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College of Podiatry Conference 2018 Diabetes SAG report

Diabetes Special Advisory Group (SAG) report

Diabetes Big Debate.jpg

Joelle Baynham
Lead Podiatrist – Diabetes Dorset Healthcare University NHS Foundation Trust ‬

The diabetes, vascular and wound care sessions opened with a debate: ‘This House believes that we can prevent lower-limb amputation’ which saw a lively interactive, informative debate between Professor Keith Harding, Director at the Welsh Wound Innovation Centre, arguing against the motion, and Mr Naseer Ahmad, a consultant vascular surgeon at Manchester Royal Infirmary, arguing for the motion. 

Professor Harding opened by arguing that it is impossible to prevent all lower-limb amputations including minor toe amputations. He presented statistics supporting this assertion, including the mortality associated with ulceration in comparison to some cancers, the effect of the globally increasing numbers of those diagnosed with diabetes and the lack of expert care per head of population. He highlighted the continued risk of disparity in care nationally, before moving to debate the use of evidence-based practice; the dearth of systematic reviews and meta-analyses versus the importance of experience; and the assertion that evidence-based medicine requires integration between evidence, clinical expertise, patient values and circumstances. The negative impact of foot ulceration on quality of life was contrasted with the notion of the ‘good amputation’. Data showing the negative social and psychological consequences of diabetic foot ulcers (DFU) were presented to support this. He concluded by maintaining the impossibility of predicting which DFU patients will heal.

Mr Ahmad opposed Professor Harding’s argument by showing data from Manchester Royal Infirmary demonstrating a 23% reduction in major amputation through working as a fully collaborative multidisciplinary team (MDT). The use of toe pressures to assess for ischaemia was highlighted along with data from complex distal bypasses on to the foot showing a 78% one-year limb salvage rate for 28 patients over 2.5 years. He argued that the prevalence of amputation in the population with diabetes is reducing compared to the population without diabetes (18% decrease in the number of major and minor lower-limb amputations in England between 2003 and 2013), with major amputations decreasing . He moved on to compare the burden of foot ulceration in populations with diabetes and without, concluding that 10% in 10% of the population with diabetes presenting with ulceration was equal to 1% in 90% of the population without diabetes. He summed up by suggesting teams consider a switch to MDT care for all high-risk foot patients to enable us to prevent all amputations.

Friday saw Martin Fox, a vascular specialist podiatrist at Manchester Local Care Organisation, opening proceedings with an inspiring lecture on the prevention of premature death with early diagnosis and management of peripheral arterial disease (PAD). His key messages centred on the importance of discussing prognosis, and risk outcomes with patients found to have PAD to enable them to make informed decisions regarding health and lifestyle choices. He highlighted the positive impact and patient support for a DFU risk awareness pilot, which included a poster, clinician advice and patient advice leaflet, to enable prognosis conversations to be engaged in clinics, and highlighted the efficacy of motivational interview skills. He finished with an interesting discussion around the need for rehabilitation and cardiovascular exercise, touching on smoking cessation and e-cigarettes.

Debbie Sharman, Diabetes and Professional Lead for Podiatry at Dorset HealthCare University NHS Foundation Trust, followed with an insightful presentation examining whether re-ulceration in the diabetic foot is preventable. Debbie highlighted the costs involved with caring for DFUs, and the concept of using ‘remission’ as a platform to discuss risk of further ulceration and amputation rather than healing, which suggests the end of care. She introduced biological, behavioural predictors for ulcer recurrence and examined the evidence for reducing risk of recurrence such as therapeutic footwear, surgical (orthopaedic) interventions, educational strategies and integrated foot care, concluding that the evidence suggests a need for clear care pathways, structured surveillance and care with a specific focus on behaviour for those in remission from DFUs.

Duncan Stang, National Diabetes Foot Co-Ordinator for Scotland, finished the sessions with an overview on work undertaken to prevent hospital acquired ulcers – CPR for feet, beginning with an explanation of the system to ensure all patients on admission to hospital have their feet checked, if their feet are at risk they are protected , and if they are found to have a problem they are referred. Duncan presented the results of the Scottish Diabetes audit, which revealed 60% of inpatients are at risk of developing an ulcer without pressure relief and 2.4% of developing an ulcer as inpatients. The group at highest risk of hospital-acquired ulceration were those with diabetes, PAD, stroke, and renal impairment, particularly during surgery and post-operatively when the ability to reposition spontaneously is reduced. He illustrated the need for collaboration with other health care experts and Parliamentary agreement in achieving buy-in across all hospitals. Duncan shared the pressure relief algorithm and range of offloading products and ended by discussing the ward-based training package, and new online training resource for clinical and social care staff.