Recent developments in targets for ischemic foot disease.

Diabetes is a key risk factor for ischaemic foot disease, which causes pain, tissue loss, hospital admission, and major amputation. Currently, treatment focuses on revascularisation, but many patients are unsuitable for surgery and revascularisation is frequently unsuccessful. The authors describe recent research in animal models and clinical trials investigating novel medical targets for ischaemia, including theories about impaired wound healing, animal models for limb ischaemia and recent randomised controlled trials testing novel medical therapies. Novel targets identified in animal models included stimulating mobilisation of CD34+ progenitor cells through upregulating oncostatin M or microRNA-181, downregulating tumour necrosis factor superfamily member 14, or activating the Wingless pathway. Within the ischaemic limb vasculature, upregulation of apolipoprotein L domain containing 1, microRNA-130b or long noncoding RNA that enhances endothelial nitric oxide synthase expression promoted limb blood supply recovery, angiogenesis, and arteriogenesis. Similarly, administration of soluble guanylate cyclase stimulators riociguat or praliciguat or 3-ketoacyl-CoA thiolase inhibitor trimetazidine promoted blood flow recovery. Translating pre-clinical findings to patients has been challenging, mainly due to limitations in clinically translatable animal models of human disease. Promising results have been reported for administering plasmids encoding hepatocyte growth factor or intra-arterial injection of bone marrow derived cells in small clinical trials. It remains to be seen whether these high resource therapies can be developed to be widely applicable. In conclusion, an ever-expanding list of potential targets for medical revascularisation is being identified. It is hoped that through ongoing research and further larger clinical trials, these will translate into new broadly applicable therapies to improve outcomes.

A prospective cohort study examining the association of claw anatomy and sole temperature with the development of claw horn disruption lesions in dairy cattle.

Foot characteristics have been linked to the development of sole lesions (sole hemorrhage and sole ulcers) and white line lesions, also known as claw horn disruption lesions (CHDL). The objective of this study was to examine the association of claw anatomy and sole temperature with the development of CHDL. A cohort of 2,352 cows was prospectively enrolled from 4 UK farms and assessed at 3 time points: before calving (T1-precalving), immediately after calving (T2-calving), and in early lactation. At each time point body condition score was recorded, a thermography image of each foot was taken for sole temperature measurement, the presence of CHDL was assessed by veterinary surgeons, and an ultrasound image was taken to retrospectively measure the digital cushion and sole horn thickness. Additionally, at the postcalving time point, foot angle and heel depth were recorded. Four multivariable logistic regression models were fit to separately examine the relationship of precalving and postcalving explanatory variables with the development of either white line lesions or sole lesions. Explanatory variables tested included digital cushion thickness, sole horn thickness, sole temperature, foot angle, and heel depth. Farm, parity, body condition score, and presence of lesion at the time of measurement were also included in the models. A thicker digital cushion shortly after calving was associated with decreased odds of cows developing sole lesions during early lactation (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.65-0.84). No association was found between digital cushion thickness and development of white line lesions. Sole temperature after calving was associated with increased odds of the development of sole lesions (OR: 1.03, 95% CI: 1.02-1.05), and sole temperature before and after calving was associated with the development of white line lesions (T1-precalving OR: 1.04, 95% CI: 1.01-1.07; T2-calving OR: 0.96, 95% CI: 0.93-0.99). Neither foot angle nor heel depth was associated with the development of either lesion type. However, an increased sole horn thickness after calving reduced the odds of cows developing sole lesions during early lactation (OR: 0.88, 95% CI: 0.83-0.93), highlighting the importance of maintaining adequate sole horn when foot trimming. Before calving, animals with a lesion at the time of measurement and a thicker sole were more likely to develop a sole lesion (OR: 1.23, 95% CI: 1.09-1.40), compared with those without a sole lesion. The results presented here suggest that white line and sole lesions may have differing etiopathogenesis. Results also confirm the association between the thickness of the digital cushion and the development of sole lesions, highlight the association between sole horn thickness and sole lesions, and challenge the potential importance of foot angle and heel depth in the development of CHDL.

The financial burden of diabetes-related foot disease in Australia: a systematic review.

