Diabetic Foot Complications Research Articles

Reconstruction of diabetic lower leg and foot soft tissue defects using thoracodorsal artery perforator chimeric flaps.

Reconstruction of complicated diabetic lower leg and foot defects involving multiple tissue components remains a challenge. The purpose of this report is to introduce thoracodorsal artery perforator (TDAP) chimeric flaps for reconstructing diabetic lower leg and foot soft tissue defects. Between April 2010 and August 2016, 17 patients with multiple diabetic lower leg and foot defects underwent reconstruction with TDAP chimeric flaps. Nine were women and the mean age of the patients was 57.7years (range 35-73years). One patient had 3 separate defects, 14 patients had 2 separate defects, and 2 patients had defects with dead space. The size of the defects ranged from 5×3cm to 20×10cm. Fifteen patients received TDAP chimeric flaps with two components (skin and muscle components), and two received three components (skin, latissimus dorsi (LD), and serratus anterior [SA] components). The skin paddle ranged from 10×3cm to 25×14cm. The LD components ranged from 3×5cm to 20×10cm and SA components ranged from 5×2cm to 8×7cm. All flaps survived except for partial loss of one muscle component. Four patients suffered postoperative complications including wound disruption and infection, all of which healed conservatively. The mean follow-up was 31.3months (range 8-60months). Fifteen patients were able to walk, one patient walked with walker, and one patient who had amputation due to Charcot joint infection walked with prosthesis. The TDAP chimeric flap may be another option for the complicated and complex wound coverage required to reconstruct diabetic lower leg and foot soft tissue defects.

Летальність у хворих з ускладненим синдромом діабетичної стопи з проявами сепсису згідно з рекомендаціями «Sepsis-3»

Мета. Провести порівняльний аналіз показників летальності у хворих із сепсисом на тлі ускладненого синдрому діабетичної стопи (СДС) з урахуванням протоколу Погоджувальної конференції (1992) та рекомендацій ІІІ Міжнародного консенсусу з визначення сепсису та септичного шоку («Sepsis-3»).
 Матеріали і методи. Ретроспективно та проспективно проаналізовано 938 історій хвороб пацієнтів з ускладненим СДС. У 92 (9,8%) пацієнтів захворювання було обтяжене сепсисом. Згідно з рекомендаціями «Sepsis-3» використовували нову шкалу під час обстеження біля ліжка - qSOFA.
 Результати. Аналіз летальних випадків з урахуванням рекомендацій «Sepsis-3» показав, що деякі форми септичного процесу віднесені до ускладнених невиправдано, тобто їх кількісна оцінка за шкалою qSOFA не перевищувала 1 бала. Це дало можливість визначити сепсис причиною смерті у 5 (11,9%) хворих, а септичний шок (СШ) - у 37 (88,1%).
 Висновки. Впровадження рекомендацій «Sepsis-3» в клінічну практику дасть змогу уникнути розбіжностей у постановці діагнозу. За допомогою шкали qSOFA можна швидко і без значних матеріальних витрат диференціювати сепсис і СШ.

Scoring Mental Health Quality of Life With the SF-36 in Patients With and Without Diabetes Foot Complications.

The aim of this study was to examine if using orthogonal and oblique factor analysis detect changes in health-related quality of life differently in diabetic patients on the Short Form-36 (SF-36) survey. A total of 155 patients had diabetic foot complications (DFC), and 145 patients had no DFCs. The SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were calculated using scoring coefficients determined by orthogonal and oblique rotation principle component analyses of the subscales. The DFC group had lower orthogonal ( P < .00001) and oblique PCS scores ( P < .00001). However, despite lower Mental Health subscale scores in the patients with DFCs, orthogonal MCS scores ( P = .156) did not differ. In contrast, the oblique MCS scores reflected the difference in the Mental Health subscale ( P = .0005). Orthogonal and oblique PCS scores did not differ significantly. However, orthogonal MCS scores were significantly higher than oblique MCS scores in those with DFCs ( P = .0004) and without DFCs ( P = .005). The shorter, 12-item SF-12 survey demonstrated similar results. Poorer physical function leads to higher orthogonal MCS scores than if determined by oblique scoring coefficients since Physical Function, Bodily Pain, and General Health are weighted more negatively in orthogonal coefficients when calculating the MCS score. Oblique scoring coefficients may address this issue, but further study is necessary to confirm whether oblique MCS scores accurately represent the mental health of patients with diabetic foot disease.

