Risk Of Foot Ulceration Research Articles

Feasibility, Acceptability and Effects of a Foot Self-care Educational Intervention in Adult Patients with Diabetes at Low Risk for Foot Ulceration: A Pilot Study

The objectives of the pilot study were to examine the feasibility, acceptability and effects of the foot care educational intervention on patients’ foot self-care knowledge, efficacy, and behaviors, and the occurrence of minor foot problems in adult patients with diabetes at low risk for foot ulceration.

Tools for design and validation of shoe lasts for diabetic patients

Background: It is common practice to prescribe customised footwear to people with diabetes to reduce the risk of foot ulceration. Although shoe customising systems have been proposed, effective tools for designing shoe lasts for diabetic patients are lacking. The shape of the lasts must meet certain biomechanical objectives, while maintaining the style of the shoe. Method: The main contributions of this work are as follows: the creation of an artificial-neural-network-based framework to correlate foot measurements and medical data to required footwear features; the definition of repeatable geometrical procedures to measure foot and last scans; and the definition of geometrical operators to modify the last shape according to its original aesthetic and specific footwear parameters. These parameters are computed by a knowledge-based system on the basis of the patient's pathology and best practices of experienced technicians. Results: Dedicated software systems integrated in a common platform are implemented to support the last design process. Test case studies and a survey show the advantages provided by the proposed approach in terms of achieved quality and shoe developing time (72% time savings). Conclusions: A design framework with dedicated tools is proposed for the customisation of shoe lasts for diabetic patients. Further research should be focused on tools to design the insole, outsole and other shoe components.

Diabetic foot disease on the renal unit

Diabetes remains the single most common cause of both end-stage renal disease and non-traumatic amputation of the lower limb. There is a close association between renal disease, peripheral symmetrical neuropathy, peripheral vascular disease, foot ulcers, amputation and survival in patients with diabetes. The risk of foot ulcers or major limb amputation appears to accelerate soon after the start of renal replacement therapy. All professionals involved in the care of patients with diabetes and renal disease should be aware of the extent to which the patients’ feet are at risk.

Screening patients at risk for diabetic foot ulceration: a comparison between measurement of vibration perception threshold and 10‐g monofilament test

The aim is to compare the frequency of increased vibration perception threshold (VPT) with abnormal 10-g Semmes-Weinstein monofilament (SWF) testing in a non-selected diabetic population, and to assess the agreement between these two screening methods. VPT was measured using a neurothesiometer at the pulp of the hallux and 10-g SWF was applied on three plantar sites on each foot according to the guidelines of the International Working Group on the Diabetic Foot, in 400 consecutive diabetic patients. VPT was considered as abnormal if ≥25 V and SWF was considered as abnormal if the patient was unable to feel ≥2 applications at a single site. Both tests were normal in 240 patients (60%) and both abnormal in 78. In 21 patients, only SWF was abnormal whereas only VPT was abnormal in 61. As a whole, 160 patients (40%) were considered at risk for foot ulceration by VPT and/or SWF. Agreement between the two screening methods was only moderate with a kappa coefficient of 0·52 (95% CI: 0·43-0·60). Using VPT as a predictor for foot ulceration, the number of patients at risk is much higher than identified by SWF. This discrepancy might have potential effects on costs and prevention policies.

Prevalence of risk factors for foot ulceration in a general haemodialysis population

It is well documented that diabetic foot ulceration contributes to increased morbidity and mortality associated with renal replacement therapy. Much less is known about the risk of foot ulceration and lower limb amputation in the non-diabetic dialysis population. The aim of this study was to determine if the prevalence of risks factors for lower limb amputation in a stable haemodialysis population was greater in the diabetic cohort compared with the non-diabetic cohort. The study design is a prospective observational cohort study. Sixty patients attending a satellite haemodialysis unit in Cardiff were invited to have a comprehensive foot assessment as part of a Podiatry service review. The medical notes and hospital information system were used to identify the diabetic cohort. Patients were classified according to diabetic status (diabetic versus non-diabetic). The Renal Foot Screening Tool was developed to prospectively identify risk factors associated with foot ulceration. The assessment included peripheral neuropathy (PN), peripheral arterial disease (PAD) and foot pathology (FP). Fifty-seven patients gave informed verbal consent prior to inclusion. Risk factors for foot ulceration were recorded at baseline in the diabetic (n = 24) and non-diabetic (n = 33) groups and mortality data was revisited after a 3-year period. FP was identified in 79% of patients. Eighteen per cent of the non-diabetic patients had PN. PAD was identified in 45% of diabetic and 30% of non-diabetic patients. Forty-nine per cent of the total cohort had ≥2 of the 3 independent risk factors for foot ulceration (16/24 diabetic versus 12/33 non-diabetic). The presence of PAD and PN was predictive of mortality independent of age. The limitations of this study are its small sample size and patients were from a single satellite dialysis unit. There was a high prevalence of risk factors for foot ulceration in this population, which were not confined to the diabetic cohort. These findings suggest that non-diabetic patients on haemodialysis therapy are also at risk of developing foot ulceration. Further work on strategies to monitor and prevent FP in this high-risk cohort is needed to minimize morbidity and mortality associated with foot ulceration.

