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The 4th International Symposium on the Diabetic Foot

One of the highlights of the 4th International Symposium on the Diabetic Foot (May 22–24 2003, Noordwijkerhout, the Netherlands) was the presentation, at the closure of the meeting, of the new consensus projects. After the successful launch of the International Consensus document and the Practical Guidelines on the Management and Prevention of the Diabetic Foot at the 3rd International Symposium in 1999 (currently translated into 22 languages) it was time to initiate new consensus projects. The editorial board of the IDF Consultative Section on the Diabetic Foot (Figure 1) and the International Working Group on the Diabetic Foot (IWGDF) decided in 2000 to produce documents on the infected diabetic foot, wound healing and ulcer classification for research purposes, as these topics were not covered in depth by the 1999 Consensus document.

Three consensus groups were formed and each had a chairman who communicated with the editorial board of the IWGDF, which in turn was responsible for communication with the members of the IWGDF. The members of each consensus group were representatives of the IWGDF and/or well-known experts in the field; in addition, the classification group included researchers who had developed an ulcer classification scheme in the past. The consensus procedure was followed according to international rules. Each group was asked to produce a text which was in line with the International Consensus of 1999 and with other related consensus projects, such as the TransAtlantic InterSociety Consensus group on peripheral arterial disease and the Infectious Disease Society of America, which was in the process of formulating guidelines on foot infections in patients with diabetes.

First, the topics and the agenda were chosen, and in collaboration with the editorial board, preliminary texts were produced by the three working groups. In this phase, the chairman of each group was in close contact with the editorial board. The texts (Panels 1–3, below) were subsequently sent to all members of the IWGDF to be commented on. The editorial board edited the comments and the new text was sent back to the chairmen of the working groups for their final comments. This process was repeated until the versions were agreeable for all people involved. The last versions were discussed in depth during a Consensus/Implementation meeting of the IWGDF on May 21 2003 in Noordwijkerhout, which preceded the 4th International Symposium.

An interactive CD-Rom  was printed containing the newly approved three supplement texts (Figure 2). The Practical Guidelines on the Management and Prevention of the Diabetic Foot in English, Spanish and French and the original International Consensus document (1999) are included in the CD-Rom, as well as a picture gallery with an interactive search system, which was presented to all participants at the closure of the 4th International Symposium.

Panel 1: Consensus on Diagnosing and Treating the Infected Diabetic Foot
The aims of the diabetic foot infection document were to provide state of the art information on the diagnosis and treatment of the infected diabetic foot. The final document and practical guidelines which were produced should be seen as a consensus report, as agreed by all 62 IWGDF members with their signatures at the Consensus/Implementation meeting on May 21, 2003, in Noordwijkerhout, the Netherlands. 

Panel 2: Wound Healing and Treatments for People with Diabetic Foot Ulcers
The aims of the wound care document were to provide state of the art information on wound healing, on barriers to healing, and on treatments for diabetic foot ulcers. Unfortunately, it became clear to the International Consensus Working Group that the evidence base to produce practical guidelines on wound care is lacking. The current document should therefore be seen as a progress report, which was agreed upon at the Consensus/Implementation meeting. During this meeting, it was also decided that there is a great need for practical guidelines and a more evidence-based report. The IWGDF hopes that within the next few years more solid data will become available. Therefore, it was decided that the present consensus process will be continued and that within 4 years, the practical guidelines will be produced, in combination with a shorter version of the current document.

Panel 3: Diabetic foot ulcer classification system for research purposes. A progress report on criteria for including patients in research studies
In 2000, the Editorial Board was given the task of guiding the consensus process on research classification on behalf of the IWGDF, which in the meantime had become a consultative section of the International Diabetes Federation (IDF). After consultation with the American Diabetes Association (ADA), it was decided that the IWGDF would formulate a classification scheme only for research purposes and the ADA would formulate a classification scheme for daily practice. These two initiatives would be developed in close collaboration. 

The aims of a research classification system were defined in a preparatory meeting of the Editorial Board with the Steering Committee (in January 2001). Moreover, the procedures for developing such a system were described and a timeframe was established. In the autumn of 2001, all experts who had developed an ulcer classification scheme in the past were invited for a consensus meeting. In this meeting, the backbone of a system to classify diabetic foot ulcers for research purposes was developed. In particular, all experts agreed that a research classification scheme should include the five items of the PEDIS system. In this PEDIS system Perfusion, Extent/size, Depth/tissue loss, Infection and Sensation should be categorised in each patient. A strict grading system was developed for each category. Definition of this grading system in unambiguous terms, which are applicable in clinical research, was the greatest challenge. This system was further refined in a meeting in Hungary, 2002, with a number of external experts, including the chairmen of the consensus groups.