СЕПСИС У ХВОРИХ ЗА УСКЛАДНЕНОГО СИНДРОМУ ДІАБЕТИЧНОЇ СТОПИ – ОКСИДАНТНИЙ СТРЕС ОРГАНІЗМУ

Вступ. Гнійні захворювання відзначають більш ніж у 35% пацієнтів хірургічних стаціонарів, з яких особливою групою є пацієнти з сепсисом на тлі ускладненого синдрому діабетичної стопи (СДС). Реакція організму на септичний процес проявляється змінами метаболічних процесів, у регуляції яких важливу роль відіграють перекисне окиснення ліпідів (ПОЛ) та система антиоксидантного захисту (АОЗ).&#x0D; Матеріали і методи. Обстежені в динаміці 724 хворих з приводу ускладненого СДС. Стан ПОЛ оцінювали на основі аналізу його первинних та вторинних продуктів – дієнових кон’югат (ДК), малонового діальдегіду (МДА), шифових основ (ШО).&#x0D; Результати. Встановлено, що у хворих як за ускладненого СДС, так і сепсису, зміни вмісту продуктів ПОЛ в сироватці крові при госпіталізації були достовірними (р &lt; 0,05), при сепсисі, більш вираженими, ніж за ускладненого СДС без сепсису.&#x0D; Обговорення. Аналіз отриманих даних свідчить, що тяжкість перебігу сепсису у хворих за ускладненого СДС залежить від стану вільнорадикального окиснення ліпідів. За результатами дослідження, первинні й вторинні продукти ПОЛ є об’єктивними маркерами тяжкості ендогенної інтоксикації, визначають оксидантний стрес організму. В системі комплексної терапії таких хворих слід застосовувати антиоксиданти як один з варіантів патогенетично обгрунтованої інтенсивної терапії.

Assessment of Knowledge toward Complications of Diabetic Septic Foot among Diabetics Patients in Saudi Arabia

Background: diabetic foot ulcer is a major health problem around the world with a high morbidity and mortality rates. The good knowledge and practice pattern could decrease the diabetic foot ulcer complications. Objectives: this study aimedto evaluate knowledge of the diabetic patients regarding the complications of diabetic foot ulcer in Saudi Arabia (KSA). Patients and Methods: this isa cross sectional community based study conducted from March 2017 to July 2017 among 920 diabetic patients. The subjects were interviewed in the shopping malls, pharmacies and coffee shops and asked to fill out a pre-tested questionnaire about the knowledge of complications. Results: the duration of diabetes was more than 10 years among 65% of them. About 40.9% of subjects were using oral hypoglycemic agents, 57.8% were using insulin for management of diabetes. The most common diabetic complication was retinopathy, while the most common foot ulcer complication was foot numbness and stiffness. The level of knowledge was good among most of subjects (77%), while 23% had insufficient knowledge regarding the diabetic foot ulcer. The good awareness was significantly associated with higher educational levels. Conclusion: the level of awareness about complications of diabetic foot was sufficient among most of Saudi subjects. But, there was an urgent need for raising the awareness and identifying the risk factors, educating the patients through increasing the patients and doctors relationship. The knowledge alone was not sufficient for assessing the practice pattern thus major studies must be conducted to assess the knowledge, attitude and practice pattern among Saudi subjects.

Feasibility of foot deformations corrective operations performing in patients with diabetes

