiogenesis and collagen deposition. To conclude, although the interest in research and management of diabetic foot disease has increased in recent years, it is still the Cinderella among diabetes complications in terms of research efforts and in resource allocation and outcomes. Additionally, the complexity of its management needs to be addressed on a multidisciplinary approach that should gather all expertise necessary for the optimal management of each aspect of this complication [2, 5]. The future should bring much more high-quality research to the area of diabetic foot disease, from basic research to properly conducted clinical trials.