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The Diabetic
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Ten years of The Diabetic Foot Journal

Alistair McInnes, Matthew Young

We think a small celebratory review is in order. We believe that The Diabetic Foot Journal has played a substantial role in promoting diabetic foot problems from a Cinderella speciality to the realisation that it is one of the most serious of the diabetes-related complications. Who would have thought ten years ago that The Diabetic Foot Journal would become one of the largest single-topic medical subscription journals in circulation? It is mailed to nearly 17 000 subscribers each quarter who read it, comment on it and like it. It still delivers exciting, innovative and informative content when some thought we would have exhausted the topics years ago. In parallel, over the past eight years we have delivered the largest annual UK conference on diabetic foot disease, with over 500 delegates attending each year and a programme often copied but never bettered in speaker quality or content. Next year, the conference will take things to a new level with more interactivity, added value and a greater potential to extend practice.

Diabetic foot care has come a long way in ten years as each of the accompanying articles in the ten-year review demonstrate (see pages 185–209). Universal screening using validated tools is the norm. Wound care has gone full circle and good basic care has triumphed over innovation (or at least is more cost effective). Vascular disease has more treatment modalities and the realisation that wider cardiovascular risk is important is starting to make inroads into the death toll from diabetic foot disease. Symptom control in painful neuropathy has more options which are more effective, but the underlying problem of sensory loss remains untreatable despite the promise of animal work and early trials.

It is a major bonus that there is rising acceptance of the need for podiatry to grow and, ultimately, lead many of the foot protection teams and diabetic foot clinics. There is a national organisation for people interested in foot care. It has delivered a competency framework and others are now extending this and trying to build a training scheme around it. 

There is, sadly, also a lot to be worried about. Agenda for Change has short changed many and only by a long process of appeals or re-gradings will its true potential for diabetes specialist podiatrists and nurses be realised. In addition, the change in NHS culture over the past year has lead to many of England’s premier diabetic foot clinics having to regroup, scale down and face the possibility of closure. This does not bode well for the future. Hopefully, structured, multidisciplinary, one-stop care – the gold standard – will survive once the dust settles on commissioning.

There is also still a lot to learn. Which antibiotic and for how long is still the subject of debate and consensus rather than actual evidence. Does education really reduce ulceration rates? It certainly seems to fail when it comes to ulcer recurrence. How best to redistribute pressure from the plantar ulcer remains unclear. Can topical negative pressure aid more than just post-amputation wounds? The diabetic foot may not be a Cinderella any more, but although a source of major healthcare expenditure few bodies are willing to invest as much money in it as cancer or heart disease and unless this changes there are unlikely to be large enough studies to answer these questions adequately.

We have hope for the long-term future of diabetic foot care. It has improved and in this journal it has a voice. We have seen ten years of success. Here’s to the next ten years and the constant search for answers. The truth is out there. Somewhere.

We think a small celebratory review is in order. We believe that The Diabetic Foot Journal has played a substantial role in promoting diabetic foot problems from a Cinderella speciality to the realisation that it is one of the most serious of the diabetes-related complications. Who would have thought ten years ago that The Diabetic Foot Journal would become one of the largest single-topic medical subscription journals in circulation? It is mailed to nearly 17 000 subscribers each quarter who read it, comment on it and like it. It still delivers exciting, innovative and informative content when some thought we would have exhausted the topics years ago. In parallel, over the past eight years we have delivered the largest annual UK conference on diabetic foot disease, with over 500 delegates attending each year and a programme often copied but never bettered in speaker quality or content. Next year, the conference will take things to a new level with more interactivity, added value and a greater potential to extend practice.

Diabetic foot care has come a long way in ten years as each of the accompanying articles in the ten-year review demonstrate (see pages 185–209). Universal screening using validated tools is the norm. Wound care has gone full circle and good basic care has triumphed over innovation (or at least is more cost effective). Vascular disease has more treatment modalities and the realisation that wider cardiovascular risk is important is starting to make inroads into the death toll from diabetic foot disease. Symptom control in painful neuropathy has more options which are more effective, but the underlying problem of sensory loss remains untreatable despite the promise of animal work and early trials.

It is a major bonus that there is rising acceptance of the need for podiatry to grow and, ultimately, lead many of the foot protection teams and diabetic foot clinics. There is a national organisation for people interested in foot care. It has delivered a competency framework and others are now extending this and trying to build a training scheme around it. 

There is, sadly, also a lot to be worried about. Agenda for Change has short changed many and only by a long process of appeals or re-gradings will its true potential for diabetes specialist podiatrists and nurses be realised. In addition, the change in NHS culture over the past year has lead to many of England’s premier diabetic foot clinics having to regroup, scale down and face the possibility of closure. This does not bode well for the future. Hopefully, structured, multidisciplinary, one-stop care – the gold standard – will survive once the dust settles on commissioning.

There is also still a lot to learn. Which antibiotic and for how long is still the subject of debate and consensus rather than actual evidence. Does education really reduce ulceration rates? It certainly seems to fail when it comes to ulcer recurrence. How best to redistribute pressure from the plantar ulcer remains unclear. Can topical negative pressure aid more than just post-amputation wounds? The diabetic foot may not be a Cinderella any more, but although a source of major healthcare expenditure few bodies are willing to invest as much money in it as cancer or heart disease and unless this changes there are unlikely to be large enough studies to answer these questions adequately.

We have hope for the long-term future of diabetic foot care. It has improved and in this journal it has a voice. We have seen ten years of success. Here’s to the next ten years and the constant search for answers. The truth is out there. Somewhere.

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