Objective: To improve methods of early diagnosis of diabetic neuropathy and suggest options for surgical prophylaxis possible purulent and necrotic complications in patients with diabetic foot syndrome. Materials and Methods. The study involved 64 patients with complicated diabetic foot syndrome (DFS). The average age of patients - 61,9 ± 3,8 years, duration of diabetes - 11,47 ± 3,2 years. The patients had neuropathic and mixed forms of DFS, fingers or arched foot deformations with the presence of pressor venous trophic ulcers in the forefoot. Patients were randomized into two groups: the main group - 34 and comparison group - 30 patients. There were representative characteristics for all groups: age, sex, comorbidity and did not differ significantly (P> 0,05). There were no statistically significant difference between the groups of these data (χ2 = 0,05; P = 0,8195). Results. After 6 months of complex treatment the ulcers were healed in more than half of patients in both groups - 19 (63,3%) of patients in the comparison group and 25 (73,5%) of the main group. In 8 (26,7%) patients in the comparison and 7 (20,6%) of the main group positive dynamics was observed, but over a longer period of treatment . After 12 months, the number of patients whose ulcers were completely healed differed significantly by the main group (P = 0,0007; χ2 = 11,41). Also in the main group was only 1 (3,0%) patient with ulcer that was not healed, in contrast to the comparison group - 7 (23,3%) patients (P = 0,0373; χ2 = 4,34). Conclusions. Operations aimed at correction of fingers and feet deformations in combination with standard therapy and unloading of the lower limb, allow improving the results of patients with complicated DFS treatment by reducing the number of relapses.

Comprehensive treatment impact on long-term results of patients with complicated diabetic foot syndrome

The study involved 90 patients with complicated diabetic foot syndrome (DFS), who were treated in purulent-septic center with beds for diabetic foot patients — City Clinical Hospital N 3 of Zaporizhzhia during the period of 2014–2015. The average age of patients was 63.4 ± 4.7 years. According to the protocol for the management of patients with diabetes mellitus type 2, none of the experts, involved in the treatment of these patients, provide a complete integrated treatment taking into account all possible complications. Upon admission to the surgical hospital, patients from the index group, along with the elimination of purulent-necrotic complications, underwent a complete examination and received the maximum comprehensive conservative therapy in contrast with the control group received standard therapy. The difference between the two groups was significant after evaluating the long-term treatment outcomes. Complex approach to the therapy of patients with complicated DFS makes it possible to heal the wounds of the foot in 76.5 % of them versus 28.2 % of patients in the control group. Relapse of the disease, if the patient complies with all the recommendations on conservative therapy, limb immobilization, wearing orthopedic shoes and preventive measures, is reduced to 7.8 % of cases per year, which is 3 times less than when the multidisciplinary approach is not implemented.

Microbial composition of purulent lesions in patients with complicated diabetic foot syndrome and the development of sepsis

Microbial composition of purulent lesions in patients with complicated diabetic foot syndrome and the development of sepsis

Lower limb amputations: Our experience single centre study

Background and objectives: Major limb amputation is reported to be a major but preventable public health problem that is associated with profound economic, social and psychological effects on the patient and family especially in developing countries where the prosthetic services are poor. Amputation has implications on both mobility and functionality. The purpose of this study was to outline the patterns, indications and short term complications of major limb amputations and to compare our experience with that of other published data. Material and methods: This was a cross-sectional descriptive study involving all patients who underwent major lower limb amputations at Bowring and Lady Curzon Hospital between March 2008 and February 2016. All patients who underwent major limb amputation were, after informed consent for the study, enrolled into the study Amputation was performed by the attending surgeon who also prescribed the postoperative care of the patient. Patients were followed up till discharge or death. Results: A total of 162 patients were entered into the study. Their ages ranged between 2180 years. The most common indication for major limb amputation was diabetic foot complications in 87.6% followed by chronic non healing ulcer and peripheral vascular disease. Above knee amputation was the most common procedure performed in 88.8%. Conclusion: Complications of diabetic foot ulcers and chronic non healing ulcer were the most common indications for major limb amputation in our environment. The majority of these amputations are preventable by provision of health education, early presentation and appropriate management of the common indications.

The Possibility of using Serum Taurine Level as an Early Marker to Control Complications of Diabetic Foot

Objective: Measuring of serum taurine as an early marker to detect and prevent complications of Diabetic foot. Methods: 90 diabetic patients were selected from the national institute of diabetes and endocrinology (NIDE), 80 patients suffered from diabetic foot and classified into 4 groups according to its surgical complication in their foot and 10 diabetic controlled patients not suffered from diabetic foot considered as diabetic control group. 10 frank healthy non diabetic persons enrolled as volunteers. Complete clinical examination, investigation and biochemical analysis (liver and kidney functions, lipid profile and complete blood count), add to measuring FBG, HbA1c, VEGF and the recent biomarker taurine, was measured for all patient and volunteers. Results: The data showed non-significant change in liver functions, Kidney functions, lipid profile, CBC and serum VEGF in all patients regarding to control group (P>0.05). Contrary there is a significance changes in FBG and HbA1c (P<0.05). On the other hand, the data showed very highly significant decrease in serum taurine in all diabetic patients according to the severity of diabetic foot compared to that recorded in healthy control (P<0.001). Conclusion: Serum taurine is reduced in diabetic patients with advanced surgical conditions of diabetic foot. Taurine Level is considered as an early marker (prognostic) to control complications of diabetic foot.

