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Aims: To ascertain the effects of improvements in diabetic foot services over 18 years on incidence of diabetic foot ulceration. We also compared survival time from first ulcer development with presence of neuropathy, peripheral vascular disease, age and healing. Methods: Persons with new ulceration and those at high risk of ulcer development were referred to community podiatry from 1998. Their details were recorded, with verbal consent, on a central database. The effects of neuropathy, peripheral vascular disease, healing and age on survival were analysed by Cox proportional hazards ratios. Results: The incidence of first ulcer presentation decreased from 11.1 to 6.1 per 1000 persons between 2003 to 2017 (P <0.0001). Recurrent ulceration incidence remained stable. Prevalence of chronic and new foot ulceration combined increased from 20.7 to 33.1 per 1000 persons (P <0.0001). Ten‐year survival was 85% for persons presenting with first ulcer and aged < 65 years, 50% for those aged 65–74 years and 25% for those aged 75–81 years (P < 0.0001). In those with peripheral vascular disease 5‐year survival was 35% (P <0.001). Conclusions: Integrated care for the diabetic foot in one National Health Service (NHS) health service area over 18 years was associated with a reduction in first presentations of diabetic foot ulceration, but failed to reduce recurrent ulceration. Cumulative prevalence of all ulcers continues to increase. Monitoring ulceration incidence can inform audit and planning of diabetic foot care services. Survival is better than reported previously in persons < 65 years and in the absence of peripheral vascular disease. What's new?: Prevention of diabetic foot ulceration has been difficult to acheiveSurvival after diabetic foot ulceration has historically been poorThis study has shown reduction in first diabetes related foot ulceration with improved foot care services Participant survival after development of first diabetic foot ulceation was longer than in recent reports especially for those under 65 years of age, where ulcers healed, and in those without peripheral vascular diseaseAdequate commissioning of diabetic foot care services is necessary to prevent first foot ulcerationCounselling for younger patients with diabetic foot ulceration can be more posisitve [ABSTRACT FROM AUTHOR]

Aims To investigate the relationship between high diabetes-related lower limb amputation incidence and foot care services in the South-West region of England. Methods The introduction of 10 key elements of foot care service provision in one area of the South-West resulted in stabilization of foot ulcer incidence and sustained reduction in amputation incidence from 2007. Services introduced included administrative support, standardized general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit. Peer reviews of the region's diabetes foot care services were undertaken to assess delivery of these service provisions and compare this with major amputation incidence in other regions with data provided by Yorkshire and Humber Public Health Observatory Hospital Episode Statistics. Recommendations were made to improve service provision. In 2015 changes in service provision and amputation incidence were reviewed. Results Initial reviews in 2013 showed that the 3-year diabetes-related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services ( P=0.0024, adjusted R 2 =0.51). Repeat reviews in 2015 found that two or more foot care service improvements were reported by six diabetes foot care providers, with improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012-2015 and in the year 2015 only ( P ≤0.0012, adjusted R 2 =0.56, and P= 0.0005, R 2=0.62, respectively). Conclusions Major diabetes-related lower limb amputation incidence is significantly inversely correlated with foot care services provision. Introduction of more effective service provision resulted in significant reductions in major amputation incidence within 2 years. Failure to improve unsatisfactory service provision resulted in continued high amputation incidence. [ABSTRACT FROM AUTHOR]

Background: Alström syndrome is an autosomal recessive condition characterized by obesity, insulin resistance and hypertriglyceridaemia. Responses to fat and carbohydrate ingestion are important in planning dietetic advice and may help to explain the mechanism of metabolic disorder in the syndrome. Methods: After a 12-h fast, five Alström subjects received a 3.1 MJ (742 kcal), 75.8% fat breakfast on day 1, and a 3.3 MJ (794 kcal), 77.5% carbohydrate breakfast on day 2. Serum glucose, triglyceride and insulin levels were measured at baseline, and 2 and 3.5 h post-meal. Abdominal computerized tomography in three subjects and magnetic resonance imaging in one demonstrated distribution of abdominal fat. Results: Body fat was distributed subcutaneously, as well as viscerally. There were no changes in serum glucose, insulin or triglycerides after the high fat meal. Triglycerides remained stable after the high carbohydrate meal but glucose and log insulin levels increased [8.4 ± 4.1 to 13.4 ± 6.9 mmol L−1 ( P < 0.05) and 2.6 ± 0.27 to 3.15 ± 0.42 pmol L−1 ( P < 0.05), respectively]. Conclusions: Dietetic advice in Alström syndrome must include calorie restriction to reduce obesity, which is predominantly subcutaneous. This study has shown that low carbohydrate advice may prove more effective than fat restriction in control of hyperglycaemia and hyperinsulinism. A single high energy meal does not exacerbate hypertriglyceridaemia. [ABSTRACT FROM AUTHOR]