BACKGROUND: Diabetes-related foot disease (DFD) is a common, costly, and severe complication of diabetes mellitus. DFD is associated with high rates of morbidity and mortality and poses a significant burden on patients, healthcare systems and society. While the detrimental impact of DFD is widely recognised, the precise financial implications of its management in Australia remain unclear due to inconsistent and inconclusive contemporary data. Therefore, the aim of this review was to identify, summarise and synthesise existing evidence to estimate the costs associated with DFD management in Australia. METHODS: Searches were conducted in MEDLINE, Embase, AMED, CINAHL, Joanna Briggs Institute EBP, and the Cochrane Library from November 2011 to July 2023. Australian studies investigating costs associated with DFD management were eligible for inclusion. Two independent reviewers performed the study selection, data extraction and quality assessment steps. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) checklist was used to assess study quality. A descriptive analysis was performed due to limited existing evidence and large heterogeneity between study populations to conduct meta-analyses. RESULTS: Three economic evaluations were included in the review. One study was rated as 'poor', one as 'very good' and one as 'excellent' when assessed against the CHEERS checklist. The estimated cost of DFD management varied between studies and comparisons were not possible due to the different methodological approaches and data sources. The studies were unable to provide an overall cost of DFD with respect to all aspects of care as they did not capture the multi-faceted level of care throughout the entire patient journey between sectors and over time. CONCLUSION: There is limited contemporary evidence for the costs associated with DFD management within Australia, particularly related to direct costs and resource utilisation. Further research into the economic impact of DFD management is needed to inform optimisation of national service delivery and improve health outcomes for individuals with DFD in Australia. Integrating real-world data on impact of clinical interventions with parallel economic evaluation could be a valuable approach for future research, which would offer a more comprehensive understanding of the clinical and economic outcomes beyond solely model-based evaluations. TRIAL REGISTRATION: PROSPERO Registration No. CRD42022290910.

The prevalence of foot pain and association with baseline characteristics in people participating in education and supervised exercise for knee or hip osteoarthritis: a cross-sectional study of 26,003 participants from the GLA:D® registry.

BACKGROUND: Osteoarthritis (OA) affecting the knee or hip is highly prevalent in the general population and has associated high disease burden. Early identification of modifiable risk factors that prevent, limit, or resolve disease symptoms is critical. Foot pain may represent a potentially modifiable factor however little is known about the prevalence of foot pain in people with knee or hip OA nor whether foot pain is associated with clinical characteristics. The main aim of this study was therefore to determine the prevalence of foot pain in people with knee or hip OA attending an education and supervised exercise-based intervention in Denmark (GLA:D®) and determine if baseline demographic or clinical characteristics are associated with foot pain. METHODS: Analysis was conducted on baseline data of 26,003 people with symptomatic knee or hip OA completing a pain mannequin as part of the Good Life with osteoArthritis in Denmark (GLA:D®) primary care programme. Odds Ratios (OR) and 95% confidence intervals (CI) were calculated to estimate the strength of association between baseline clinical characteristics (including pain severity in worst knee/hip joint, number of painful knee/hip joints, pain medication use and physical activity level) and the presence of baseline foot pain. RESULTS: Twelve percent of participants (n = 3,049) reported foot pain. In those people with index knee OA (n = 19,391), knee pain severity (OR 1.01 CI 1.00, 1.01), number of painful knee/hip joints (OR 1.67 CI 1.58, 1.79), and use of pain medication (OR 1.23 CI 1.12, 1.36) were statistically associated with foot pain. Excluding use of pain medication, similar associations were seen in those with index hip OA. CONCLUSION: Twelve percent of people with knee or hip OA participating in GLA:D® had foot pain. Those with worse knee/hip pain, and greater number of painful joints were more likely to report foot pain. This study is the first to demonstrate a significant relationship between clinical characteristics and foot pain in people with knee or hip OA participating in education and supervised exercise. Future investigation should consider the role that foot pain may play on knee and hip related outcomes following therapeutic intervention.

The foot in diabetes - a reminder of an ever-present risk.

