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The diabetic foot in 2007: Some progress – still far to go

Andrew Boulton

The days following the very successful 5th International Symposium on the Diabetic Foot in Noordwijkerhout, The Netherlands, were ideal for a reflection on what has been achieved in the last three decades and, more importantly, what the agenda should be for the next decade.

Thirty years ago, there were no regular meetings on the diabetic foot, few active research groups in the area and a paucity of publications: truly, the foot was the Cinderella of diabetic complications. There are now many regularly held international diabetic foot meetings, including the biennial Malvern Diabetic Foot Conference since 1986, the International Symposium on the Diabetic Foot every 4 years since 1991 and the annual Diabetic Foot Global Conference since 2002. 

The recent international symposium attracted more than 1000 delegates from 81 countries – a magnificent achievement. Similarly, there has been an exponential increase in research publications on diabetic foot disease in the last decade. Despite these impressive achievements, we cannot afford to be complacent. Reports at the recent meeting suggested that less than 2 % of all publications on footwear in diabetes were eligible for inclusion in a systematic review, whereas less than 1 % of papers on the treatment of osteomyelitis in the diabetic foot met the criteria for levels 1 or 2 evidence. A similar and dismally low level of evidence for the use of any particular dressings was reported last year by Knowles (2006).

It is clear that we are moving from an era of predominantly descriptive studies to one of evidenced-based diabetic foot care – but only the first few steps have been taken. This shift in evidence does not negate the need for good descriptive reports – it merely emphasises that such reports should be followed by prospective studies. Thus, the observation by Game et al (2006) of the frequent occurrence of foot ulcers in diabetic patients recently started on dialysis will be followed by prospective studies. Similarly, the observation by Bowling et al (2007) that MRSA is removed by larval therapy of wounds will be confirmed in a randomised trial.

Many recent publications also give cause for optimism: these include the important observation by Sotto and colleagues (2007) on the use of a genotyping method that can detect bacterial genes in wound tissue samples, which encode for virulence and antibiotic resistance. In an accompanying editorial, Lipsky (2007) suggests that the application of this technique could revolutionise how we target antimicrobials against pathogenetic bacteria. Such techniques may well enable us to distinguish accurately between contamination and infection. 

Finally, a recent review reports encouraging progress in the use of stem cells in wound healing (Cha and Falanga, 2007). In future studies, not only bone marrow-derived mesenchymal stem cells, but types of cells such as those derived from hair follicles, or subsets of marrow-derived cells may be used.

The years leading to the next international foot meeting in 2011 promise to be exciting ones for diabetic foot research.

The days following the very successful 5th International Symposium on the Diabetic Foot in Noordwijkerhout, The Netherlands, were ideal for a reflection on what has been achieved in the last three decades and, more importantly, what the agenda should be for the next decade.

Thirty years ago, there were no regular meetings on the diabetic foot, few active research groups in the area and a paucity of publications: truly, the foot was the Cinderella of diabetic complications. There are now many regularly held international diabetic foot meetings, including the biennial Malvern Diabetic Foot Conference since 1986, the International Symposium on the Diabetic Foot every 4 years since 1991 and the annual Diabetic Foot Global Conference since 2002. 

The recent international symposium attracted more than 1000 delegates from 81 countries – a magnificent achievement. Similarly, there has been an exponential increase in research publications on diabetic foot disease in the last decade. Despite these impressive achievements, we cannot afford to be complacent. Reports at the recent meeting suggested that less than 2 % of all publications on footwear in diabetes were eligible for inclusion in a systematic review, whereas less than 1 % of papers on the treatment of osteomyelitis in the diabetic foot met the criteria for levels 1 or 2 evidence. A similar and dismally low level of evidence for the use of any particular dressings was reported last year by Knowles (2006).

It is clear that we are moving from an era of predominantly descriptive studies to one of evidenced-based diabetic foot care – but only the first few steps have been taken. This shift in evidence does not negate the need for good descriptive reports – it merely emphasises that such reports should be followed by prospective studies. Thus, the observation by Game et al (2006) of the frequent occurrence of foot ulcers in diabetic patients recently started on dialysis will be followed by prospective studies. Similarly, the observation by Bowling et al (2007) that MRSA is removed by larval therapy of wounds will be confirmed in a randomised trial.

Many recent publications also give cause for optimism: these include the important observation by Sotto and colleagues (2007) on the use of a genotyping method that can detect bacterial genes in wound tissue samples, which encode for virulence and antibiotic resistance. In an accompanying editorial, Lipsky (2007) suggests that the application of this technique could revolutionise how we target antimicrobials against pathogenetic bacteria. Such techniques may well enable us to distinguish accurately between contamination and infection. 

Finally, a recent review reports encouraging progress in the use of stem cells in wound healing (Cha and Falanga, 2007). In future studies, not only bone marrow-derived mesenchymal stem cells, but types of cells such as those derived from hair follicles, or subsets of marrow-derived cells may be used.

The years leading to the next international foot meeting in 2011 promise to be exciting ones for diabetic foot research.

REFERENCES:

Bowling FL, Salgami EV, Boulton AJM (2007) Larval therapy: a novel treatment in eliminating methicillin-resistantStaphylococcus aureus from diabetic foot ulcers. Diabetes Care 30: 370–1
Cha K, Falanga V (2007) Stem cells in cutaneous wound healing. Clinical Dermatology 25: 73–8
Game FL, Chipchase SY, Hubbard R et al (2006) Temporal association between the incidence of foot ulceration and the start of dialysis in diabetes mellitus. Nephrology, Dialysis Transplantation 21: 3207–10
Lipsky BA (2007) Diabetic foot infections: microbiology made modern? Array of hope. Diabetes Care 30 (in press)
Knowles EA (2006) Dressings: Is There an Evidence Base? In: Boulton AJM, Cavanagh PR, Rayman G eds. The Foot in Diabetes. 4th ed. Wileys, Chichester
Sotto A, Richard J-L, Jourdan N et al (2007) Miniaturized oligonucleotide arrays: a new tool for discriminating colonization from infection due to Staphylococcus aureus in diabetic foot ulcers. Diabetes Care 30 (in press)

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