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Never say never again

Before discussing the actual content of the papers this quarter, I would like to discuss the continuing rise in the estimated lifetime prevalence of foot ulceration among the diabetes population. Crews et al quote last year’s Armstrong et al paper, which now puts the estimated cumulative lifetime prevalence of foot ulceration as high as 34%, which was 15% 20 years ago. While not everyone is referred, I do find it hard to understand how one in three individuals with diabetes will develop a foot ulcer.

Before discussing the actual content of the papers this quarter, I would like to discuss the continuing rise in the estimated lifetime prevalence of foot ulceration among the diabetes population. Crews et al quote last year’s Armstrong et al (2017) paper, which now puts the estimated cumulative lifetime prevalence of foot ulceration as high as 34%, which was 15% 20 years ago (Reiber et al, 1998). While not everyone is referred, I do find it hard to understand how one in three individuals with diabetes will develop a foot ulcer. This may be true in selected secondary care populations, or those without universal health care or low access to rates to healthcare, but in Scotland, where there is a national population database, the data would suggest otherwise. Since population screening for risk factors for diabetes foot ulceration was introduced, the percentage of low-risk patients has increased to nearly 80% of the diabetes population as more patients are diagnosed with relatively low HbA1c levels (NHS Scotland, 2016) and the prevalence of past or present foot ulceration has remained static at around 4.7% of the total diabetes population. The mathematical model used to work out the possible lifetime prevalence needs to be validated by more real-world data or else we will need to have even bigger foot clinics!

The Crews et al paper concentrates, as do most, on plantar offloading. It includes a wide ranging review of modalities and some interesting information that was new to me. Adherence remains a major problem, particularly with removable devices, and one way in which that might be improved is by using ankle-length walkers (moon boots), which in one study were as effective as knee-length ones at offloading, while being less heavy and more acceptable to patients. This is something I will trial in my clinic.

The same is unlikely to be true for amniotic membrane dressings. As the systematic review by Paggiaro reports, there is some evidence of reducing wound sizes using these dressings, but no statistical evidence of improved healing rates, which contrasts with last year’s review (Haugh et al, 2017), which lead in part to their inclusion in NICE guidance. Having lived through the era of previous skin substitutes, I will wait for clearer evidence before I use them.

To read the article summaries, please download the PDF.

Armstrong DG, Boulton AJ, Bus SA (2017) Diabetic foot ulcers and their recurrence. N Engl J Med 376(24): 2367–75
Haugh AM, Witt, JG, Hauch, A et al (2017) Amnion Membrane in Diabetic Foot Wounds: A Meta-analysis. Plast Reconstr Surg Glob Open 5(4): e1302
NHS Scotland (2016) Scottish Diabetes Survey. NHS Scotland, Edinburgh. Available at: http://bit.ly/2wLd4Ce (accessed 16.03.2018)
NICE (2018) EpiFix for Chronic Wounds. NICE, London. Available at: http://bit.ly/2pifwKs (accessed 16.03.2018)
Reiber GE, Lipsky BA, Gibbons GW (1998) The burden of diabetic foot ulcers. Am J Surg 176: 5S–10S

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