The current text, into which the received comments of 41 IWGDF members were incorporated was finalised after a meeting of the Editorial Board in May 2003. This 4th version was sent to all experts involved in the consensus process and was presented as a progress report during the Consensus/Implementation meeting. This report was extensively debated and modified during the consensus meeting. Subsequently, the document was approved by all IWGDF members present. Moreover, it was decided that the current system needed validation before it could be published as a formal IWGDF consensus document.

Members of the editorial board of the International Working Group on the Diabetic Foot: J. Apelqvist (Co-Chairman), Lund, Sweden; K Bakker (Chairman), Heemstede, The Netherlands EJG Peters, Leiden, The Netherlands; WH van Houtum (Secretary), Leiden, The Netherlands; MH Nabuurs-Franssen (Secretary), Maastricht, The Netherlands; NC Schaper (Scientific Secretary), Maastricht, The Netherlands.

The International Consensus Working Group on Diagnosing and Treating the Infected Diabetic Foot
(Chairman: BA Lipsky, Seattle, USA). Members: A Berendt, Oxford, UK; J Embil, Winnipeg, Canada; M Eneroth, Lund, Sweden; V Urbancic-Rovan, Ljubljana, Slovenia. Corresponding members: A Jirkovska, Prague, Czech Republic; Z Gulam-Abbas, Dar-es-Salaam, Tanzania; F de Lalla, Vincenza, Italy; V Viswanathan, Tamilnadu, India; and D Yue, Sydney, Australia. 

The International Consensus Working Group on Wound Healing and Treatments for People with Diabetic Foot Ulcers (Chairman: KG Harding, Cardiff, UK). Members: J Apelqvist, Lund-Malmø, Sweden; ME Edmonds, London, UK; J Embil, Winnipeg, Canada; F Gottrup, Odense, Denmark; V Falanga, Providence, USA; LB Harkless, San Antonio, USA; P Holstein, Copenhagen, Denmark; WJ Jeffcoate, Nottingham, UK; PE Price, Cardiff, UK; and K van Acker, Antwerp, Belgium.

The International Consensus Working Group on research ulcer classification
(Chairman: NC Schaper, Maastricht, the Netherlands). Members: K van Acker, Antwerpen, Belgium; J Apelqvist, Lund/Malmö, Sweden; D Armstrong, Tucson, USA; AJM Boulton, Miami, USA and Manchester, UK; H Connor, Hereford, UK; ME Edmonds, London, UK; RG Frykberg, Des Moines, USA; KG Harding, Cardiff, UK; WJ Jeffcoate, Nottingham, UK; G Reiber, Seattle, UK

One of the highlights of the 4th International Symposium on the Diabetic Foot (May 22–24 2003, Noordwijkerhout, the Netherlands) was the presentation, at the closure of the meeting, of the new consensus projects. After the successful launch of the International Consensus document and the Practical Guidelines on the Management and Prevention of the Diabetic Foot at the 3rd International Symposium in 1999 (currently translated into 22 languages) it was time to initiate new consensus projects. The editorial board of the IDF Consultative Section on the Diabetic Foot (Figure 1) and the International Working Group on the Diabetic Foot (IWGDF) decided in 2000 to produce documents on the infected diabetic foot, wound healing and ulcer classification for research purposes, as these topics were not covered in depth by the 1999 Consensus document.

Three consensus groups were formed and each had a chairman who communicated with the editorial board of the IWGDF, which in turn was responsible for communication with the members of the IWGDF. The members of each consensus group were representatives of the IWGDF and/or well-known experts in the field; in addition, the classification group included researchers who had developed an ulcer classification scheme in the past. The consensus procedure was followed according to international rules. Each group was asked to produce a text which was in line with the International Consensus of 1999 and with other related consensus projects, such as the TransAtlantic InterSociety Consensus group on peripheral arterial disease and the Infectious Disease Society of America, which was in the process of formulating guidelines on foot infections in patients with diabetes.

First, the topics and the agenda were chosen, and in collaboration with the editorial board, preliminary texts were produced by the three working groups. In this phase, the chairman of each group was in close contact with the editorial board. The texts (Panels 1–3, below) were subsequently sent to all members of the IWGDF to be commented on. The editorial board edited the comments and the new text was sent back to the chairmen of the working groups for their final comments. This process was repeated until the versions were agreeable for all people involved. The last versions were discussed in depth during a Consensus/Implementation meeting of the IWGDF on May 21 2003 in Noordwijkerhout, which preceded the 4th International Symposium.

An interactive CD-Rom  was printed containing the newly approved three supplement texts (Figure 2). The Practical Guidelines on the Management and Prevention of the Diabetic Foot in English, Spanish and French and the original International Consensus document (1999) are included in the CD-Rom, as well as a picture gallery with an interactive search system, which was presented to all participants at the closure of the 4th International Symposium.