Diagnostic Accuracy and Surgical Utility of MRI in Complicated Diabetic Foot.

Diabetic foot complications pose a significant public health hazard and have negative effect on life quality. These complications are associated with increased risk of amputations and premature death. So focus is increasing on early treatment of complicated diabetic foot. To assess the diagnostic accuracy and surgical utility of MRI in complicated diabetic foot. Thirty four complicated diabetic patients were evaluated prospectively. Initially x-ray was done and a provisional management plan was formulated. Later T1W, T2W and FSat sequences of the affected foot and ankle was carried out. The soft tissue, tendons and osseous apparatus were evaluated and subsequently compared with histopathological examination. Before and after MRI, change in management plan was marked. Previously operated cases with persistent ulcer of affected foot were excluded from the study. Twenty two males and 12 females with mean age of 52±8.8 years were analysed. The sensitivity of MRI for tenosynovitis and osteomyelitis was 88% and 100% respectively. The specificity for the same was 100% and 90%. Of all 34 cases, MRI reshapes surgical planning in 23.5% cases (8 patients). The difference between MRI and histopathological findings was evaluated statistically using Fisher-Z test and the proportion of difference between these two groups was not significant as values for tenosynovitis was Z=0.50 (p-value >0.05) and for osteomyelitis Z= 0.54 (p-value>0.05). The result indicates that MRI is a sensitive and accurate imaging modality for evaluation of diabetic foot and for planning proper treatment and the MRI correlates significantly with the surgical finding.

Utility of PET/CT with fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes for diagnosing diabetic foot osteomyelitis in patients with Charcot's neuroarthropathy.

Diabetic foot osteomyelitis (DFO) is difficult to diagnose in the presence of Charcot's neuroarthropathy (CN) and bone biopsy is not always possible. We aimed to assess the efficacy of PET/computed tomography using F-fluoride (F-fluoride PET/CT) and fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes (F-FDG-LL PET/CT) in comparison with contrast-enhanced MRI (CEMRI) for the detection of DFO. Thirty-two patients with chronic CN and foot ulcer suspected of having DFO were prospectively evaluated. All patients underwent radiography, CEMRI, F-fluoride PET/CT, and F-FDG-LL PET/CT of the feet. Bone biopsy and microbiological culture from the suspected site of osteomyelitis was considered the gold standard. Twenty-three patients fulfilled the inclusion criteria. Bone culture was suggestive of DFO in 12 patients. CEMRI identified 10 of the 12 cases of osteomyelitis. F-fluoride PET/CT and F-FDG-LL PET/CT showed increased tracer uptake (SUVmax=22.7±18.1 and 8.4±4.7, respectively) at the clinically involved site in 10 of the 12 patients (TP). Among 11 biopsy-negative patients, CEMRI reported DFO in four (false positive); there were no false positives with F-FDG-LL PET/CT. The sensitivity and specificity of F-FDG-LL PET/CT was 83.3 and 100% compared with 83.3 and 63.6% for CEMRI, respectively, for the diagnosis of DFO in the background of CN. F-FDG-LL PET/CT has high specificity for the diagnosis of DFO in complicated diabetic foot. The F-fluoride PET/CT helps in the characterization the extent of underlying CN. An early and accurate diagnosis with F-FDG-LL PET/CT aids the rational initiation of antibiotics for DFO.

Effects of Foot Reflexology Integrated with Medical use on Hemoglobin A1c and Ankle Brachial Index in Older Adults with Type 2 Diabetes Mellitus.