The term 'diabetic foot disease' (DFD) often signifies the presence of foot ulceration and infection, but one must also be wary of the rarer occurrence of Charcot foot disease. The worldwide prevalence of DFD is 6.3% (95%CI: 5.4-7.3%). Foot complications present a major challenge to both patients and healthcare systems, with increased rates of hospitalisation and an almost trebled 5-year mortality. The Charcot foot often occurs in patients with long-standing diabetes, presenting as an inflamed or swollen foot or ankle, following unrecognised minor trauma. This review focuses on the prevention and early identification of the 'at-risk' foot. DFD is best managed by a multi-disciplinary foot clinic team consisting of podiatrists and healthcare professionals. This ensures a combination of expertise and provision of a multi-faceted evidence-based treatment plan. Current research using endothelial progenitor cells (EPC) and mesenchymal stem cells (MSC) offers a new dimension in wound management.

A multistate modeling approach to investigate long-term effects of claw horn disruption lesions and early lesion development in dairy cows.

Claw horn disruption lesions (CHDL) are a leading cause of lameness in dairy cattle, and the development, effect, and pathology of these lesions remains an open area of interest within dairy cattle health. Current literature typically attempts to measure the effect of risk factors on the development of CHDL over a relatively short time period. Further understanding of the interaction of CHDL and the long-term effect of early CHDL in a cow's life remains an important area of research which is so far mostly unexplored. In this study 57,974 cows from 1,332 herds were selected and their regular claw trimming records containing important claw health information were used to model the long-term effect of lesions in a cow's lifetime in a 6-state multistate model. A multistate model predicts the time before transition from any one state to another and the probability of transition to a future state. The 6 lesion states that were modeled were as follows: never had a lesion, first recorded lesion event, no recorded lesion after first lesion event, second or subsequent recorded lesion event, no recorded lesion after second or subsequent lesion event, and culled. The effect of various cow level covariates on the transition probabilities between various states was tested. For the first time, this study shows the importance and effect of the first lesion and other cow level factors on long-term claw health. Model results showed that the timing and severity of the first recorded lesion event significantly influenced the likelihood of a future lesion being present. Cows with CHDL present within the 180 d of first calving had a short-term increased risk and long-term decreased risk of a future lesion, compared with cows that present with CHDL later than 180 d of first lactation. Moreover, presence of a severe first lesion increased a cow's risk of a future lesion being present. The model was used to evaluate the relative difference between high-risk cows (age of first calving ≥793 d, breeding values in the lowest quartile) and low-risk cows (age of first calving ≤718 d, breeding values in the highest quartile). Our results indicated that these low-risk cows present with a lesion on an average 3 mo later than high-risk cows. Furthermore, results from the model evaluation of a simulated herd with cows with breeding values in the higher quartile indicated that cows present with a CHDL on an average 7.5 mo later compared with a herd where cows have breeding values distributed in a lower quartile.

Cost of lameness in dairy herds: An integrated bioeconomic modeling approach.

Foot disorders are costly health disorders in dairy farms, and their prevalence is related to several factors such as breed, nutrition, and farmer's management strategy. Very few modeling approaches have considered the dynamics of foot disorders and their interaction with farm management strategies within a holistic farm simulation model. The aim of this study was to estimate the cost of foot disorders in dairy herds by simulating strategies for managing lameness. A dynamic and stochastic simulation model (DairyHealthSim) was used to simulate the herd dynamics, reproduction management, and health events. A specific module was built for lameness and related herd-level management strategies. Foot disorder occurrences were simulated with a base risk for each etiology [digital dermatitis (DD), interdigital dermatitis, interdigital phlegmon, sole ulcer (SU), white line disease (WLD)]. Two state machines were implemented in the model: the first was related to the disease-induced lameness score (from 1 to 5), and the second concerned DD-state transitions. A total of 880 simulations were run to represent the combination of the following 5 scenarios: (1) housing (concrete vs. textured), (2) hygiene (2 different scraping frequencies), (3) the existence of preventive trimming, (4) different thresholds of DD prevalence detected and from which a collective footbath is applied to treat DD, and (5) farmer's ability to detect lameness (detection rate). Housing, hygiene, and trimming scenarios were associated with risk factors applied for each foot disorder etiologies. The footbath and lameness detection scenarios both determined the treatment setup and the policy of herd observance. The economic evaluation outcome was the gross margin per year. A linear regression model was run to estimate the cost per lame cow (lameness score ≥3), per case of DD and per week of a cow's medium lameness duration. The bioeconomic model reproduced a lameness prevalence varying from 26 to 98% depending on the management scenario, demonstrating a high capacity of the model to represent the diversity of the field situations. Digital dermatitis represented half of the total lameness cases, followed by interdigital dermatitis (28%), SU (19%), WLD (13%), and interdigital phlegmon (4%). The housing scenarios dramatically influenced the prevalence of SU and WLD, whereas scraping frequency and threshold for footbath application mainly determined the presence of DD. Interestingly, the results showed that preventive trimming allowed a better reduction in lameness prevalence than spending time on early detection. Scraping frequency was highly associated with DD occurrence, especially with a textured floor. The regression showed that costs were homogeneous (i.e., did not change with lameness prevalence; marginal cost equals average cost). A lame cow and a DD-affected cow cost €307.50 ± 8.40 (SD) and €391.80 ± 10.0 per year on average, respectively. The results also showed a cost of €12.10 ± 0.36 per week-cow lameness. The present estimation is the first to account for interactions between etiologies and for the complex DD dynamics with all the M-stage transitions, bringing a high level of accuracy to the results.