New Monitoring Technology to Objectively Assess Adherence to Prescribed Footwear and Assistive Devices During Ambulatory Activity

Bus SA, Waaijman R, Nollet F. New monitoring technology to objectively assess adherence to prescribed footwear and assistive devices during ambulatory activity. ObjectiveTo assess the validity and feasibility of a new temperature-based adherence monitor to measure footwear use. DesignObservational study. SettingUniversity medical center and participants' homes. ParticipantsConvenience sample of healthy subjects (n=11) and neuropathic diabetic patients at high risk for foot ulceration (n=14). InterventionsIn healthy subjects, the validity of the in-shoe attached adherence monitor was investigated by comparing its registrations of donning and doffing of footwear during 7 days to an accurately kept log registration. In diabetic patients, the feasibility of using the adherence monitor for 7 days in conjunction with a time-synchronized ankle-worn step activity monitor to register prescribed footwear use during walking was assessed. Furthermore, a usability questionnaire was completed. Main Outcome MeasuresFor validity, the mean time difference and 95% confidence interval (CI) between moments of donning/doffing footwear recorded with the adherence monitor and in the log were calculated. For feasibility, technical performance, usability, and the percentage of steps that the footwear was worn (adherence) were assessed. ResultsThe mean time difference between the adherence monitor and log recordings was 0.4 minutes (95% CI, 0.2–0.6min). One erroneous recording and 2 incomplete recordings were obtained in diabetic patients. Three patients reported discomfort with the step activity monitor, and 4 patients would not favor repeated testing. Patients used their footwear for between 9% and 99% of their walking steps. ConclusionsThe adherence monitor shows good validity in measuring when footwear is used or not, and is, together with instrumented monitoring of walking activity, a feasible and objective method to assess treatment adherence. This method can have wide application in clinical practice and research regarding prescribed footwear and other body-worn assistive devices.

Retinal nerve fibre layer thinning associated with diabetic peripheral neuropathy

To investigate the relationship between retinal nerve fibre layer thickness and peripheral neuropathy in patients with Type 2 diabetes, particularly in those who are at higher risk of foot ulceration. Global and sectoral retinal nerve fibre layer thicknesses were measured at 3.45 mm diameter around the optic nerve head using optical coherence tomography (OCT). The level of neuropathy was assessed in 106 participants (82 with Type 2 diabetes and 24 healthy controls) using the 0-10 neuropathy disability score. Participants were stratified into four neuropathy groups: none (0-2), mild (3-5), moderate (6-8), and severe (9-10). A neuropathy disability score ≥ 6 was used to define those at higher risk of foot ulceration. Multivariable regression analysis was performed to assess the effect of neuropathy disability scores, age, disease duration and retinopathy on RNFL thickness. Inferior (but not global or other sectoral) retinal nerve fibre layer thinning was associated with higher neuropathy disability scores (P = 0.03). The retinal nerve fibre layer was significantly thinner for the group with neuropathy disability scores ≥ 6 in the inferior quadrant (P < 0.005). Age, duration of disease and retinopathy levels did not significantly influence retinal nerve fibre layer thickness. Control participants did not show any significant differences in thickness measurements from the group with diabetes and no neuropathy (P > 0.24 for global and all sectors). Inferior quadrant retinal nerve fibre layer thinning is associated with peripheral neuropathy in patients with Type 2 diabetes, and is more pronounced in those at higher risk of foot ulceration.

