Year: 2006
Type: article
Abstract: The 11th Malvern Diabetic Foot Conference, held on 17–19 May 2006, was attended by delegates and speakers from five continents and over 30 countries. Physicians, nurses, podiatrists, orthotists, surgeons, radiologists and other professionals involved in diabetic foot care were represented. Sessions took the form of practical interactive workshops, scientific oral presentations and plenary lectures from a distinguished international faculty, and covered topical issues on the diabetic foot. These ranged from risk factors and aetiopathogenesis to diabetic foot care and prevention, as well as perspectives for the future. Amputation rates remain disturbingly high despite efforts made worldwide at reducing foot ulceration and amputation. The stage was set by Karel Bakker (Netherlands) who gave a global perspective of amputations in diabetes. He reminded participants that a limb is lost every 30 seconds as a result of diabetes and that diabetic patients are 25 times more likely to undergo an amputation than those without diabetes. He remarked on some of the successes of the International Working Group on the Diabetic Foot (IWGDF) such as the organisation of the world diabetes day 2005 and the organisation of training courses on the diabetic foot in several developing countries in Africa, South America and Asia. The DARTS project (Diabetes Audit and Research in Tayside Scotland) which aimed at risk stratification for amputation was explained by Graham Leese (Scotland). Patients could be classified as low, moderate or high risk with the aid of specially designed software and this helps to guide management. The North West Diabetic Foot study showed that the likelihood of ulceration is highest in Europeans compared to Africans and South Asians (ulcer rates 5.5%, 2.7% and 1.8%, respectively), explained Caroline Abbott (UK). Differences in foot deformities and footwear are largely responsible for these variations. William Van Houtum (Netherlands) explained that in the Netherlands, multidisciplinary foot clinics have reduced amputation rates, albeit the determinants of these benefits are not clearly known. In Greece, the number of foot clinics has increased from four in 1997 to 18 in 2006 and the Hellenic Association for the Diabetic Foot has been established with the aim of improving education and treatment, said Nicholas Tentoulouris (Greece). In Russia, a mobile research and practical screening team for diabetic foot ulcers has been created and this has reduced the delay for patients in seeking podiatric care (Irina Gurieva [Russia]). In Suffolk, UK, a multidisciplinary audit team has been set up. This has led to an overall reduction in amputation rates via quick referrals and increased foot clinic attendance, explained Gerry Rayman (UK). William Jeffcoate (UK) gave an insightful overview of the pathogenesis of Charcot neuroarthropathy. The OPG/RANK-L (osteoprotegerin/ receptor activator nuclear factor kappa B ligand) signalling pathway has been incriminated. RANK-L normally binds to the RANK receptor on pre-osteoclasts converting them to osteoclasts with a resultant increase in bone turnover/osteolysis. This action is opposed by the binding of OPG on RANK-L, hence over-expression of RANK-L leads to a commensurate increase in OPG secretion. In Charcot neuroarthropathy, there is loss of coordination between expression of RANK-L and OPG secretion. Geraint Jones (UK) presented preliminary data on the Charcot UK study stating that over 200 patients have been registered. The tarsal and metatarsal bones are more affected than the ankle and toe joints and the male:female ratio is 3:1, illustrating a male predisposition. Andrew Boulton (UK/USA) gave the evidence base for screening for neuropathy in diabetic patients. Hyperglycaemia and blood glucose flux are the most important risk factors for neuropathy, thus management should target near-normal and stable glycaemic control. Pregabalin, duloxetine and, if these fail, opioids such as tramadol are efficacious in relieving neuropathic pain, although tricyclics remain an essential first-line consideration. The role of physiotherapy in improving diabetic neuropathy was stressed by Carine Van Schie (UK). Loretta Vileikyte (UK/USA) showed that depression and anxiety are the emotional accompaniments of neuropathy and should be reckoned with when treating these patients. Patients' representations of diabetic foot complications should also be considered in order to guide management, drawing from results of a recent longitudinal study carried out in Manchester and the USA. Although neuropathy, ischaemia and foot care are recognised mechanisms to foot ulceration, recent studies from Africa suggest other potential culprits — especially atypical mycobacterial infections, insect bites and alternative medicine. This was highlighted by Agbor Ndip (Cameroon) and Zulfiqarali Gulam-Abbas (Tanzania) as they noted predominance of ulcers on the dorsum of the foot. However, in the UK new diabetic foot ulcers are still caused by footwear although, as Geraint Jones noted, these figures show a progressive decline. A multidisciplinary foot team is pivotal if we are to succeed in reducing amputation rates. This has been shown to reduce diabetes-related major lower limb amputation, as described by Ronan Canavan (UK) who presented results of better-organised diabetes care from 1995–2000 in South Tees, UK. Setting