Panel 1: Consensus on Diagnosing and Treating the Infected Diabetic Foot
The aims of the diabetic foot infection document were to provide state of the art information on the diagnosis and treatment of the infected diabetic foot. The final document and practical guidelines which were produced should be seen as a consensus report, as agreed by all 62 IWGDF members with their signatures at the Consensus/Implementation meeting on May 21, 2003, in Noordwijkerhout, the Netherlands. 

Panel 2: Wound Healing and Treatments for People with Diabetic Foot Ulcers
The aims of the wound care document were to provide state of the art information on wound healing, on barriers to healing, and on treatments for diabetic foot ulcers. Unfortunately, it became clear to the International Consensus Working Group that the evidence base to produce practical guidelines on wound care is lacking. The current document should therefore be seen as a progress report, which was agreed upon at the Consensus/Implementation meeting. During this meeting, it was also decided that there is a great need for practical guidelines and a more evidence-based report. The IWGDF hopes that within the next few years more solid data will become available. Therefore, it was decided that the present consensus process will be continued and that within 4 years, the practical guidelines will be produced, in combination with a shorter version of the current document.

Panel 3: Diabetic foot ulcer classification system for research purposes. A progress report on criteria for including patients in research studies
In 2000, the Editorial Board was given the task of guiding the consensus process on research classification on behalf of the IWGDF, which in the meantime had become a consultative section of the International Diabetes Federation (IDF). After consultation with the American Diabetes Association (ADA), it was decided that the IWGDF would formulate a classification scheme only for research purposes and the ADA would formulate a classification scheme for daily practice. These two initiatives would be developed in close collaboration. 

The aims of a research classification system were defined in a preparatory meeting of the Editorial Board with the Steering Committee (in January 2001). Moreover, the procedures for developing such a system were described and a timeframe was established. In the autumn of 2001, all experts who had developed an ulcer classification scheme in the past were invited for a consensus meeting. In this meeting, the backbone of a system to classify diabetic foot ulcers for research purposes was developed. In particular, all experts agreed that a research classification scheme should include the five items of the PEDIS system. In this PEDIS system Perfusion, Extent/size, Depth/tissue loss, Infection and Sensation should be categorised in each patient. A strict grading system was developed for each category. Definition of this grading system in unambiguous terms, which are applicable in clinical research, was the greatest challenge. This system was further refined in a meeting in Hungary, 2002, with a number of external experts, including the chairmen of the consensus groups.

The current text, into which the received comments of 41 IWGDF members were incorporated was finalised after a meeting of the Editorial Board in May 2003. This 4th version was sent to all experts involved in the consensus process and was presented as a progress report during the Consensus/Implementation meeting. This report was extensively debated and modified during the consensus meeting. Subsequently, the document was approved by all IWGDF members present. Moreover, it was decided that the current system needed validation before it could be published as a formal IWGDF consensus document.

Members of the editorial board of the International Working Group on the Diabetic Foot: J. Apelqvist (Co-Chairman), Lund, Sweden; K Bakker (Chairman), Heemstede, The Netherlands EJG Peters, Leiden, The Netherlands; WH van Houtum (Secretary), Leiden, The Netherlands; MH Nabuurs-Franssen (Secretary), Maastricht, The Netherlands; NC Schaper (Scientific Secretary), Maastricht, The Netherlands.

The International Consensus Working Group on Diagnosing and Treating the Infected Diabetic Foot
(Chairman: BA Lipsky, Seattle, USA). Members: A Berendt, Oxford, UK; J Embil, Winnipeg, Canada; M Eneroth, Lund, Sweden; V Urbancic-Rovan, Ljubljana, Slovenia. Corresponding members: A Jirkovska, Prague, Czech Republic; Z Gulam-Abbas, Dar-es-Salaam, Tanzania; F de Lalla, Vincenza, Italy; V Viswanathan, Tamilnadu, India; and D Yue, Sydney, Australia. 

The International Consensus Working Group on Wound Healing and Treatments for People with Diabetic Foot Ulcers (Chairman: KG Harding, Cardiff, UK). Members: J Apelqvist, Lund-Malmø, Sweden; ME Edmonds, London, UK; J Embil, Winnipeg, Canada; F Gottrup, Odense, Denmark; V Falanga, Providence, USA; LB Harkless, San Antonio, USA; P Holstein, Copenhagen, Denmark; WJ Jeffcoate, Nottingham, UK; PE Price, Cardiff, UK; and K van Acker, Antwerp, Belgium.

The International Consensus Working Group on research ulcer classification
(Chairman: NC Schaper, Maastricht, the Netherlands). Members: K van Acker, Antwerpen, Belgium; J Apelqvist, Lund/Malmö, Sweden; D Armstrong, Tucson, USA; AJM Boulton, Miami, USA and Manchester, UK; H Connor, Hereford, UK; ME Edmonds, London, UK; RG Frykberg, Des Moines, USA; KG Harding, Cardiff, UK; WJ Jeffcoate, Nottingham, UK; G Reiber, Seattle, UK

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