Foot self-care competence reported by patients with rheumatoid arthritis: a cross-sectional study.

BACKGROUND: Foot self-care is important for preventing foot problems and maintaining one's foot health. Foot self-care requires competence to identify foot problems, knowledge and skills to care for those problems, and a willing attitude to care for one's foot health. However, there is major gap in the research evidence of foot self-care competence among patients with rheumatoid arthritis. This study aimed to analyse self-reported levels of competence in foot self-care among patients with rheumatoid arthritis. METHODS: A cross-sectional study design was used. Data were collected using a survey consisting of a self-reported competence in foot self-care competence scale (response options on 5-point Likert scale, higher values indicate higher competence) and background questions. The data were analysed with descriptive and inferential statistics and the psychometric properties of the scale using Rasch analysis. RESULTS: The participants' (n = 251) self-reported level of competence in foot self-care was moderate (mean 3.50, standard deviation [SD], 0.66). On the sum variable level, the highest mean score was for attitude towards foot self-care (3.98; SD, 0.69), followed by foot self-care knowledge (3.45; SD, 0.67) and experience providing foot self-care (3.38; SD, 0.69). Higher self-reported foot self-care knowledge and female sex were associated with higher self-reported competence in every sum variable. CONCLUSIONS: Patients with rheumatoid arthritis evaluated their level of competence in foot self-care as moderate and some deficiencies were identified. These results indicate the importance of educating patients with rheumatoid arthritis about how to advance their foot self-care skills and knowledge. In the future, patients with rheumatoid arthritis could benefit from interventions that increase their knowledge of foot self-care together with practical examples, such as online videos, that demonstrate the practical conduct of foot self-care skills in daily life.

Hoof lesions in partly housed pasture-based dairy cows.

Lameness is a symptom of a painful disorder affecting the limbs, which impacts dairy cow welfare and productivity. Lameness is primarily caused by hoof lesions. The prevalence of different lesion types can differ depending on environmental conditions and farm management practices. The aims of this observational study were to establish the cow-level and herd-level lesion prevalence during both housing and grazing periods in a partly housed, pasture-based system, establish the prevalence of lesions always associated with pain ("alarm" lesion), identify the lesions associated with a higher lameness score, determine relationships between lesions, and identify risk factors for digital dermatitis. On 98 farms during the grazing period and on 74 of the same farms during the housing period, every cow was lameness scored (0-3 lameness scoring scale), and the hind hooves of lame cows (score 2 and 3) were examined (maximum 20 cows per visit) and the prevalence of each lesion type recorded. To gather data on potential predictors for the risk factor analysis, a questionnaire with the farmer was conducted on lameness management practices and infrastructure measurements were taken at each visit. Cow-level data were also collected (e.g., parity, breed, milk yield, and so on). Noninfectious lesions were found to be more prevalent than infectious lesions in this system type. The most prevalent lesion types during both grazing and housing periods were white line separation, sole hemorrhages and overgrown claws; all remaining lesions had a cow-level prevalence of less than 15%. The cow-level prevalence of alarm lesions was 19% during the grazing period and 25% during the housing period; the most prevalent alarm lesion was sole ulcers during both periods. We found significantly more foreign bodies within the hoof sole (grazing = 14%, housing = 7%) and overgrown claws (grazing = 71%, housing = 55%) during the grazing period compared with the housing period. Cows with foul of the foot, sole ulcer, white line abscess, toe necrosis or an amputated claw had higher odds of being more severely lame, compared with mildly lame. The strongest correlation between lesions were between toe necrosis and digital dermatitis (r = 0.40), overgrown claws and corkscrew claws (r = 0.33), and interdigital hyperplasia and digital dermatitis (r = 0.31) at herd level. At the cow level, the strongest correlation was between overgrown claws and corkscrew claws (r = 0.27), and digital dermatitis and heel erosion (r = 0.22). The farmers' perception of the presence of digital dermatitis (and lameness) was significantly correlated with the actual presence of digital dermatitis recorded. Additional risk factors for the presence of digital dermatitis were cow track and verge width near the collecting yard, and stone presence on the cow tracks. Results from this study help further our understanding of the causes of lameness in partly housed, pasture-based dairy cows, and can be used to guide prevention and treatment protocols.

