Multidisciplinary Foot Research Articles

Current Practice of Podiatrists in Testing for Diabetic Polyneuropathy and Implementing Foot Care (PROTECT Study Survey 2)

AimsPodiatrists constitute a key member of a multidisciplinary foot care team, but their services remain underutilized. We sought to gain insights into the daily practice of podiatrists focusing on screening for and monitoring of diabetic sensorimotor polyneuropathy (DSPN) as well as foot management. MethodsThis cross-sectional survey included 125 podiatrists from 12 federal states across Germany who responded to an online questionnaire. ResultsThe majority of patients treated in podiatry practices were referred by general practitioners and diabetologists. Screening for or follow-up of DSPN was performed by 36% of the respondents at least once a year, by 28% only at initial examination, by 21% only at suspicion, and by 10% basically at each treatment visit. Instruments to assess vibration, touch/pressure, and temperature sensation were used by 81% to 94% of the podiatrists. Previously undiagnosed DSPN and foot ulcers were detected frequently/very frequently (≥6 cases/mo) by 24.0 and 18.4% of the podiatrists, respectively. Almost all podiatrists advised daily self-monitoring of feet and appropriate foot care and >50% gave advice on medical treatment. ConclusionsPodiatrists play an important role in the detection, monitoring, and management of both DSPN and diabetic foot ulcers, suggesting that the utilization of their services should be fostered.

Gap analysis of diabetes-related foot disease management systems in Pacific Islands Countries and Territories

BackgroundPacific Island Countries and Territories (PICTs) are known to have high prevalence of Diabetes Mellitus and high incidence of diabetes-related foot disease. Diabetes-related foot disease can lead to lower limb amputation and is associated with poor outcomes, with increased morbidity and mortality. The purpose of this study was to gain a better understanding of diabetes-related foot disease management in selected countries in PICTs and to identify potential barriers in management of diabetes-related foot disease management in the region.MethodsA cross-sectional survey was sent to eleven hospitals across six selected PICTs. The survey instrument was designed to provide an overview of diabetes-related foot disease (number of admissions, and number of lower limb amputations over 12 months) and to identify clinical services available within each institution. Two open-ended questions (free text responses) were included in the instrument to explore initiatives that have helped to improve management and treatment of diabetes-related foot diseases, as well as obstacles that clinicians have encountered in management of diabetes-related foot disease. The survey was conducted over 6 weeks.ResultsSeven hospitals across four countries provided responses. Number of admissions and amputations related to diabetes-related foot disease were only reported as an estimate by clinicians. Diabetes-related foot disease was managed primarily by general medicine physician, general surgeon and/or orthopaedic surgeon in the hospitals surveyed, as there were no subspecialty services in the region. Only one hospital had access to outpatient podiatry. Common themes identified around barriers faced in management of diabetes-related foot disease by clinicians were broadly centred around resource availability, awareness and education, and professional development.ConclusionDespite the high prevalence of diabetes-related foot disease within PICTs, there appears to be a lack of functional multi-disciplinary foot services (MDFs). To improve the outcomes for diabetes-related foot disease patients in the region, there is a need to establish functional MDFs and engage international stakeholders to provide ongoing supports in the form of education, mentoring, as well as physical resources.

Optimising & Integrated Effective Diabetic Foot Services at the Regional Scale: The NHS Midlands Model

Introduction: Diabetic foot disease represents a costly and challenging complication for healthcare services internationally, and one the diabetes complications associated with the highest degree of morbidity and mortality. It is estimated that between five and seven cent of people with diabetes will have a diabetic foot ulcer at some point in their lives, at an estimated cost of £935 million to the NHS. It is well recognised that effective diabetic foot care requires multidisciplinary care approaches. Whilst pockets of locally effective integrated care have been proven, scaling this to regional models has proved difficult. Here we present an effective optimised approach to integrated diabetic foot care in the Midlands Region as a model for other services internationally.
 Methods: Four pillars are underpin effective change at a regional level in the United Kingdom covering 5.4 million people. These pillars are (1) Utilisation of standardised audit data as a driver for change, (2) Regional self appraisal and peer review (3) Cross-boundary integrated root cause analysis and (4) adoption, piloting and testing of new digital technologies. We present an example of “guerrilla PPI” to facilitate real-time representative patient and public involvement. Central to the success was an infographic base communication and dissemination strategy with a focus on prevention.
 Results: Successful creation of a 300 person multidisciplinary foot care network including podiatrists, consultants, diabetes nurses, commissioners, community representatives, transformation leads, Diabetes UK, patient representatives and nurse specialists. Peer review, root cause analysis and audit presentation data across the whole of the Midlands region covering all diabetes providers. High impact bespoke infographics presented for all sub-regions to further drive change. Major 6 month amputation rates from reduced from 2.9% in 2014/2015 to 2.1% in 2020/2021 and reduction in audit active ulcer rates from 47.1% to 42.4%despite the pandemic environment.
 Conclusions: Effective integrated diabetic foot care can be delivered at the regionally scale for large populations if underpinned by a defined network with shared vision, transparent structures and shared Trust. Cross-organisation working is fundamental but can be enabled through standardised peer review, audit, root cause analysis and self-appraisal models.

