Guidelines on the classification of foot ulcers in people with diabetes (IWGDF 2023 update).

BACKGROUND: This publication represents a scheduled update of the 2019 guidelines of the International Working Group of the Diabetic Foot (IWGDF) addressing the use of systems to classify foot ulcers in people with diabetes in routine clinical practice. The guidelines are based on a systematic review of the available literature that identified 28 classifications addressed in 149 articles and, subsequently, expert opinion using the GRADE methodology. METHODS: First, we have developed a list of classification systems considered as being potentially adequate for use in a clinical setting, through the summary of judgements for diagnostic tests, focussing on the usability, accuracy and reliability of each system to predict ulcer-related complications as well as use of resources. Second, we have determined, following group debate and consensus, which of them should be used in specific clinical scenarios. Following this process, in a person with diabetes and a foot ulcer we recommend: (a) for communication among healthcare professionals: to use the SINBAD (Site, Ischaemia, Bacterial infection, Area and Depth) system (first option) or consider using WIfI (Wound, Ischaemia, foot Infection) system (alternative option, when the required equipment and level of expertise is available and it is considered feasible) and in each case the individual variables that compose the systems should be described rather than a total score; (b) for predicting the outcome of an ulcer in a specific individual: no existing system could be recommended; (c) for characterising a person with an infected ulcer: the use of the IDSA/IWGDF classification (first option) or consider using the WIfI system (alternative option, when the required equipment and level of expertise is available and it is considered as feasible); (d) for characterising a person with peripheral artery disease: consider using the WIfI system as a means to stratify healing likelihood and amputation risk; (e) for the audit of outcome(s) of populations: the use of the SINBAD score. CONCLUSIONS: For all recommendations made using GRADE, the certainty of evidence was judged, at best, as being low. Nevertheless, based on the rational application of current data this approach allowed the proposal of recommendations, which are likely to have clinical utility.

Classification of foot ulcers in people with diabetes: A systematic review.

BACKGROUND: Classification and scoring systems can help both clinical management and audit the outcomes of routine care. AIM: This study aimed to assess published systems used to characterise ulcers in people with diabetes to determine which should be recommended to (a) aid communication between health professionals, (b) predict clinical outcome of individual ulcers, (c) characterise people with infection and/or peripheral arterial disease, and (d) audit to compare outcomes in different populations. This systematic review is part of the process of developing the 2023 guidelines to classify foot ulcers from the International Working Group on Diabetic Foot. METHODS: We searched PubMed, Scopus and Web of Science for articles published up to December 2021 which evaluated the association, accuracy or reliability of systems used to classify ulcers in people with diabetes. Published classifications had to have been validated in populations of >80% of people with diabetes and a foot ulcer. RESULTS: We found 28 systems addressed in 149 studies. Overall, the certainty of the evidence for each classification was low or very low, with 19 (68%) of the classifications being assessed by ≤ 3 studies. The most frequently validated system was the one from Meggitt-Wagner, but the articles validating this system focused mainly on the association between the different grades and amputation. Clinical outcomes were not standardized but included ulcer-free survival, ulcer healing, hospitalisation, limb amputation, mortality, and cost. CONCLUSION: Despite the limitations, this systematic review provided sufficient evidence to support recommendations on the use of six particular systems in specific clinical scenarios.

Differences between national and international guidelines for the management of diabetic foot disease.

AIM: No studies have investigated if national guidelines to manage diabetic foot disease differ from international guidelines. This study aimed to compare guidelines of Western Pacific nations with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. METHODS: The 77 recommendations in five chapters of the 2015 IWGDF guidance documents were used as the international gold standard reference. The IWGDF national representative(s) from 12 Western Pacific nations were invited to submit their nation's diabetic foot guideline(s). Four investigators rated information in the national guidelines as "similar," "partially similar," "not similar," or "different" when compared with IWGDF recommendations. National representative(s) reviewed findings. Disagreements in ratings were discussed until consensus agreement achieved. RESULTS: Eight of 12 nations (67%) responded: Australia, China, New Zealand, Taiwan, and Thailand provided national guidelines; Singapore provided the Association of Southeast Asian Nations guidelines; and Hong Kong and the Philippines advised no formal national diabetic foot guidelines existed. The six national guidelines included were 39% similar/partially similar, 58% not similar, and 2% different compared with the IWGDF recommendations. Within individual IWGDF chapters, the six national guidelines were similar/partially similar with 53% of recommendations for the IWGDF prevention chapter, 42% for wound healing, 40% for infection, 40% for peripheral artery disease, and 20% for offloading. CONCLUSIONS: National diabetic foot disease guidelines from a large and diverse region of the world showed limited similarity to recommendations made by international guidelines. Differences between recommendations may contribute to differences in national diabetic foot disease outcomes and burdens.