OBJECTIVE: To compare hemoglobin A1c (HbA1c) levels and ankle brachial index(ABI) in older adults with type 2 diabetes mellitus (T2DM) between the experimentalgroup and the control group two months after receiving the foot reflexology program, andto compare HbA1c levels and ABI in older adults with T2DM in the experimental groupbefore and two months after receiving the foot reflexology program.MATERIALS AND METHODS: A randomized experimental design with a randomizedcontrolled two-group pretest-posttest design. The purpose of the study was toinvestigate the effects of foot reflexology integrated with medication use on HbA1cand ABI in older adults with T2DM who sought treatment at the diabetes clinic ofManorom Hospital, Manorom District, Chai Nat Province. The study sample consistedof 40 older adults with T2DM who sought treatment at the diabetes clinic who metthe inclusion criteria. The subjects were recruited through random sampling, with 20assigned into the experimental group and the other 20 into the control group. The subjectsin the experimental group received foot reflexology every day for a period of twomonths, while those in the control group did not receive such treatment. All of thesubjects in both groups received pharmacological treatment of diabetes with eitheroral medication or insulin injection as prescribed in the treatment plan based on theirmeasurements with HbA1c used the ARRAY High Performance Liquid Chromatography(HPLC), and ABI level use the doppler ultrasound with handheld doppler probe.Data were analyzed using inferential statistics, Independent t-test and Paired t-test.RESULTS: The results revealed that after receiving foot reflexology, the HbA1c of theexperimental subjects was lower than that of the control subjects (t = 2.76, p = 0.009,SD = 1.37). In addition, their ABI levels in the right leg and left leg were higher thanthose of the control subjects (t = 5.921, p &lt; 0.001, SD = 0.044 and t = 9.155, p = &lt;0.0001, SD = .016 respectively). Also, after receiving foot reflexology, the subjects inthe experimental group had lower HbA1c (t = 10.54, p &lt; 0.001, SD = 0.96) and ABIlevels in their right leg and left leg (t = -8.475, p &lt; 0.001, SD = 0.044 and t = -10.249,p &lt; 0.001, SD = 0.060 respectively).CONCLUSION: Foot reflexology can reduce HbA1c and increase ABI in older adultswith T2DM. It can be implemented as a complementary therapy to control diabetes andreduce severity of complications of diabetic foot in older adults with T2DM.

Management of diabetic individuals with emphasis on prevention of foot amputation

Goal: The purpose of this work was to determine whether the duration of the disease in diabetic patients and their age have an effect on the quality of their life in relation to this disease. Determine the preference in measures aimed at the prevention of the diabetic foot complications in diabetic patients. Methods: The research population included 172 patients from Trencin region in Slovakia. The research was based on a questionnaire developed by amending the standardized questionnaire of the WHO - WHOQOL-BREF to include additional items focusing on the choice of preventive measures related to the prevention of the complications of a diabetic foot. Results: No association was demonstrated between the duration of the disease in diabetic patients and their quality of life. However, the results demonstrated that there is an association between the age of the patients and their quality of life. We also found statistically significant differences in the choice of the most important areas of preventive measures preventing the complications of diabetic foot between men and women. Conclusion: Diabetic patients are not only passive recipients of care but also individuals who are active, independent and jointly responsible for the achieved results. Very important aspect is the knowledge of the preventive measures focused especially on the prevention of the complications of diabetic foot.

Effects of foot complications in patients with Type 2 diabetes mellitus on public healthcare: An analysis based on the Korea National Diabetes Program Cohort

AimDiabetes mellitus (DM) patients are susceptible to foot injury or foot diseases such as diabetic foot and peripheral arterial disease. Although these conditions are considered important, few studies have investigated them in detail. Therefore, we investigated the epidemiology of diabetic foot complications (DFC) with respect to the effects on the public healthcare system. MethodsWe evaluated the incidence, clinical characteristics, health service utilization frequency and medical expenses of DFC in type 2 DM patients in the Korea National Diabetes Program (KNDP), the largest multi-center, prospective cohort in Korea (n=4405). To determine precise outcomes, we used national representative databases, including claims data from the Health Insurance Review & Assessment Service of Korea. ResultsDuring a median follow-up period of 3.30years, 528 patients (12.0%) were newly diagnosed with DFC at an incidence rate of 43.02 cases per 1000 person-years. The patients with DFC were significantly older than patients without DFC, but other clinical characteristics were similar between the two groups. The patients with DFC had more hospital visits (p<0.001), longer duration of hospitalization (p<0.001), and increased expenses (p<0.001) compared to patients without DFC. After multiple adjustments, the differences in number of hospital visits and medical expenses were consistent. In a before and after comparison within the DFC group, all three variables increased significantly after the onset of DFC (p<0.001). ConclusionsDFC were significantly associated with poor clinical outcomes and caused a substantial burden to the national healthcare system in Korea. Therefore, intervention to prevent DFC is important.

