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Aims/hypothesis: The risk of dying within 2 years of presentation with diabetic foot ulceration is over six times the risk of amputation, with CVD the major contributor. Using an observational evaluation of a real-world implementation pilot, we aimed to assess whether for those presenting with diabetic foot ulceration in England, introducing a 12-lead ECG into routine care followed by appropriate clinical action was associated with reduced mortality., Methods: Between July 2014 and December 2017, ten multidisciplinary diabetic foot services in England participated in a pilot project introducing 12-lead ECGs for new attendees with foot ulceration. Inception coincided with launch of the National Diabetes Footcare Audit (NDFA), whereby all diabetic footcare services in England were invited to enter data on new attendees with foot ulceration. Poisson regression models assessed the mortality RR at 2 and 5 years following first assessment of those receiving care in a participating pilot unit vs those receiving care in any other unit in England, adjusting for age, sex, ethnicity, deprivation, type and duration of diabetes, ulcer severity, and morbidity in the year prior to first assessment., Results: Of the 3110 people recorded in the NDFA at a participating unit during the pilot, 33% (1015) were recorded as having received an ECG. A further 25,195 people recorded in the NDFA had attended another English footcare service. Unadjusted mortality in the pilot units was 16.3% (165) at 2 years and 37.4% (380) at 5 years for those who received an ECG, and 20.5% (430) and 45.2% (950), respectively, for those who did not receive an ECG. For people included in the NDFA at other units, unadjusted mortality was 20.1% (5075) and 42.6% (10,745), respectively. In the fully adjusted model, mortality was not significantly lower for those attending participating units at 2 (RR 0.93 [95% CI 0.85, 1.01]) or 5 years (RR 0.95 [95% CI 0.90, 1.01]). At participating units, mortality in those who received an ECG vs those who did not was lower at 5 years (RR 0.86 [95% CI 0.76, 0.97]), but not at 2 years (RR 0.87 [95% CI 0.72, 1.04]). Comparing just those that received an ECG with attendees at all other centres in England, mortality was lower at 5 years (RR 0.87 [95% CI 0.78, 0.96]), but not at 2 years (RR 0.86 [95% CI 0.74, 1.01])., Conclusions/interpretation: The evaluation confirms the high mortality seen in those presenting with diabetic foot ulceration. Overall mortality at the participating units was not significantly reduced at 2 or 5 years, with confidence intervals just crossing parity. Implementation of the 12-lead ECG into the routine care pathway proved challenging for clinical teams-overall a third of attendees had one, although some units delivered the intervention to over 60% of attendees-and the evaluation was therefore underpowered. Nonetheless, the signals of potential mortality benefit among those who had an ECG suggest that units in a position to operationalise implementation may wish to consider this., Data Availability: Data from the National Diabetes Audit can be requested through the National Health Service Digital Data Access Request Service process at: https://digital.nhs.uk/services/data-access-request-service-dars/dars-products-and-services/data-set-catalogue/national-diabetes-audit-nda., (© 2024. The Author(s).)

Cardiovascular disease (CVD) risk in those with diabetic foot disease is very high. Non-pharmacological interventions may improve this risk, though no previous evidence synthesis has been completed. This systematic review aimed to investigate the impact of non-pharmacological interventions on CVD risk factors in diabetic ulcer disease. Multiple databases and trials registers were searched from inception to December 6th 2023. We included reports of randomised controlled trials investigating the impact of non-pharmacological interventions on cardiovascular risk in those with type 1 or type 2 diabetes and current or previous diabetic foot disease. Twenty studies were included. Extracted data included: study design and setting; participant sociodemographic factors; and change in cardiovascular risk factors. Data were synthesised using random effects meta-analyses and narrative syntheses. Interventions included nutritional supplementation, collaborative care, hyperbaric oxygen therapy, patient education, nurse-led intervention, self-management, family support, relaxation and exercise, over a median duration of 12 weeks. Significant post-intervention changes were observed in fasting plasma glucose, serum insulin levels, insulin sensitivity and resistance, glycated haemoglobin, triglycerides, total cholesterol, low-density lipoprotein-cholesterol and C-reactive protein. No effects were detected in very low- or high-density lipoprotein-cholesterol or body mass index. Non-pharmacological interventions show promise in improving CVD risk in diabetic foot disease., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: JV is National Clinical Director for Diabetes and Obesity at NHS England. JV is supported by the NW London NIHR Applied Research Collaboration and the Imperial NIHR Biomedical Research Centre. MD has acted as consultant, advisory board member and speaker for Boehringer Ingelheim, Eli Lilly, Novo Nordisk and Sanofi, an advisory board member Lexicon, Pfizer, ShouTi Pharma Inc, AstraZeneca and Medtronic and as a speaker for AstraZeneca, Napp Pharmaceuticals, Novartis and Amgen, and has received grants from AstraZeneca, Novo Nordisk, Boehringer Ingelheim, Janssen and Sanofi-Aventis and Eli Lilly. KK has acted as a consultant, speaker or received grants for investigator-initiated studies for Astra Zeneca, Bayer, Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme, Boehringer Ingelheim, Oramed Pharmaceuticals, Roche and Applied Therapeutics., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