Foot Care Prioritization Among Health Care Providers Treating Diabetic Patients in Saudi Arabia: A Survey-Based Study.

Diabetic foot disease (DFD) is a significant complication associated with diabetes, characterized by the potential for progressive amputation of specific foot segments or the entire lower limb in the absence of timely identification of infection and intervention. The aim of our research is to evaluate the degree of importance given to foot care by healthcare professionals who are responsible for treating individuals with diabetes in Riyadh, Saudi Arabia. This cross-sectional study utilized an online survey previously validated in Australia. The mean foot care prioritization score was used to identify the dummy variable for binary logistic regression analysis, which was used to identify predictors of foot care prioritization. A total of 222 participants were involved in this study. Assessing for the risk of developing foot complications, visually inspecting feet for wounds, and providing or recommending footwear to prevent foot complications were the most commonly reported practices, accounting for 80.60% (n = 178), 76.10% (n = 169), and 75.20% (n = 167), respectively. The most commonly referred patients to a specialist tertiary multi-disciplinary foot care team were patients with ulcers in patients with absent foot pulses, ulcers with ascending cellulitis, and diabetic ulceration, accounting for 73.50% (n = 163), 71.60% (n = 159), and 66.70% (n = 148), respectively. The mean foot care prioritization score for the study participants was 54.1 (standard deviation: 11.7) out of 78 (69.4%), which demonstrates a moderately high level of foot care prioritization. Binary logistic regression analysis identified that healthcare professionals who are aged 35-44 years, those who have 5-10 years of experience, those who work at private hospitals, those who have a higher number of practice clinics per week, and those who have to manage a higher number of patients with diabetes in each clinic were more likely to prioritize foot care in their practices (p < 0.05). Our study found that healthcare professionals in Saudi Arabia place a moderate degree of emphasis on foot care. Healthcare professionals falling within the age range of 35-44 years, possessing 5-10 years of experience, employed at private hospitals, overseeing a greater number of practice clinics weekly, and managing a greater number of patients with diabetes per clinic exhibited a greater propensity to prioritize foot care within their respective practices. Policymakers should consider the integration of continuous glucose monitoring technologies, the establishment of standardized foot screening protocols, and the implementation of targeted educational programs for healthcare professionals.

Neuropathic diabetic foot ulcers in the elderly: clinical outcomes and healing

There is little evidence on healing outcomes of neuropathic foot ulcers in elderly patients. Aims: To determine the healing rates of neuropathic diabetic foot ulcers at 12 and 24 weeks achieved by standard care provided at an established multidisciplinary diabetes foot clinic in patients aged 65 years and above. Data on the incidence of falls and hypoglycaemia were also collected due to their perceived clinical risk in the group studied. Methods: This was a retrospective observational study looking at clinical outcomes of neuropathic foot ulcers. Patients aged 65 years or more presenting with a non-infected neuropathic ulcer at the time of their initial review were identified and classified into two groups: Group E patients were aged above 80 years and Group Y patients 65-80 years. Results: A total of 97 patients, presenting with 106 ulcer episodes, were identified. Mean HbA1c was 60 mmol/mol in Group Y and 55 mmol/mol in Group E. Healing rates of all ulcers at 12 and 24 weeks in the elderly group lagged behind rates in the younger group (67.6% at 12 weeks and 73% at 24 weeks in Group E vs. 78.2% at both intervals in Group Y). The elderly group had more falls, 11% vs. 2% in Group Y. In all, 50% of the falls in Group E were attributed to their prescribed pressure relief (off-loading) devices. Conclusions: With standard foot care given in a multi- disciplinary foot service, neuropathic diabetic foot ulcers can heal in the elderly despite their age-related skin changes. The rate of healing of neuropathic ulcers noted in our study provides a benchmark for healing outcomes and enables comparison with other age groups and centres. Our study identifies a risk of falls associated with off-loading devices and highlights the need for structured falls risk and mobility assessments in this group.