Foot pain and inflammatory markers: a cross sectional study in older adults.

BACKGROUND: Foot disorders may limit independence and reduce quality of life for older adults. Obesity is a risk factor for foot conditions; both mechanical load and metabolic effects may contribute to these conditions. This study determined cross-sectional associations between inflammatory markers and foot disorders. METHODS: Participants were drawn from the Framingham Foot Study (2002-2008). C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-α) were each examined for associations with foot pain, forefoot pain, hindfoot pain, hallux valgus, hallux rigidus, and toe deformities (claw, hammer, or overlapping toes). Unadjusted and adjusted (age, body mass index, physical activity, smoking status) sex-specific logistic regression was performed. RESULTS: Of 909 participants, 54% were women (mean age 65 [Formula: see text] 9 years), 20% had foot pain, 29% had hallux valgus, 3% had hallux rigidus, and 27% had toe deformities. In unadjusted models, higher CRP (OR [95% CI] = 1.5 [1.1, 2.0]) and IL-6 (OR [95% CI] = 1.8 [1.2, 2.6]) were associated with foot pain among men; higher CRP was associated with foot pain (OR [95% CI] = 1.3 [1.0, 1.5]) among women. Higher CRP (OR [95% CI] = 1.9 [1.1, 3.2]) and IL-6 (OR [95% CI] = 2.4 [1.2, 4.7]) were associated with forefoot pain in men. Higher CRP was associated with hindfoot pain ([95% CI] = 1.8 [1.2, 2.6]) in women. After adjustment, CRP ([95% CI] = 1.5 [1.1, 2.0]) and IL-6 ([95% CI] = 1.8 [1.2, 2.6]) remained associated with foot pain in men, and IL-6 with forefoot pain ([95% CI] = 2.9 [1.4, 6.1]) in men. No associations with structural foot disorders were observed. CONCLUSIONS: Inflammation may impact foot pain. Future work assessing whether inflammation is part of the mechanism linking obesity to foot pain may identify areas for intervention and prevention.

Radiographic Cutoff Values for Predicting Lateral Bony Impingement in Progressive Collapsing Foot Deformity.