Prevalence of risk factors for foot ulceration in patients with end‐stage renal disease on haemodialysis

End-stage renal disease (ESRD) has been associated with foot ulceration and lower extremity amputation (LEA). However, the underlying risk factors for foot ulceration have received limited attention in this population. The aim of this study was to investigate the prevalence and type of risk factors for foot ulceration present in patients with ESRD on haemodialysis without the coexistence of diabetes mellitus (DM). One hundred and ninety participants with ESRD and/or DM were recruited over a 6-week period. Participants were allocated into one of three groups: (i) ESRD without DM; (ii) DM without ESRD; and (iii) coexisting ESRD and DM. Participants were screened for the risk factors for foot ulceration. Statistical comparisons were made between the three groups for both the prevalence and type of risk factors using a Fisher's exact test. Risk factors for foot ulceration were found to be highly prevalent in the ESRD population. Participants with both ESRD and DM exhibited statistically significant differences in risk factor presentation for peripheral neuropathy (P= 0.033), vascular insufficiency (P= 0.001) and footwear (P= 0.037) in comparison with participants with DM alone. There are high prevalence rates of risk factors for foot ulceration in the ESRD population on haemodialysis and are comparable with those with DM. Individuals with coexisting ESRD and DM have an even greater risk for foot ulceration and LEA. This highlights the importance that regular foot screening, preventative education and treatment are necessary for patients with ESRD potentially to reduce the risk of foot ulcerations and LEAs.

Two-Year Foot Care Program for Minority Patients with Type 2 Diabetes Mellitus of Zhuang Tribe in Guangxi, China

ObjectiveThe aim of this study is to design and implement a foot care program for minority patients with type 2 diabetes mellitus of Zhuang tribe in Guangxi, China, which will achieve the following: 1) improve patients’ foot care behaviour, 2) improve their glycated hemoglobin (A1C) and 3) decrease the incidence of foot ulcers and amputation. BackgroundIn Guangxi, China, foot care resources are limited, and diabetes self-management and foot care is poor for patients with diabetes. Thus developing a program with the limited resources for diabetes foot care is very important. MethodsA multidisciplinary team led by a diabetes nurse was established. A foot care kit and set of teaching materials focusing on foot care and diabetes self-management was developed. Sixty-two inpatients with type 2 diabetes mellitus, under the same attending physician’s service, were screened to be at high risk for foot ulcers and randomized into 2 groups. The subjects in the study group received didactic diabetes education, tailored foot care and focused teaching for 2 hours. Every patient was given a foot care kit during hospitalization and then followed up in the clinic monthly with a systematic foot exam. Subsequently, diabetes education classes were given every 3 to 6 months. The subjects in the control group were just given usual care according to 2007 Americans with Disabilities Act standards. ResultsFor patients in the study group, the average score of knowledge and self foot care behaviours were higher than those of the patients in the control group both after 1 year (88.31 ± 8.15, 86.35 ± 5.17 vs. 70.27 ± 7.92, 75.86 ± 6.19) and 2 years (87.24 ± 6.20, 89.56 ± 7.00 vs. 71.43 ± 5.17, 67.87 ± 5.26). The mean A1C (6.5% ± 2.3% vs. 7.9% ± 4.2%), the incidence of foot ulcer (0% vs. 24.14%), and amputation (0% vs. 6.90%) were much lower than that of the patients in the control group after 2 years. ConclusionThe foot care program delivered by a multidisciplinary team can markedly improve foot care behaviours and reduce complications of the minority diabetes patients who are at risk of developing foot ulcer, thereby reducing the incidence of foot ulcer and amputation. In areas where resources are limited, the foot care program will be a cost-effective approach to reduce the incidence of diabetes foot ulcer.

DIABETIC FOOT CARE: PREVENTION IS BETTER THAN CURE

SUMMARYPatients receiving renal replacement therapy especially haemodialysis (HD) are at high risk of foot ulcers which can lead to amputation. With the increasing numbers of patients with diabetes now presenting with renal failure, renal nurses are in a pivotal position to educate patients and initiate and oversee good foot care. This paper describes the risk factors for these patients and discusses general care for prevention and treatment of these factors. Factors such as regular screening which can be done easily and effectively in an HD setting where patients attend regularly is the first method towards prevention. Care and treatment of foot wounds based on results from the author's unit are discussed. The creation of a diabetes care programme for the author's HD unit have resulted in a more holistic approach to the care of the patient with diabetes and renal disease with special attention to foot care, which in turn has lead to an improved standard of care and better management of the patients’ diabetes. This paper discusses information from this programme offering a summary of risks and treatments to assist those caring for these patients.