Assessment and management of diabetes-related foot infection according to the new International Working Group on the Diabetic Foot guidelines 2023-Multidisciplinary grand rounds.

Diabetes-related foot disease is a serious and common complication for people with diabetes mellitus. The gold standard care for a person with diabetes-related foot disease is the involvement of a multidisciplinary foot team engaged in evidence-based care. To date, there are seven International Working Group on the Diabetic Foot (IWGDF) guidelines published to assist healthcare providers in managing diabetes-related foot disease around the world. This review discusses the acute management of diabetes-related foot infection with insights from experts of various specialities (internal medicine, infectious disease, vascular surgery, radiology) with a discussion on the implementation of IWGDF guidelines in real life practice and the challenges that healthcare providers may face.

Non-coding RNAs in diabetic foot ulcer- a focus on infected wounds.

Diabetes mellitus is associated with a wide range of neuropathies, vasculopathies, and immunopathies, resulting in many complications. More than 30% of diabetic patients risk developing diabetic foot ulcers (DFUs). Non-coding RNAs (ncRNAs), including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs), play essential roles in various biological functions in the hyperglycaemic environment that determines the development of DFU. Ulceration results in tissue breakdown and skin barrier scavenging, thereby facilitating bacterial infection and biofilm formation. Many bacteria contribute to diabetic foot infection (DFI), including Staphylococcus aureus (S. aureus) etal. A heterogeneous group of "ncRNAs," termed small RNAs (sRNAs), powerfully regulates biofilm formation and DFI healing. Multidisciplinary foot care interventions have been identified for nonhealing ulcers. With an appreciation of the link between disease processes and ncRNAs, a novel therapeutic model of bioactive materials loaded with ncRNAs has been developed to prevent and manage diabetic foot complications.

Reduction in the prevalence of methicillin-resistant Staphylococcus aureus in tissue and wound swab samples taken from outpatients attending a specialist diabetic foot clinic 2005-2021.

To assess annual change in prevalence of methicillin resistant Staphylococcus aureus (MRSA) from tissue and wound swab samples from foot ulcers (DFUs) in people with diabetes between 2005 and 2021. A retrospective analysis of everyone with MRSA positive wound or tissue swabs taken from our specialist multidisciplinary foot clinic between July 2005 and July 2021. A total of 406 MRSA positive isolates from DFU swabs were identified from 185 individuals attending the foot clinic. There were 22 hospital-acquired infections (HAIs) and 159 community-acquired infections (CAIs). Fifty-two per cent (n= 37) of these individuals from 2010 to 2021 (n= 71) had presence of at least three risk factors for MRSA. The total number of swabs sent was 6312 from 1916 individuals living with diabetes. Annual MRSA DFU prevalence peaked in 2008 at 14.6% (n= 38), decreased in 2013 to 5.2% (n= 20) and did not exceed 4% (n= 6) from 2015 to 2021. Hospital MRSA was lowest in 2021 (n= 211), a 76% fall from 2007 (n= 880). Incidence of MRSA HAI from 2015 to 2021 ranged from 5.4% (n= 14) in 2020 to 11.5% (n= 41) in 2018. Prevalence of MRSA in DFU infections treated as outpatients is decreasing in line with falls in hospital acquired blood-borne infections and with overall hospital MRSA incidence. This is likely a reflection of the combination of interventions, including stringent antibiotic prescribing and decolonisation strategies. Reduction in prevalence should have positive impact on outcomes in people living with diabetes, reducing the complication of osteomyelitis and necessity for long-term antibiotic administration.