To document frequency of severe hypertriglyceridaemia in Alström's syndrome (AS) and its relationship to hepatic and renal function, glycaemia and insulin resistance. Thirty-seven subjects with AS aged 5–35 years, 51% male, were assessed at multidisciplinary clinics in Canada, UK and Italy. Diagnostic criteria were: severe cone/rod dystrophy leading to severe visual impairment in early childhood, sensorineural deafness, moderate overall obesity and normal intelligence. Three patients were treated with thyroxine for primary hypothyroidism and one female patient for secondary amenorrhoea with 20 µg ethinyloestradial combined oral contraceptive. Two male patients were receiving monthly intramuscular testosterone enanthate for secondary hypogonadism. Fasting bloods were taken for serum insulin, serum glucose, serum triglycerides, hepatic and renal function and glycosylated Hb. Triglyceride levels > 8 mmol/l and fasting serum insulin levels > 16 microunits/ml were considered to represent severe hypertriglyceridaemia and severe insulin resistance, respectively. All subjects with (23) hypertriglyceridaemia also had high insulin resistance, as measured by HOMA modelling. However, there was no significant correlation between log tyriglyceride and log serum insulin or HOMA in the whole group ( P = 0·2 and 0·14, respectively). There was no clear relationship between serum triglyceride levels and age, body mass index (BMI), hepatic or renal impairment or glycaemia. The first overview of serum triglyceride levels in a significant number of reported cases of Alström Syndrome shows an overlap between severe hypertriglyceridaemia and severe hyperinsulinism, but not a direct correlation between the two nor with insulin resistance measured by HOMA. Triglyceride levels were not related to glycaemia, hepatic or renal dysfunction. [ABSTRACT FROM AUTHOR]

Aims To complete 5-year follow-up of an intensive weight loss programme in established type 2 diabetic subjects. Methods Forty-five obese type 2 diabetic subjects, Body mass index (BMI) > 30, expressed interest in an intensive weight loss programme. Group 1 comprised 15 who selected very low calorie diet (VLCD), Group 2, 15 selected intensive conventional diet and exercise (ICD), 15 failed to follow either programme. Group sessions of eight to 15 subjects continued weekly for 6 months, then monthly for 12 months with prospective recording at 3, 6 and 12 months and then annually of quality of life, BMI, waist/hip ratio, blood pressure, fasting blood glucose, serum fructosamine and serum lipids. Results Weight loss was slower in the intensive conventional diet group than in the VLCD group, but better maintained at 5 years: group 1, 4.8 ± 6 kg; group 2, 8.9 ± 4 kg. In the intensive conventional diet group, 5 year high-density lipoprotein cholesterol was increased 1.78 ± 0.26 mmol L-1 vs. 1.10 ± 0.32 mmol L-1 at baseline, and diastolic blood pressure reduced 74.5 ± 13.3 vs. 85.5 ± 13.3 at baseline, both P < 0.05. Conclusions Out-patient VLCD treatment proved safe and effective in overweight diabetic subjects but those who chose conventional diet and exercise had a slower but more sustained weight loss. Diabetic patients willing to attempt VLCD may safely lose sufficient weight to allow major surgery, but weight regain is inevitable. Patients willing to undertake a long-term group programme of conventional diet can sustain significant weight loss for 5 years, but still require antidiabetic medication. [ABSTRACT FROM AUTHOR]

Fasting serum lipoproteins were measured in 10 untreated patients with carcinoma of the prostate (Group I), 17 patients with non malignant urological disorders (Group II), and 12 patients on cyproterone acetate (Group III) and 5 on a long-acting luteinizing hormone-releasing hormone (LHRH) analogue (Group IV) for at least 2 months for carcinoma of the prostate. Total high-density lipoprotein (HDL) cholesterol levels were significantly lower in patients in Group III than all the other groups. Very low-density lipoprotein (VLDL) triglyceride levels were significantly higher in patients in Group III than those in Groups II and IV. These results suggest a potentially adverse effect of cyproterone acetate, but not of the long-acting LHRH analogue, on serum lipids, which is likely to be of relevance only in younger patients. [ABSTRACT FROM AUTHOR]