There is a much higher incidence of diabetic foot disease in those with concurrent renal disease and outcomes, including amputation and mortality, are generally poorer. The risk factors contributing to the higher incidence of foot disease in those with both diabetes and renal disease are outlined, and the evidence explored demonstrating higher incidence of foot disease across categories of renal disease, including impaired renal function (chronic kidney disease stages 3 and 4), haemodialysis, continuous ambulatory peritoneal dialysis, renal transplantation and simultaneous pancreas and kidney transplantation. Three major pathological aspects of diabetic foot disease in which concurrent renal disease either contributes to a higher incidence, or modifies the clinical manifestations and outcomes, are described: ulceration; Charcot neuroarthropathy and necrotic toes. Pathophysiology, clinical features and management strategies for these three conditions are described. Finally, the evidence for preventative strategies for foot disease is explored, and the important role of speed of access to specialist multi-disciplinary diabetic foot services discussed., (© 2012 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Objective: We conducted a retrospective cohort study assessing the prevalence and clinical and radiological outcome of remote areas of bone marrow edema on magnetic resonance imaging (MRI) in the feet of subjects with diabetes and neuropathic foot ulceration., Research Design and Methods: MRIs performed over 6 years looking for osteomyelitis associated with neuropathic lesions were assessed for remote areas of signal change., Results: Seventy MRI studies were assessed. Remote areas of signal change were present in 21 (30%) subjects, involved midfoot or hindfoot in 20 subjects, were associated with younger age and renal replacement therapy, and did not predict future Charcot neuroarthropathy or infection at that site. Repeat MRIs in 11 subjects with such areas found that none had progressed, six had improved, and two had resolved; in 29 subjects without such areas, five had developed new areas., Conclusions: Bone marrow edema in the midfoot and hindfoot of subjects with diabetes and neuropathic lesions is common, often transient, and of unknown significance.

Abstract: Foot disease is a common complication of type-1 and type-2 diabetes. The term ‘diabetic foot’ refers to a spectrum of disease that includes the foot at risk of ulceration, the ulcerated foot, and the Charcot foot. Risk of ulceration is conferred by peripheral neuropathy and peripheral vascular disease. The ulcerated foot can be classified as neuropathic, neuroischaemic or ischaemic. The principles of ulcer management include diagnosis and treatment of infection, establishment and treatment of vascular insufficiency, off-loading and optimization of the wound environment. The Charcot foot is a rare complication of the neuropathic foot and off-loading in the acute phase is important to prevent destruction of joint architecture. Long-established multidisciplinary foot clinics have achieved up to 50% reductions in major amputations in the UK. [Copyright &y& Elsevier]

Abstract: Foot disease is a common complication of type-1 and type-2 diabetes. The term ‘diabetic foot’ refers to a spectrum of disease that includes the foot at risk of ulceration, the ulcerated foot, and the Charcot foot. Risk of ulceration is conferred by peripheral neuropathy, and peripheral vascular disease. The ulcerated foot can be classified as neuropathic, neuroischaemic or ischaemic. The principles of ulcer management include diagnosis and treatment of infection, establishment and treatment of vascular insufficiency, off-loading and optimization of the wound environment. The Charcot foot is a rare complication of the neuropathic foot and off-loading in the acute phase is important to prevent destruction of joint architecture. Long established multidisciplinary foot clinics have achieved up to 50% reductions in major amputations in the UK. [Copyright &y& Elsevier]