Anxiety and depression among patients attending a multidisciplinary foot clinic

AbstractAim: Diabetic foot ulcers (DFUs) are linked to morbidity, decreased mobility, and feelings of isolation, powerlessness and sadness. The aim of our study was to explore the prevalence of anxiety and depression symptoms in adult patients with DFU.Method: We analysed questionnaires completed by patients with DFU attending our University Hospital Multidisciplinary Foot Clinic service over a one‐month period in March 2022. The patients had completed three questionnaires, comprising of questions relating to socio‐demographic status and care perceptions, the Patient Health Questionnaire‐9 (PHQ‐9) scale to assess depression, and the Generalized Anxiety Disorder scale (GAD‐7) to assess anxiety.Results: Of the 60 patients who completed the questionnaires, 35% (n=21) reported anxiety symptoms and 40% (n=24), depressive symptoms. Individuals with comorbidities were three times more likely to report depression relative to those without any comorbidities (OR 3.3; 95% CI 1.13–12.56). Younger individuals (less than 50 years), were almost nine times more likely to report anxiety in comparison to those aged 60 years or more (adjusted OR 8.9; 95% CI 1.01–86.41), despite adjustment for confounding variables.Conclusion: The prevalence of depression and anxiety in this cohort of patients with DFU was low, but those who were affected reported moderate to severe symptoms. Younger individuals and those with comorbid conditions with DFU are more likely to experience an adverse impact on their mental health. This is a crucial factor to consider in the management of people undergoing DFU care. Strategies to reduce anxiety and/or depressive symptoms could impact both quality of life and wound healing. Copyright © 2023 John Wiley &amp; Sons.

Tackling diabetic foot: limb salvage during the COVID-19 pandemic.

Lower extremity amputation resulting from diabetic foot ulcer, with neuropathic and/or ischemic etiologies, remains a devastating and costly complication of diabetes mellitus. This study evaluated changes in care delivery of diabetic foot ulcer patients during the COVID-19 pandemic. A longitudinal assessment evaluating the ratio of major lower extremity amputation to minor lower extremity amputations after implementation of novel strategies to combat access restrictions was compared to the pre-COVID-19 era. The ratio of major to minor lower extremity amputation (i.e. the high-to-low ratio) was assessed at two academic institutions, the University of Michigan, and University of Southern California, in a population of patients with diabetes who had direct access to multidisciplinary foot care clinics in the 2 years prior to the pandemic and the first 2 years of the COVID-19 pandemic. Patient characteristics and volumes including patients with diabetes and those with a diabetic foot ulcer were similar between eras. In addition, inpatient diabetic foot-related admissions were similar, but were suppressed by government shelter in placed mandates and subsequent COVID-19 variants surges (e.g. delta, omicron). In the control group, the Hi-Lo ratio increased every 6 months by an average of 11.8%. Meanwhile, following STRIDE implementation during the pandemic, the Hi-Lo ratio reduced by (-)11% (p < 0.001) and doubled limb salvage efforts as compared to the baseline era. The reduction of the Hi-Lo ratio was not influenced significant by patient volumes or inpatient admissions for foot infections. These findings signify the importance of podiatric care in the at-risk diabetic foot population. Through strategic planning and rapid implementation of at-risk diabetic foot ulcer triage, multidisciplinary teams were able to maintain accessible care during the pandemic which resulted in a reduction of amputations. Furthermore, this manuscript highlights the value of the Hi-Lo ratio as an indicator of institutional limb salvage efforts.

Access to inpatient diabetes resources: hospital characteristics from the inaugural Queensland Inpatient Diabetes Survey

