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Background Crohn's disease ( CD) and ulcerative colitis ( UC) are two pathotypes of inflammatory bowel disease ( IBD) with unique pathology, risk factors and significant morbidity. Aim To estimate incidence and identify IBD risk factors in a US military population, a healthy subset of the US population, using information from the Millennium Cohort Study. Methods Incident IBD was identified from medical encounters from 2001 to 2009 or by self-report. Our primary risk factor of interest, infectious gastroenteritis, was identified from medical encounters and self-reported post-deployment health assessments. Other potential risk factors were assessed using self-reported survey responses and military personnel files. Hazard ratios were estimated using Cox proportional hazards analysis. Results We estimated 23.2 and 21.9 diagnoses per 100 000 person-years, respectively, for CD and UC. For CD, significant risk factors included [adjusted hazard ratio ( aHR), 95% confidence interval]: current smoking ( aHR: 2.7, 1.4-5.1), two life stressors ( aHR: 2.8, 1.4-5.6) and prior irritable bowel syndrome ( aHR: 4.7, 1.5-15.2). There was no significant association with prior infectious gastroenteritis. There was an apparent dose-response relationship between UC risk and an increasing number of life stressors. In addition, antecedent infectious gastroenteritis was associated with almost a three-fold increase in UC risk ( aHR: 2.9, 1.4-6.0). Moderate alcohol consumption ( aHR: 0.4, 0.2-0.6) was associated with lower UC risk. Conclusions Stressful conditions and the high risk of infectious gastroenteritis in deployment operations may play a role in the development of IBD in military populations. However, observed differences in risk factors for UC and CD warrant further investigation. [ABSTRACT FROM AUTHOR]

Examine a patient with diabetes annually for the presence of peripheral artery disease (PAD); this should include, at a minimum, taking a history and palpating foot pulses. (GRADE strength of recommendation: strong; quality of evidence: low) Evaluate a patient with diabetes and a foot ulcer for the presence of PAD. Determine, as part of this examination, ankle or pedal Doppler arterial waveforms; measure both ankle systolic pressure and systolic ankle brachial index (ABI). (strong; low) We recommend the use of bedside non-invasive tests to exclude PAD. No single modality has been shown to be optimal. Measuring ABI (with <0.9 considered abnormal) is useful for the detection of PAD. Tests that largely exclude PAD are the presence of ABI 0.9-1.3, toe brachial index ≥0.75 and the presence of triphasic pedal Doppler arterial waveforms. (strong; low) In patients with a foot ulcer in diabetes and PAD, no specific symptoms or signs of PAD reliably predict healing of the ulcer. However, one of the following simple bedside tests should be used to inform the patient and healthcare professional about the healing potential of the ulcer. Any of the following findings increases the pre-test probability of healing by at least 25%: a skin perfusion pressure ≥40 mmHg, a toe pressure ≥30 mmHg or a transcutaneous oxygen pressure (TcPO2 ) ≥25 mmHg. (strong; moderate) Consider urgent vascular imaging and revascularisation in patients with a foot ulcer in diabetes where the toe pressure is <30 mmHg or the TcPO2 <25 mmHg. (strong; low) Consider vascular imaging and revascularisation in all patients with a foot ulcer in diabetes and PAD, irrespective of the results of bedside tests, when the ulcer does not improve within 6 weeks despite optimal management. (strong; low) Diabetic microangiopathy should not be considered to be the cause of poor wound healing in patients with a foot ulcer. (strong; low) In patients with a non-healing ulcer with either an ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularisation. (strong; moderate) Colour Doppler ultrasound, computed tomography angiography, magnetic resonance angiography or intra-arterial digital subtraction angiography can each be used to obtain anatomical information when revascularisation is being considered. The entire lower extremity arterial circulation should be evaluated, with detailed visualisation of below-the-knee and pedal arteries. (strong; low) The aim of revascularisation is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, with the aim of achieving a minimum skin perfusion pressure ≥40 mmHg, a toe pressure ≥30 mmHg or a TcPO2 ≥25 mmHg. (strong; low) A centre treating patients with a foot ulcer in diabetes should have the expertise in and rapid access to facilities necessary to diagnose and treat PAD; both endovascular techniques and bypass surgery should be available. (strong; low) There is inadequate evidence to establish which revascularisation technique is superior, and decisions should be made in a multidisciplinary team on a number of individual factors, such as morphological distribution of PAD, availability of autogenous vein, patient co-morbidities and local expertise. (strong; low) After a revascularisation procedure for a foot ulcer in diabetes, the patient should be treated by a multidisciplinary team as part of a comprehensive care plan. (strong; low) Patients with signs of PAD and a foot infection are at particularly high risk for major limb amputation and require emergency treatment. (strong; moderate) Avoid revascularisation in patients in whom, from the patient perspective, the risk-benefit ratio for the probability of success is unfavourable. (strong; low) All patients with diabetes and an ischaemic foot ulcer should receive aggressive cardiovascular risk management including support for cessation of smoking, treatment of hypertension and prescription of a statin as well as low-dose aspirin or clopidogrel. (strong; low). [ABSTRACT FROM AUTHOR]

Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus are important to estimate the risk of amputation, ulceration, wound healing and the presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another and to evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction angiography and colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies instrument. Of the 6629 studies identified, ten met the criteria for inclusion. In these studies, the patients had a median age of 60-74 years and a median duration of diabetes of 9-24 years. Two studies reported exclusively on patients with symptomatic (ulcerated/infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio and negative likelihood ratio (NLR) of an ABI threshold <0.9 ranged from 2 to 25 (median 8) and <0.1 to 0.7 (median 0.3), respectively. In patients with neuropathy, the NLR of the ABI was generally higher (two out of three studies), indicating poorer performance, and ranged between 0.3 and 0.5. A toe brachial index <0.75 was associated with a median positive likelihood ratio and NLRs of 3 and ≤ 0.1, respectively, and was less affected by neuropathy in one study. Also, in two separate studies, pulse oximetry used to measure the oxygen saturation of peripheral blood and Doppler wave form analyses had NLRs of 0.2 and <0.1. The reported performance of ABI for the diagnosis of PAD in patients with diabetes mellitus is variable and is adversely affected by the presence of neuropathy. Limited evidence suggests that toe brachial index, pulse oximetry and wave form analysis may be superior to ABI for diagnosing PAD in patients with neuropathy with and without foot ulcers. There were insufficient data to support the adoption of one particular diagnostic modality over another and no comparisons existed with clinical examination. The quality of studies evaluating diagnostic techniques for the detection of PAD in individuals with diabetes is poor. Improved compliance with guidelines for methodological quality is needed in future studies. [ABSTRACT FROM AUTHOR]

Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure ≥ 40 mmHg, toe pressure ≥ 30 mmHg (and ≥ 45 mmHg) and transcutaneous pressure of oxygen (TcPO2 ) ≥ 25 mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressure < 70 mmHg and fluorescein toe slope < 18 units each increased the likelihood of major amputation by around 25%. The combined test of ankle pressure < 50 mmHg or an ankle brachial index (ABI) < 0.5 increased the likelihood of major amputation by approximately 40%. Among patients with diabetic foot ulceration, the measurement of skin perfusion pressures, toe pressures and TcPO2 appear to be more useful in predicting ulcer healing than ankle pressures or the ABI. Conversely, an ankle pressure of < 50 mmHg or an ABI < 0.5 is associated with a significant increase in the incidence of major amputation. [ABSTRACT FROM AUTHOR]

Symptoms or signs of peripheral artery disease (PAD) can be observed in up to 50% of the patients with a diabetic foot ulcer and is a risk factor for poor healing and amputation. In 2012, a multidisciplinary working group of the International Working Group on the Diabetic Foot published a systematic review on the effectiveness of revascularization of the ulcerated foot in patients with diabetes and PAD. This publication is an update of this review and now includes the results of a systematic search for therapies to revascularize the ulcerated foot in patients with diabetes and PAD from 1980 to June 2014. Only clinically relevant outcomes were assessed. The research conformed to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, and Scottish Intercollegiate Guidelines Network methodological scores were assigned. A total of 56 articles were eligible for full-text review. There were no randomized controlled trials, but there were four nonrandomized studies with a control group. The major outcomes following endovascular or open bypass surgery were broadly similar among the studies. Following open surgery, the 1-year limb salvage rates were a median of 85% (interquartile range of 80-90%), and following endovascular revascularization, these rates were 78% (70-89%). At 1-year follow-up, 60% or more of ulcers had healed following revascularization with either open bypass surgery or endovascular techniques. Studies appeared to demonstrate improved rates of limb salvage associated with revascularization compared with the results of conservatively treated patients in the literature. There were insufficient data to recommend one method of revascularization over another. There is a real need for standardized reporting of baseline demographic data, severity of disease and outcome reporting in this group of patients. [ABSTRACT FROM AUTHOR]

The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabetic Foot conducted a systematic review seeking all published reports relating to any type of treatment for infection of the foot in persons with diabetes published as of 30 June 2014. This review, conducted with both PubMed and EMBASE, was used to update an earlier one undertaken on 30 June 2010 using the same search string. Eligible publications included those that had outcome measures reported for both a treated and a control population that were managed either at the same time, or as part of a before-and-after case design. We did not include studies that contained only information related to definition or diagnosis, but not treatment, of DFI. The current search identified just seven new articles meeting our criteria that were published since the 33 identified with the previous search, making a total of 40 articles from the world literature. The identified articles included 37 randomised controlled trials (RCTs) and three cohort studies with concurrent controls, and included studies on the use of surgical procedures, topical antiseptics, negative pressure wound therapy and hyperbaric oxygen. Among the studies were 15 RCTs that compared outcomes of treatment with new antibiotic preparations compared with a conventional therapy in the management of skin and soft tissue infection. In addition, 10 RCTs and 1 cohort study compared different treatments for osteomyelitis in the diabetic foot. Results of comparisons of different antibiotic regimens generally demonstrated that newly introduced antibiotic regimens appeared to be as effective as conventional therapy (and also more cost-effective in one study), but one study failed to demonstrate non-inferiority of a new antibiotic compared with that of a standard agent. Overall, the available literature was both limited in both the number of studies and the quality of their design. Thus, our systematic review revealed little evidence upon which to make recommendations for treatment of DFIs. There is a great need for further well-designed trials that will provide robust data upon which to make decisions about the most appropriate treatment of both skin and soft tissue infection and osteomyelitis in diabetic patients. [ABSTRACT FROM AUTHOR]