BACKGROUND: Lateral bony impingement is a major cause of lateral foot pain in progressive collapsing foot deformity (PCFD). Weightbearing computed tomography (WBCT) provides better sensitivity than standard radiographs for detecting impingement. However, many orthopaedic centers have not yet acquired WBCT imaging. This study aimed to (1) investigate the correlation of common radiographic parameters measured on standard weightbearing radiographs with talocalcaneal and calcaneofibular distance assessed with WBCT and (2) establish radiographic cutoff values to detect bony impingement as identified on WBCT. METHODS: Ninety-one patients treated for PCFD with standard preoperative radiographs and WBCT were identified. Patients with asymmetric ankle arthritis (talar tilt >2 degrees) were excluded. The talocalcaneal distance at the sinus tarsi and calcaneofibular distance were measured in multiplanar reconstructed WBCT images. Impingement was defined as direct abutment between bones. The relationships between WBCT measurements and 4 common parameters (talonavicular coverage angle [TNC], talo-first metatarsal angle, calcaneal pitch, and hindfoot moment arm [HMA]) in standard radiographs were assessed with Pearson correlations. Receiver operating characteristic curve analysis evaluated the ability of radiographic cutoffs to detect sinus tarsi or calcaneofibular bony impingement, and the area under curve (AUC), sensitivity, specificity, negative and positive predictive value (PPV) were calculated. RESULTS: Talocalcaneal distance narrowing at the sinus tarsi strongly correlated with TNC (r = 0.64, P < .001), and the calcaneofibular distance narrowing correlated with the HMA moderately yet best among the parameters (r = 0.55, P < .001). TNC (AUC = 0.837, 95% CI 0.745-0.906) and HMA (AUC=0.959, 95% CI 0.895-0.989) provided the best predictive ability for sinus tarsi and calcaneofibular bony impingement, respectively. A TNC threshold of 41.2 degrees had a 100% PPV for predicting sinus tarsi impingement, whereas an HMA threshold of 38.1 mm had a 100% PPV for calcaneofibular impingement. CONCLUSION: This study provides evidence that TNC and HMA measurements made on standing radiographs could be used to indicate potential lateral bony impingement in PCFD. Narrowing of talocalcaneal distance best correlated with abduction deformity of the foot, and the narrowing of calcaneofibular distance was best correlated with valgus hindfoot deformity. LEVEL OF EVIDENCE: Level III, case control study.

Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

Diabetes-related foot infections cause substantial morbidity and mortality, both globally and in Australia. There is a need for up-to-date evidence-based guidelines to ensure optimal management of patients with diabetes-related foot infections. We aimed to identify and adapt high quality international guidelines to the Australian context to become the new Australian evidence-based guideline for people with a diabetes-related foot infection. Following Australian National Health and Medical Research Council (NHMRC) procedures we identified the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines as suitable for adaptation to the Australian context. Guidelines were screened, assessed and judged by an expert panel for the Australian context using the guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Judgements led to recommendations being adopted, adapted or excluded, with additional consideration regarding their implementation, monitoring and future research for the Australian context. Clinical pathways were then developed to assist implementation. Of 36 original diabetes-related foot infection IWGDF sub-recommendations, 31 were adopted, four were adapted and one was excluded. Adaption was primarily undertaken due to differences or clarification of the sub-recommendations' intended population. One sub-recommendation was excluded due to substantial differences in judgements between the panel and IWGDF and unacceptable heterogeneity of the target population. Therefore, we developed 35 evidence-based sub-recommendations for the Australian context that should guide best practice diagnosis and management of people with diabetes-related foot infection in Australia. Additionally, we incorporated these sub-recommendations into two clinical pathways to assist Australian health professionals to implement these evidence-based sub-recommendations into clinical practice. A new national guideline for the diagnosis and management of people with diabetes-related foot infections were successfully developed for the Australian context. In combination with simplified clinical pathway tools they provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections across Australia and highlight considerations for implementation and monitoring.

Guidelines development protocol and findings: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease.

BACKGROUND: Diabetes-related foot disease (DFD) is a leading cause of the Australian disease burden. The 2011 Australian DFD guidelines were outdated. We aimed to develop methodology for systematically adapting suitable international guidelines to the Australian context to become the new Australian evidence-based guidelines for DFD. METHODS: We followed the Australian National Health Medical Research Council (NHMRC) guidelines for adapting guidelines. We systematically searched for all international DFD guideline records. All identified records were independently screened and assessed for eligibility. Those deemed eligible were further assessed and included if scoring at least moderate quality, suitability and currency using AGREE II and NHMRC instruments. The included international guidelines had all recommendations extracted into six sub-fields: prevention, wound classification, peripheral artery disease, infection, offloading and wound healing. Six national panels, each comprising 6-8 multidisciplinary national experts, screened all recommendations within their sub-field for acceptability and applicability in Australia using an ADAPTE form. Where panels were unsure of any acceptability and applicability items, full assessments were undertaken using a GRADE Evidence to Decision tool. Recommendations were adopted, adapted, or excluded, based on the agreement between the panel's and international guideline's judgements. Each panel drafted a guideline that included all their recommendations, rationale, justifications, and implementation considerations. All underwent public consultation, final revision, and approval by national peak bodies. RESULTS: We screened 182 identified records, assessed 24 full text records, and after further quality, suitability, and currency assessment, one record was deemed a suitable international guideline, the International Working Group Diabetic Foot Guidelines (IWGDF guidelines). The six panels collectively assessed 100 IWGDF recommendations, with 71 being adopted, 27 adapted, and two excluded for the Australian context. We received 47 public consultation responses with > 80% (strongly) agreeing that the guidelines should be approved, and ten national peak bodies endorsed the final six guidelines. The six guidelines and this protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/ CONCLUSION: New Australian evidence-based guidelines for DFD have been developed for the first time in a decade by adapting suitable international guidelines. The methodology developed for adaptation may be useful for other foot-related conditions. These new guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia.