Diabetes is common in hospitalised patients and despite this inpatient diabetes care in Queensland has not had large scale benchmarking or audit. To establish the prevalence of diabetes in Queensland hospitals and assess the availability of specialised diabetes staff, educational resources and policies for inpatient diabetes management, including assessing equity of access to these resources. The hospital capacity, prevalence of diabetes, diabetes-related resources and the availability of diabetes-related guidelines were assessed in 25 hospitals medical, surgical, mental health, high-dependency and intensive care wards across Queensland. Dedicated diabetes staffing measured in full-time equivalents (FTE), care delivery resources, access to educational resources, standard policies and procedures for care were assessed. Twenty-five hospitals included 4265 occupied beds. The median prevalence of diabetes was 22.9% (interquartile range (IQR) 17.3-28.5%) with an average 2.9 FTE per 100 patients with diabetes (IQR 0-6.3). There was difficulty in accessing a diabetes educator in 48% (n = 12), diabetes specialist in 44% (n = 11), orthopaedic surgeon in 48% (n = 12), podiatrist in 58% (n = 14) and vascular surgeon in 64% (n = 16) of hospitals. Small hospitals had more difficulty accessing all members of the diabetes team compared with large hospitals including credentialled diabetes educators 33% (n = 4) versus 62% (n = 8) (P < 0.01), diabetes specialists 17% (n = 2) versus 69% (n = 9) (P < 0.01) and vascular surgeons 33% (n = 4) versus 92% (n = 12) (P < 0.01). Diabetes-related staff education and regular nurse training was available in 40% (n = 10) of hospitals. A multi-disciplinary foot care team was available in 28% (n = 7) of hospitals. Queensland has a high prevalence of diabetes in hospitalised patients and they have limited and inequitable access to inpatient diabetes-related care.

Resource use within a multidisciplinary foot team clinic

The establishment of multidisciplinary foot team clinics reduces the risk of amputation, but little is known about its resource requirement. This study evaluates the service's resource use for first visit attendees to an established multidisciplinary foot team clinic. A retrospective evaluation was performed for new referrals to the clinic over six months, including demographics, resource use and clinical outcome. Data were extracted electronically with retrospective review of electronic clinical notes. A total of 240 first visit attendees were analysed. Mean age was 64±15years, 63% were male, 72% had type 2 diabetes, 16% had type 1 diabetes, 15% had a previous amputation, and 40% had a previous ulceration. Common presentations were ulcers (62%), osteomyelitis (11%), Charcot foot (19%), foot ischaemia (17%), post-surgical wounds (13%), and osteomyelitis (11%). At first attendance, 79% of patients required specialist services including diabetologist (45%), joint vascular review (23%), joint orthopaedics services (8%), dermatologist (2%), and orthotics services (1%). A total of 4% of patients had complex debridement, 0.4% total nail excision, 0.8% pus drainage, 3% cast-related procedures, and 1% vacuum-assisted dressing. Of the patients, 4% were admitted to hospital, 38% had vascular duplex investigations, 7% had a deep vein thrombosis scan, 16% had magnetic resonance imagine (MRI), and 5% had a bone scan. A functional multidisciplinary foot team clinic requires significant resources-both clinical and administrative-for prompt investigations and revascularisation to sustain low amputation rates. Regular appraisal of resource use helps with clinic and pathway planning.

Pressure relieving interventions for the management of diabetes-related foot ulcers: a study from the Northern Territory of Australia.

Offloading intervention is an important component in the management of diabetes-related foot ulcer (DFU). The NT population is unique with certain distinctive challenges. Potential advantages of and barriers to optimal offloading methods in our setting were investigated. Consecutive patients with DFU treated with offloading devices between 2003 and 2015 at the Multidisciplinary Foot Clinic (MDFC), Royal Darwin Hospital were included. The outcome measures were healing, amputation and discontinuation. Risk factors for offloading failure were studied. Total contact cast (TCC) was the most common offloading used (n=175). The other removable non-TCC devices used were therapeutic footwear (n=74), CamWalker (n=35), and orthotic devices (n=43). The overall healing rate was 88.7%. Healing rates were higher (93.2% versus 83.5%, P < 0.05) and amputation rates were lower (4.0% versus 7.3%, P=0.026) in the TCC group than in the removable non-TCC group. The mean duration of offloading was longer in the TCC group (3.6 ± 1.5 versus. 3.2 ± 1.5months, P=0.008). Wagner grade ≥ 2 and removable non-TCC devices were significant risk factors for offloading failure. Patients treated with TCC had higher healing rates than those treated with removable non-TCC devices. The duration of offloading was longer than reported in other studies. Higher Wagner grade and removable non-TCC devices were risk factors for offloading failure. Non-removable offloading devices are the first choice in diabetes-related neuropathic ulcers.

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study.

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

People living with diabetes are unaware of their foot risk status or why they are referred to a multidisciplinary foot team.