Improving ability to predict and prevent diabetic foot ulceration is imperative because of the high personal and financial costs of this complication. We therefore conducted a systematic review in order to identify all studies of factors associated with DFU and assess whether available DFU risk stratification systems incorporate those factors of highest potential value. We performed a search in PubMed for studies published through April 2011 that analysed the association between independent variables and DFU. Articles were selected by two investigators-independently and blind to each other. Divergences were solved by a third investigator. A total of 71 studies were included that evaluated the association between diabetic foot ulceration and more than 100 independent variables. The variables most frequently assessed were age, gender, diabetes duration, BMI, HbA1c and neuropathy. Diabetic foot ulceration prevalence varied greatly among studies. The majority of the identified variables were assessed by only two or fewer studies. Diabetic neuropathy, peripheral vascular disease, foot deformity and previous diabetic foot ulceration or lower extremity amputation - which are the most common variables included in risk stratification systems - were consistently associated with diabetic foot ulceration development. Existing diabetic foot ulceration risk stratification systems often include variables shown repeatedly in the literature to be strongly predictive of this outcome. Improvement of these risk classification systems though is impaired because of deficiencies noted, including a great lack of standardization in outcome definition and variable selection and measurement. Copyright © 2012 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Diabet. Med. 27, 1226-1232 (2010) Aims Risk of Type 2 diabetes varies by ethnicity, but whether ethnicity remains important among those who have impaired glucose tolerance or impaired fasting glucose is uncertain. Whether the effect of thiazolidinedione treatment on diabetes prevention in persons with non-diabetic dysglycaemia varies by ethnicity is also not known. We addressed these questions using data collected in the DREAM trial. Methods A 2-by-2 factorial double-blind randomized controlled trial to compare the effects of rosiglitazone and ramipril on the primary outcome of diabetes or death in persons meeting criteria for impaired glucose tolerance or impaired fasting glucose. The effect of these interventions by ethnicity was estimated using Cox regression analysis. Results Of 5269 adults, 2365 were randomly assigned to rosiglitzone and 2634 to placebo. South Asians showed a higher hazard for the primary outcome compared with Europeans (hazard ratio, 95% confidence interval 2.21, 1.41-3.47) adjusted for age, gender, BMI, waist-hip ratio and geographic region. A lesser increase in risk was seen in Black people (1.37, 1.04-1.81). A significant reduction in risk of the primary outcome with rosiglitazone treatment assignment was seen in all ethnic groups, but the treatment effect significantly differed by ethnicity ( P = 0.0242), with South Asians experiencing a smaller, and Latinos a larger preventive effect. Conclusions Ethnicity is an important risk factor for Type 2 diabetes in dysglycaemic persons. All ethnic groups experienced a large significant reduction in diabetes risk because of rosiglitazone. The magnitude of this reduction differed by ethnicity. Given the post hoc nature of this analysis, further confirmation of these findings is needed. [ABSTRACT FROM AUTHOR]

Background Age is associated with both impaired glucose and insulin metabolism. To what extent the age-related changes in insulin resistance (IR) and β-cell function contribute to the increase in prevalence of impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) is less known, and this is investigated in this study. Methods This study included 6610 men and 7664 women of different ethnic groups aged 30-69 years. IR and β-cell function were examined by the homeostasis model assessment of insulin resistance (HOMA-IR) and homeostasis model assessment of β-cell function (HOMA-B). Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated using logistic regression analysis adjusting for body mass index and study. Results In Chinese men, the ORs (95% CIs) for IFG were 2.69 (1.70, 4.26), 2.51 (1.49, 4.21) and 2.89 (1.68, 4.97), respectively, in age groups of 40-49, 50-59 and 60-69 years compared with 30-39 years ( p < 0.001 for trend); the corresponding figures for IGT were 1.73 (1.25, 2.38), 2.54 (1.78, 3.63) and 3.57 (2.46, 5.19) ( p < 0.001 for trend). Similar trends for IGT were observed also in Chinese women and other ethnic groups, but not for IFG in Mauritius Indian and Creole men. Adjustment for HOMA-IR and HOMA-B reduced the ORs in all age groups of all ethnicities for both IFG and IGT, but the risk gradient between age groups remained particularly for the IGT. Conclusions The age-related increase in glucose intolerance may not be fully explained by the defect in HOMA-IR and HOMA-B. As HOMA-IR and HOMA-B are only surrogate measures of insulin sensitivity and insulin secretion, the results need to be further investigated. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]