up a team requires time and lobbying for finance and collaboration, explained Isobel Got (France) as she gave her 18-year experience. The nurse could play a pivotal role in education and this requires both enthusiasm and commitment (Laura Roehrick [USA]). The role of the interventional radiologist in lower limb ischaemia was stressed by Nick Charmers (UK) as he explained the benefits of exercise as well as newer techniques including sub-intimal balloon angioplasty. He pointed out that proximal obstructive arterial disease may prevent the development of distal disease. Surgery, by correcting structural deformity, reduces the recurrent ulcerations, explained Larry Lavery (USA). Much progress has been made to improve foot care in developing countries. Through the STEP BY STEP project, foot care teams in India and Tanzania have been empowered by means of educational courses, as Sharad Pensay (India) pointed out. An illustrative foot care video cartoon was used to facilitate learning. To assess the impact of any team work, Paul Chadwick (UK) explained that critical event analysis is a useful tool. This could be done annually and, essentially, it is a method of reflection on practice to improve future care. Offloading foot ulcers still remains a cornerstone in the healing process. In their presentations, Nicolaas Schaper (Netherlands) and Alberto Piaggesi (Italy) both underpinned the need for offloading and casting. Debriding these ulcers speeds wound healing. Maggot/larva therapy is best indicated in sloughy wounds that could be difficult to debride and these ‘biological surgeons’ are affordable with a formidable side effect profile and eradicate methicillin-resistant Staphylococcus aureus colonisation of wounds, as explained by John Church and Frank Bowling (UK). The importance of proper wound dressing modalities was addressed and Edward Jude (UK) showed the benefits of dressings with Hydrofibre® containing ionic silver over those with calcium alginate in a recent randomised controlled trial. It is important to rule out osteomyelitis when there is suspected infection. Alison Shone (UK) pointed out that the probe to bone test, although useful to diagnose osteomyelitis, should always be interpreted, based on the clinical situation as this depends on the prevalence of the disease in a community. Of course, antibiotics are essential for all infected wounds and their use should be based on probable causative agents. Anthony Berendt (UK) noted the efficacy of agents like linezolid and daptomycin, but said that their routine use is not indicated given their high costs. Research interest in diabetic foot disease has heightened recently and, attendant to this, there has been a remarkable surge in new therapies. Wound chronicity in diabetes stems from four main factors: unresponsive and/or senescent cells; proteolytic environment; unavailability of growth factors; and the presence of bacteria that impede healing. Alluding to this, Rob Kirsner (USA) presented a number of potential new therapeutic agents, each targeting different factors. Thus, bio-engineered skin grafts, like Apligraft®, have been enhanced with 450nm laser (to improve type III collagen), and oestrogen (female hormones enhance healing) to augment their efficacy. The antibiotic, doxycycline (a topical metalloproteinase inhibitor) has been shown to increase vascularisation in chronic wounds. Living skin replacement therapy and xenografts are under investigation and neuropathy has been shown to accelerate the loss of pro-healing cytokines and so impede wound healing. Negative pressure wound (vacuum assisted closure [VAC]) therapy is another treatment modality that has been proven to speed wound healing. Through his wide experience and publications on this modality, David Armstrong (USA) re-iterated the evidence base for its use in diabetic foot wounds and gave practical sessions on how to apply the VAC device, remarking that it could be used as an outpatient procedure. Trivial fungal foot infections should always be sought for and treated appropriately in all diabetic patients. They usually act as a nidus for secondary bacterial infection leading to cellulitis and wound infection. As Ivan Bristow (UK) noted, Trichophyton rubrum infections are the most common and present as dry striated skin on the plantar aspects and could be mistaken for diabetic sudomotor neuropathy. Terbinafin creams are the most effective in treating fungal foot infections. George Cherry (UK) noted that, despite the availability of ‘advanced’ therapies, alternative medicine still has a role to play and should not be completely overlooked. In this regard, there is on-going research into potential herbal therapies with proven healing properties. The biennial Malvern Diabetic Foot Conference is undoubtedly an important forum for all those involved in the care of diabetic foot problems. To arrive at a destination, we need to take a train. If reducing foot ulceration and amputation as stated in the St Vincent Declaration is our aim, then the Malvern meeting is the train to board. The 12th Biennial Malvern Diabetic Foot Conference will be held in Malvern, UK, from 14-16 May 2008
Source: Practical Diabetes
DOI: 10.1002/pdi.976
Authors: EA Agbor Ndip, Andrew JM Boulton, Gerry Rayman
Language: English
Subfield: Endocrinology, Diabetes and Metabolism
Field: Medicine
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W1541900510