Coming events cast their shadows before: detecting inflammation in the acute diabetic foot and the foot in remission

The incidence of diabetic foot complications, most notably wounds, is increasing worldwide. Most people who present for care of a foot wound will become infected. Globally, this results in one major amputation every 30 seconds with over 2500 limbs lost per day. Presently, clinicians assess circulation, neuropathy and plantar pressures to identify the risk of foot ulceration. Several studies have suggested prevention of foot ulcers by identifying individuals at high risk and treating for lower extremity complications. Our group has proposed several diagnostics as well as prevention strategies, especially thermography and thermometry for management of patients with diabetic foot complications. These strategies employ non-invasive assessment of inflammation for acute as well as chronic care for the foot, with the intent to prevent ulceration/re-ulceration and subsequent traumatic amputations. The authors' review some important clinical studies and ongoing research in this area, with the long-term goal to further the role of thermography and thermometry in clinical care for the diabetic foot.

Patient education for preventing diabetic foot ulceration

Treatment of diabetic foot ulceration is very challenging, costly and often needs to be of long duration. This leads to substantial economic burden. Population-based research suggests that a meaningful reduction of the incidence of amputations caused by diabetes mellitus has already been achieved since the St. Vincent resolution in 1989. Still, it cannot be inferred from these studies that the current preventive efforts are (cost-)effective because reduction of amputation incidence can also be the result of improvements in ulcer treatment. Nevertheless, education of people with diabetes is widely advocated and implemented in standard practice. Despite the fact that preventive interventions are often combined in daily practice, there is little scientific evidence demonstrating the effect of those efforts. In systematically reviewing the evidence, there is insufficient evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence. To date, high quality evidence that more complex interventions including patient education can prevent diabetic foot ulceration is not available either. This, however, should be interpreted as lack of evidence rather than evidence of no effect. Future directions for research and practice may be to concentrate preventive effort on those patients who appear to be at highest risk of foot ulceration after careful screening and selection.

Advances in the epidemiology, pathogenesis and management of diabetic peripheral neuropathy

Diabetic peripheral neuropathy (DPN) affects up to 50% of patients with diabetes and is a major cause of morbidity and increased mortality. Its clinical manifestations include painful neuropathic symptoms and insensitivity, which increases the risk for burns, injuries and foot ulceration. Several recent studies have implicated poor glycaemic control, duration of diabetes, hyperlipidaemia (particularly hypertryglyceridaemia), elevated albumin excretion rates and obesity as risk factors for the development of DPN. Although there is now strong evidence for the importance of nerve microvascular disease in the pathogenesis of DPN, the risk factors for painful DPN are not known. However, emerging evidence regarding the central correlates of painful DPN is now afforded by brain imaging. The diagnosis of DPN begins with a careful history of sensory and motor symptoms. The quality and severity of neuropathic pain if present should be assessed using a suitable scale. Clinical examination should include inspection of the feet and evaluation of reflexes and sensory responses to vibration, light touch, pinprick and the 10-g monofilament. Glycaemic control and addressing cardiovascular risk is now considered important in the overall management of the neuropathic patient. Pharmacological treatment of painful DPN includes tricyclic compounds, serotonin-norepinephrine reuptake inhibitors (e.g. duloxetine), anticonvulsants (e.g. pregabalin), opiates, membrane stabilizers, the antioxidant alpha lipoic acid and others. Over the past 7 years, new agents with perhaps less side effect profiles have immerged. Management of patients with painful neuropathy must be tailored to individual requirements and will depend on the presence of other co-morbidities. There is limited literature with regard to combination treatment.

The effectiveness of using in‐shoe plantar pressure assessment and monitoring in prescription therapeutic footwear to prevent plantar foot ulcer recurrence in diabetic patients: a multicenter randomized controlled trial

Background Diabetic patients at high risk for foot ulceration are often prescribed with custom-made therapeutic footwear. However, the evidence base to support the use of this footwear for ulcer prevention is still meagre [1]. The lack of offloading efficacy may play a role in this. In-shoe plantar pressure assessment is a valuable tool for evaluating footwear and guiding modifications to optimize the footwear’s offloading properties [2]. The aim of this multicenter randomized trial was to assess the effectiveness of this approach and long-term pressure monitoring in prescription footwear to prevent plantar foot ulcer recurrence in neuropathic diabetic patients.

