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The Diabetic
Foot Journal

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Response: Classification vs description

Matthew Young

Clinical effectiveness requires accurate and concise ulcer descriptions and classifications to improve interdisciplinary communication and for meaningful inter-centre comparisons. Ulcer classifications should delineate unique ulcer types with definable characteristics distinct from other ulcer categories, guiding prognosis, audit and research. A good example is the classification of ulcers by suspected aetiology, e.g. neuropathic, or by perceived severity, e.g. superficial. Ulcer classifications should be applied once, based on the initial characteristics, and should not alter with the progress of therapy, allowing outcome evaluations for each ulcer type.

In contrast, descriptions use definable characteristics which are ephemeral, changing as the ulcer progresses. Descriptive terms may also be used in classifications but generally have too many variables to have workable numbers of categories. Therefore, descriptions are not a basis for classifying an ulcer, but should be used to prompt adjustments in treatment as the ulcer changes, and to facilitate referrals in an unambiguous way. 

The Diabetic Foot journal has published the Simple Staging System and the S(AD) SAD, joining the Texas and Wagner systems in the literature. The Texas and Wagner systems have both been validated, but neither of the recent British systems has been validated formally. 

In smaller units with a clinical focus, delineating neuropathic and neuroischaemic ulcers, or use of the Wagner system, will suffice to audit outcomes and guide management. The Simple Staging System, its subcategorisations and treatment schema  will also aid management decisions. However, in research and for comparisons between units, I believe that a more detailed system, such as the Texas or S(AD) SAD, should be used. Discussion and research to reach a consensus is urgently required.

Clinical effectiveness requires accurate and concise ulcer descriptions and classifications to improve interdisciplinary communication and for meaningful inter-centre comparisons. Ulcer classifications should delineate unique ulcer types with definable characteristics distinct from other ulcer categories, guiding prognosis, audit and research. A good example is the classification of ulcers by suspected aetiology, e.g. neuropathic, or by perceived severity, e.g. superficial. Ulcer classifications should be applied once, based on the initial characteristics, and should not alter with the progress of therapy, allowing outcome evaluations for each ulcer type.

In contrast, descriptions use definable characteristics which are ephemeral, changing as the ulcer progresses. Descriptive terms may also be used in classifications but generally have too many variables to have workable numbers of categories. Therefore, descriptions are not a basis for classifying an ulcer, but should be used to prompt adjustments in treatment as the ulcer changes, and to facilitate referrals in an unambiguous way. 

The Diabetic Foot journal has published the Simple Staging System and the S(AD) SAD, joining the Texas and Wagner systems in the literature. The Texas and Wagner systems have both been validated, but neither of the recent British systems has been validated formally. 

In smaller units with a clinical focus, delineating neuropathic and neuroischaemic ulcers, or use of the Wagner system, will suffice to audit outcomes and guide management. The Simple Staging System, its subcategorisations and treatment schema  will also aid management decisions. However, in research and for comparisons between units, I believe that a more detailed system, such as the Texas or S(AD) SAD, should be used. Discussion and research to reach a consensus is urgently required.

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