Preventing foot complications in diabetes: the St Vincent Declaration 26 years on

Preventing foot complications in diabetes: the St Vincent Declaration 26 years on

Diabetic foot complicated by vertebral osteomyelitis and epidural abscess.

SummaryVertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a ‘possible’ diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain.Learning pointsVertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes.The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access.Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot.Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a “possible” diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain.Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes.

Les Amputations Majeures Des Membres A L’hopital General De Reference Nationale De N’djamena, Tchad

The aim of this study was to describ major limb amputations in a tertiary teaching hospital in N’Djaména, Chad. Patients and Method We realized a both retrospective and prospective study from 01/08/2013 to 31/07/2015 in the General Surgery ward and Orthopedics and Traumatology ward of the National Reference General Hospital of N'Djamena, Chad. Data were collected from patient records, operating theater records and equipment center. Studied parameters: age, sex, indication and level of amputation, length of hospital stay, prosthetic devices and mortality. Results The study population included 155 patients divided into 118 men (70.1%) and 37 women (29.9%), a sex ratio of 2.3. The average age was 43.1 years. Severe limb injuries by road traffic crushes were the first major amputation indication in 74 cases (47.6%), followed by complications of diabetic ulcers in 33 cases (21.4%) and arterial occlusive disease in 21 cases (13.6%). The pelvic and thoracic limbs were affected respectively in 130 cases (84.9%) and 25 cases (16.1%). The levels of amputations were: the leg in 78 cases (50.3%), the thigh in 50 cases (32.3%) and the forearm in 9 cases (5.8%). The average hospital stay was 16 days. We noted wound suppuration in 28.4% of cases and psychiatric events in 4.6%. Mortality was 15.6%. Only 35 patients (22.6%) received a prosthetic device after amputation. Conclusion: road traffic trauma with irreversible vascular damage is the leading indication of major limb amputations in our setting. Complications of diabetic foot are increasing indication. Mostly, traditional bonesetters practiced on the patients before reaching to hospital care. The amputees face great prosthetic difficulties. Major limb amputations are preventable by education, early presentation and management of common indications.

Acute Charcot neuro-osteoarthropathy.

Charcot neuro-osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Charcot foot when the X ray is still negative (stage 0 or incipient Charcot foot). Recent advances in imaging modalities have enabled the detection of initial signs of inflammation and underlying bone damage before overt bone and joint destruction has occurred. Casting therapy remains the mainstay of medical therapy of acute CN. If timely instituted, offloading can arrest disease activity and prevent foot deformity. In cases with severe deformity, modern surgical techniques can correct the unstable deformity for improved functional outcome and limb survival. Emerging new studies into the cellular mechanisms of severe bone destruction have furthered our understanding of the mechanisms of pathological bone and joint destruction in CN. It is hoped that these studies may provide a scientific basis for new interventions with biological agents.

Capacity-building of the allied health workforce to prevent and control diabetes: Lessons learnt from the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project.

In 2008, to tackle the exponential rise in the clinical burden of diabetes that was challenging the health systems in Sri Lanka, a shift in focus towards patient-centred care linked with community health promotion was initiated by the National Initiative to Reinforce and Organize General Diabetes Care in Sri Lanka (NIROGI Lanka) project of the Sri Lanka Medical Association. Specific training of "diabetes educator nursing officers" (DENOs), field staff in maternal and child health, footwear technicians, and health promoters from the community, was instituted to improve knowledge, skills and attitudes in the area of control and prevention of diabetes. This article highlights some of the activities carried out to date with the allied health workforce and volunteer community. Specifically, it describes experiences with the DENO programme: the educational and administrative processes adopted, challenges faced and lessons learnt. It also highlights an approach to prevention and management of complications of chronic diabetic foot through training a cohort of prosthetics and orthotics technicians, in the absence of podiatrists, and an initiative to provide low-cost protective footwear. Harnessing the enthusiasm of volunteers - adults and schoolchildren - to address behavioural risk factors in a culturally appropriate fashion has also been a key part of the NIROGI Lanka strategy.