Diabetic peripheral neuropathy in type 2 diabetes mellitus in Korea.

Diabetic peripheral neuropathy (DPN), a common and troublesome complication in patients with type 2 diabetes mellitus (T2DM), contributes to a higher risk of diabetic foot ulcer and lower limb amputation. These situations can negatively impact the quality of life of affected individuals. Despite its high prevalence and clinical importance, most diabetes mellitus patients not only do not recognize the presence of diabetic neuropathy, but also do not report their symptoms to physicians or other health care providers. Therefore, DPN is usually under diagnosed and undertreated. For early detection and appropriate intervention for DPN, a careful history, physical with neurologic examination, and prompt treatment are needed in T2DM patients.

Experience with the treatment of diabetic foot syndrome in Barnaul

The interdisciplinary service organized in the city of Barnaul provides care for patients with diabetic foot syndrome (DFS) including regular medicalexamination, diagnostics, treatment, and prophylactic measures to prevent new lesions and amputations. The service is based on the DiabeticFoot Cabinet of City Hospital No 5, Department of Wound Infections of City Hospital No 3, and Barnaul Prosthetics and Orthopedics Company,a manufacturer of prostheses and orthopedic devices for patients with DFS. These organizations have just begun cooperation with the Departmentsof Vascular Surgery of City Hospital No 5 and Regional Clinical Hospital aimed to perform vascular reconstructive surgery. The joint efforts areexpected to ensure long-term observation of the patients, their education in podiatric self-care, and introduction of the total contact cast method foroff-loading the foot at the stage of ulcer formation with the ultimate purpose of reducing it by 45-75%. Almost 3000 patients (10,000 visits) have beenexamined by specialist of Diabetic Foot Cabinet since 2005; most of them were referred to the group of high and very high risk of foot ulceration. Thenumber of patients with DFS hospitalized for the treatment of wound infections decreased from 263 in 2005 to 122 in 2010 despite a rise in overalldiabetes morbidity among the population of Barnaul. During the same period, the total number of amputations decreased from 269 to 64 and thenumber of high-level amputations from 119 to 3. The number of amputations in the patients regularly visiting the Cabinet is much lower than in thegeneral population and continues to decrease (4.7% in 2008 and 1.6% in 2010). 23% of the patients with DFS referred to the Cabinet underwentamputation in 2008 compared with 11% in 2010. In 2010, savings to the Altai region budget in direct medical expenditures for the patients with DFSamounted to 41,000,000 rubles (exclusive of management and drug costs and social benefits). The total savings to the budget in direct expendituresfor the hospital-based treatment of such patients during the last 3 years are estimated at more than 108,000,000 rubles.

Calculation of plantar pressure time integral, an alternative approach

In plantar pressure measurement, both peak pressure and pressure time integral are used as variables to assess plantar loading. However, pressure time integral shows a high concordance with peak pressure. Many researchers and clinicians use Novel software (Novel GmbH Inc., Munich, Germany) that calculates this variable as the summation of the products of peak pressure and duration per time sample, which is not a genuine integral of pressure over time. Therefore, an alternative calculation method was introduced. The aim of this study was to explore the relevance of this alternative method, in different populations. Plantar pressure variables were measured in 76 people with diabetic polyneuropathy, 33 diabetic controls without polyneuropathy and 19 healthy subjects. Peak pressure and pressure time integral were obtained using Novel software. The quotient of the genuine force time integral over contact area was obtained as the alternative pressure time integral calculation. This new alternative method correlated less with peak pressure than the pressure time integral as calculated by Novel. The two methods differed significantly and these differences varied between the foot sole areas and between groups. The largest differences were found under the metatarsal heads in the group with diabetic polyneuropathy. From a theoretical perspective, the alternative approach provides a more valid calculation of the pressure time integral. In addition, this study showed that the alternative calculation is of added value, along peak pressure calculation, to interpret adapted plantar pressures patterns in particular in patients at risk for foot ulceration.