People with active diabetic foot disease should be rapidly referred by health professionals along a pathway of care to a multidisciplinary foot team. The aim was to investigate patients' self-reported understanding of their foot risk status and reasons for their referral to a multidisciplinary foot team. This seven-month service evaluation included consecutive newly referred patients. Participants completed a questionnaire which asked firstly about their understanding of their foot risk status, secondly about their pathway of care before presentation to the multidisciplinary foot team, and thirdly about their interest in diabetes-related foot education and preferred learning style. There were 202 participants; 65% were male, mean age was 64±15 years (mean±standard deviation (SD)), 86% had type 2 diabetes, and mean HbA1c was 65±23mmol/mol (8.3±3.7%). Only 4% of participants knew their current foot risk status and 52% did not know why their care had been escalated to a multidisciplinary foot clinic. Participants with type 2 diabetes more readily expressed an interest in further foot education compared with participants with type 1 diabetes, (70% versus 29%, p=0.001). These findings show that people with diabetes and foot disease are less aware of their foot risk status or why they are referred to a multidisciplinary team. Participants indicated a variable interest in further learning about foot complications. These findings indicate possible communication and educational barriers between patients and health professionals which may contribute to delayed presentation or suboptimal engagement.

Mortality in 98 type 1 diabetes mellitus and type 2 diabetes mellitus: Foot ulcer location is an independent risk determinant.

We previously demonstrated in both a longitudinal study and in meta-analysis (pooled relative-risk RR, 2.45) that all-cause mortality is significantly higher in people with diabetes foot ulceration (DFU) than with those without a foot ulcer. In this prospective study, we looked at the factors linked to mortality after presentation to podiatry with DFU. Ninety-eight individuals recruited consecutively from the Salford Royal Hospital Multidisciplinary Foot Clinic in Spring 2016 were followed up for up to 48months. Data concerning health outcomes were extracted from the electronic patient record (EPR). Seventeen people (17) had type 1 diabetes mellitus, and 81 had type 2 diabetes mellitus. Thirty-one were women. The mean age (range) was 63.6 (28-90) years with maximum diabetes duration 45years. Mean HbA1c was 72 (95% CI: 67-77) mmol/mol; 97% had neuropathy (International Working Group on the Diabetic Foot (IWGDF) monofilament); 62% had vascular insufficiency (Doppler studies); 69% of ulcers were forefoot, and 23% of ulcers were hind foot in location. Forty of 98 (40%) patients died in follow-up with 27% of death certificates including sepsis (not foot-related) and 35% renal failure as cause of death. Multivariate regression analysis indicated a 6.3 (95% CI: 3.9-8.1) fold increased risk of death with hind foot ulcer, independent of age/BMI/gender/HbA1c/eGFR/total cholesterol level. This prospective study has indicated a very high long-term mortality rate in individuals with DFU, greater for those with a hind foot ulcer and shown a close relation between risk of sepsis/renal failure and DFU mortality, highlighting again the importance of addressing all risk factors as soon as people present with a foot ulcer.

Diabetic foot ulcer management in a multidisciplinary foot centre: one-year healing, amputation and mortality rate.

To describe the rates of healing, major amputation and mortality after 12 months in patients with a new diabetic foot ulcer (DFU) and their care in a French diabetic foot service (DFS). A prospective single-centre study including patients from March 2009 to December 2010. The length of time to healing, minor amputation, major amputation and mortality rate after inclusion were analysed using the Kaplan-Meier method. Some 347 patients were included (3% lost to follow-up), with a median follow-up (IQR) of 19 (12-24) months. The mean (SD) age was 65±12 years, 68% were male, and the median duration of the ulcer was 49 (19-120) days. Complications of the DFU were ischaemia (70%), infection (55%) and osteomyelitis (47%). Of the patients, 50% were inpatients in the DFS at inclusion (median duration of hospitalisation 26 (15-41) days). The rate of healing at one year was 67% (95% confidence interval (CI): 61-72); of major amputation 10% (95% CI: 7-17); of minor amputation 19% (95% CI: 14-25), and the death rate was 9% (95% CI: 7-13). Using an adjusted hazard ratio, the predictive factors of healing were perfusion and the area of the wound. The risk factors for a major amputation were active smoking and osteomyelitis. The risk factors for mortality were perfusion and age. This study confirms the need to treat DFUs rapidly, in a multidisciplinary DFS.