Psychological factors associated with foot and ankle pain: a mixed methods systematic review.

BACKGROUND: Foot and ankle pain is common, and generally viewed through a biomedical lens rather than applying a biopsychosocial model. The objectives of this review were to evaluate: (1) the psychosocial characteristics of participants with foot/ankle pain compared to participants without foot/ankle pain; (2) the association between psychosocial factors with pain and function in people with foot/ankle pain; and (3) understand the psychosocial factors associated with the lived experience of foot/ankle pain. METHODS: A mixed methods systematic review was conducted according to the PRISMA guidelines and guided by the Joanna Briggs Institute methodology for mixed methods systematic reviews. The databases MEDLINE, Embase, CINAHL, SPORTDiscus, PsychInfo, and Scopus were searched. The Mixed Methods Assessment Tool was used to evaluate study quality. A convergent segregated approach was used to synthesise and integrate quantitative and qualitative data. RESULTS: Eighteen studies were included, consisting of 13 quantitative, 4 qualitative and 1 mixed methods study. The overall quality of the studies was considered high. Integration of the quantitative and qualitative data were not possible due to the disparate nature of the included studies. A narrative synthesis of the quantitative data revealed that negative emotional and cognitive factors were more common in people with foot/ankle pain compared to those without foot/ankle pain. A significant association was also found between emotional distress with foot pain and foot function in some people with plantar heel pain. In addition, kinesiophobia and pain catastrophising were significantly associated with impaired foot function, and pain catastrophising was significantly associated with first step pain in people with plantar heel pain. The qualitative data revealed emotional impacts, physical challenges, and a loss of self which was individual and unpredictable. CONCLUSIONS: This review provides evidence that negative psychological constructs are greater in participants with foot/ankle pain compared to those without foot/ankle pain, although the cross-sectional nature of the study designs included in this review reduces the certainty of the evidence. These findings indicate that psychological constructs are associated with foot/ankle pain. Further research should evaluate the predictive ability of multidimensional screening tools to identify patients at risk of developing persistent foot/ankle pain.

Malignant neoplasms originating from the bones of the foot: Predilection of hematological malignancies and sex-related and ethnic disparities in amputation.

PURPOSE: Neoplasms originating from the "small bones of the lower limb and the overlapping joints" are rare but portend a serious prognosis. Current study utilizes a population-based registry in the United States to characterize the malignancies of the foot. METHODS: National Cancer Institute's Surveillance, Epidemiology and End Result database from 1975 to 2017 was queried to report incidence and survival data in 514 patients in the Uited States. Kaplan-Meier and Cox Regression were used to determine the prognostic factors affecting survival. Chi square test was used to assess the correlation. RESULTS: Hematological malignancies constituted 14.8% of the entire cohort. Incidence of the foot neoplasms was 0.024 per 100 000 persons in 2017 and has not significantly changed since 1975 (p > 0.05). Disease-specific-5-year survival for the entire cohort was 73%. On multivariate analysis younger age groups, "localized" stage and extent of surgical resection were predictors of improved outcomes. A significant correlation was found between amputation with male sex and Hispanic ethnicity. CONCLUSIONS: The current study analyzes data from population-based registry reporting incidence and survival data for patients with neoplasms of the foot. Independent prognostic factors include age, stage and extent of surgical resection. Amputation was found to be associated with male sex and Hispanic ethnicity.