Evaluation and Optimization of Therapeutic Footwear for Neuropathic Diabetic Foot Patients Using In-Shoe Plantar Pressure Analysis

OBJECTIVETherapeutic footwear for diabetic foot patients aims to reduce the risk of ulceration by relieving mechanical pressure on the foot. However, footwear efficacy is generally not assessed in clinical practice. The purpose of this study was to assess the value of in-shoe plantar pressure analysis to evaluate and optimize the pressure-reducing effects of diabetic therapeutic footwear.RESEARCH DESIGN AND METHODSDynamic in-shoe plantar pressure distribution was measured in 23 neuropathic diabetic foot patients wearing fully customized footwear. Regions of interest (with peak pressure >200 kPa) were selected and targeted for pressure optimization by modifying the shoe or insole. After each of a maximum of three rounds of modifications, the effect on in-shoe plantar pressure was measured. Successful optimization was achieved with a peak pressure reduction of >25% (criterion A) or below an absolute level of 200 kPa (criterion B).RESULTSIn 35 defined regions, mean peak pressure was significantly reduced from 303 (SD 77) to 208 (46) kPa after an average 1.6 rounds of footwear modifications (P < 0.001). This result constitutes a 30.2% pressure relief (range 18–50% across regions). All regions were successfully optimized: 16 according to criterion A, 7 to criterion B, and 12 to criterion A and B. Footwear optimization lasted on average 53 min.CONCLUSIONSThese findings suggest that in-shoe plantar pressure analysis is an effective and efficient tool to evaluate and guide footwear modifications that significantly reduce pressure in the neuropathic diabetic foot. This result provides an objective approach to instantly improve footwear quality, which should reduce the risk for pressure-related plantar foot ulcers.

Beyond the Monofilament for the Insensate Diabetic Foot

Foot ulcers in patients with diabetes lead to infections, amputations, and high costs, and their prevention is a stated goal of the American Diabetes Association. To assess the benefits of various interventions on the prevention of future diabetic foot ulcers, we searched for and reviewed all randomized clinical trials (RCTs) on the prevention of diabetic foot ulcers and evaluated their efficacy and scientific validity on the basis of an established systemic grading system. Only 13 RCTs were identified. All involved secondary prevention or a mixture of primary and secondary prevention. Most were small and of poor quality, with negative studies generally being of better quality than positive studies. Of all methods proposed to prevent diabetic foot ulcers, only foot temperature-guided avoidance therapy was found beneficial in RCTs, although this needs to be validated in other populations. These observations only apply to high-risk populations, and the benefits to the general population with diabetes are unclear. ### Introduction Diabetic foot ulcers are the cause of immense suffering and health system costs (1). The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is as high as 2% (2–6). Multiple component causes, including peripheral neuropathy, peripheral vascular disease (PVD), foot deformity, and smoking, interact in the causal pathway to foot ulceration. In several cross-sectional and retrospective studies, the prevalence of PVD and peripheral neuropathy in patients was found to be as high as 40%. However, no prospective study clearly documented their relative contribution. This review is concerned primarily with clinical trials on the prevention of foot ulcers in the neuropathic, or insensate, foot. Several physiologic measurements of the presence and degree of peripheral neuropathy have been shown to be predictive of the risk of future foot ulcer in …

A national strategic approach to diabetic foot disease in Scotland: changing a culture

A diabetes foot action plan was introduced to Scotland in 2006. This has included developing a foot-screening programme with foot risk stratification. Currently 140,000 people (61% of all patients with diabetes) have undergone foot risk stratification, with 69% categorised as low risk, 20% as moderate risk and 11% as being at high risk of foot ulceration. This has helped support the introduction of needs-related care pathways. Schemes to support community-based podiatrists and strengthen links and referral pathways to specialist foot services have been introduced. Identifying key competencies for podiatrists and orthotists working for patients with diabetes has underpinned the development of a competency framework for each profession. Nationally agreed and utilised patient education leaflets and staff education programmes, including online training programmes have been introduced. Surveys of multidisciplinary foot services, have shown amongst other things, a low level of consultant involvement in such clinics (58% of Health Boards). Overall, national data indicated that across Scotland in 2009 the prevalence of foot ulceration was 2.5% in December 2010 and amputation was 0.5% in 2009, the latter having declined from 0.8% in 2003.