446-P: Mortality in 98 Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus (DM): Foot Ulcer Location Is an Independent Risk Determinant

We previously demonstrated(relative-risk RR, 2.45) that all-cause mortality is much higher in people with DM foot ulceration(DFU) than those without DFU. In this prospective study, we looked at factors linked to mortality after presentation with DFU. 98 individuals recruited consecutively from an NHS Multidisciplinary Foot Clinic in Spring2016 were followed for up to 48/12. Data concerning health outcomes were extracted from the electronic patient record(EPR).17 people had type 1 DM. 81 had type 2 DM. 31 were women. The mean age(range) was 62(28-90) years with maximum DM duration 45 years. Mean HbA1c was 72(95%CI: 67-77) mmol/mol. 97% had neuropathy (International Working Group on the DM Foot(IWGDF) monofilament). 62% had vascular insufficiency(Doppler studies). 69% of ulcers were forefoot and 23% of ulcers were hind foot in location.40/98 (40.8%) died in follow-up with 27% of death certificates including sepsis (not foot-related); 35% renal failure. Regression analysis indicated a 6.3 (95%CI 3.9-8.1) fold increased risk of death with hind foot ulcer, independent of age/BMI/gender/HbA1c/eGFR/total cholesterol level. We here describe a close relation between risk of sepsis/renal failure and death in people with diabetes FU with hind foot ulceration an independent risk factor, highlighting the importance of addressing all risk factors as soon as people present with DFU. Disclosure A. H. Heald: None. M. E. Edmonds: Advisory Panel; Self; Bayer, Biomonde, Molnlycke, Urgo Medical. S. G. Anderson: None. A. Robinson: Other Relationship; Self; Napp Pharmaceuticals, Speaker’s Bureau; Self; Novo Nordisk.

Factors Associated With Key Outcomes in Diabetes Related Foot Disease: A Prospective Observational Study

Diabetic foot disease is a serious and common complication of diabetes mellitus. The aim of this study was to assess limb and patient factors associated with key clinical outcomes in diabetic patients with foot ulcers. This was a prospective observational study of diabetic patients with foot wounds admitted to a major tertiary teaching hospital in South Australia or seen at associated multidisciplinary foot clinics between February 2017 and December 2018. Patient demographic and clinical data were collected, including limb status severity assessed by the WIfI system and grip strength. Participants were followed up for 12 months. The primary outcomes were major amputation, death, amputation free survival, and completion of healing of the index wound within one year. A total of 153 participants were recruited and outcome data were obtained for 152. Forty-two participants underwent revascularisation during the research period. Eighteen participants (11.8%) suffered major amputation of the index limb and 16 (10.5%) died during follow up. Complete wound healing was achieved in 106 (70%) participants. There was a statistically significant association between WIfI stage and major amputation (subdistribution hazard ratio [SHR] 2.75), mortality (hazard ratio [HR] 2.60), amputation free survival (odds ratio [OR] 0.32), and wound healing (SHR 0.69). There was also a statistically significant association between time to healing and grip strength (SHR 0.50), and previous amputations (major or minor) (SHR 0.57). This prospective study supports the ability of the WIfI classification system to predict one year key clinical outcomes in a diabetic population with foot ulcers. It also demonstrated that grip strength may be a useful predictor of wound healing.

Lower extremity amputations in Ireland: a registry-based study.

To analyse the current provision of lower extremity amputations (LEA) in Irish public hospitals by patient characteristics and assess the potential savings for reducing numbers if a national multi-disciplinary foot protection clinic (MDFPC) was established nation-wide. Patient characteristics of LEA conducted during 2016-2019 were analysed based on discharge data from the national hospital inpatient enquiry system. Reported consequences from existing literature were used to extrapolate national consequences. Public hospitals registered 3104 hospital admissions with LEA during 2016-2019. 68% (n=2099) of these were minor amputations. About 76% (n=1592) of minor amputations and 52% (n=525) of major amputations were performed on patients with a diagnosis of diabetes. If the implementation of a national MDFPC programmed could reduce the number of diabetic amputations by 20%, 80 minor and 26 major amputations could be avoided annually. This would avoid nearly 3000 hospital bed days and correspond to a potential annual saving of €3M. LEA has severe impact on patients' lives and hospital resources. Potential savings from effective prevention strategies may offer both health improvements and cost-savings.