An Asian Perspective on Povidone Iodine in Wound Healing.

Antiseptics, with a broader spectrum of antimicrobial efficacy, lower risk of antibiotic resistance development, and minimal collateral damage to host tissues, are important alternatives to control the bioburden in wounds. Povidone iodine (PVP-I), in use for several decades, has the broadest spectrum of activity, a persistent antimicrobial effect, an ability to penetrate biofilms, and a lack of acquired or cross-resistance. It demonstrates good skin tolerance and low cytotoxicity. However, some reports on PVP-I have raised concerns over allergy, ineffective penetration, and toxic effects on host cells. The majority of these concerns are based on in vitro or rodent wound studies with diverse study designs and outcomes; these results may not be directly applicable in the clinical reality in humans. In this paper, we discuss the efficacy and safety of PVP-I and outline its place in wound healing in Asia, based on an appraisal of recent literature and clinical practice across the region.

Effect of hand size on the stimulation intensities required for median and ulnar sensory nerve conduction studies.

OBJECTIVES: To examine the effect of hand size on median and ulnar sensory nerve conduction study (NCS) stimulation intensities and pain scores. DESIGN: Prospective, single group design to compare main outcomes by using a standard distance of 14cm versus the proximal wrist crease in 3 different hand sizes. SETTING: Electrodiagnostic laboratory in a department of rehabilitation medicine. PARTICIPANTS: Healthy volunteers (N=25) aged 20 to 30 years. INTERVENTIONS: Hand size was determined, based on the distance between the proximal wrist crease and the base of the long finger, resulting in 3 groups (≤11cm, >11-12cm, >12cm) with 12 hands per group. Antidromic median and ulnar sensory NCSs were performed. The nerves were randomly stimulated at the proximal wrist crease and 14cm from the recording electrode. MAIN OUTCOME MEASURES: Supramaximal stimulation intensities and 10-cm visual analog scale (VAS) pain scores at each stimulating site were recorded and compared. RESULTS: Thirty-six hands from 25 young healthy volunteers were studied. There was no correlation between the body mass index (BMI) and stimulation intensity, and BMI and VAS (r<0.3) in both median and ulnar nerves. Overall analysis showed that the stimulation intensity and VAS at 14cm were significantly greater than at the proximal wrist crease. Subgroup analysis showed the same result in all groups for the median sensory NCS, but in only the small hand group for the ulnar sensory NCS. CONCLUSIONS: When the same distance is used for NCSs regardless of patient size, smaller individuals required greater stimulation and reported greater discomfort. This may reflect greater nerve depth and suggests that one size fits all may not be the best approach with NCSs.

The effect of calf stretching box on stretching calf muscle compliance: a prospective, randomized single-blinded controlled trial.

PRIMARY OBJECTIVE: To study the effect of calf stretching box usage in increasing the compliance of performing calf stretching exercise as compared to the conventional exercise method. SECONDARY OBJECTIVE: To study the effect of calf stretching box usage in decreasing the calf muscle tightness and complications as compared to the conventional exercise method. MATERIAL AND METHOD: Eighty patients older than 45 years old with calf muscles tightness were enrolled in a prospective, randomized single-blinded controlled trial at the out-patient Rehabilitation medicine clinic, Siriraj Hospital, Bangkok Thailand between April and August 2009. Patients were randomized into two groups, the study group (stretching by using calf stretching box) and the control group (stretching by the conventional exercise method). Patients in both groups were asked to hold the stretch for at least 1 minute and to perform the stretching program at least two times per day, every day for two weeks. Furthermore, they were asked to record the real frequency and duration of their exercise and complications in a logbook every day. RESULTS: Thirty-eight patients in each group completed the study. The baseline characteristics of the patients in both groups were similar. The study group had higher frequency and longer duration of performing calf stretching exercise than the control group. They also reported more decrease of calf muscle tightness with less pain complication (shoulder pain, knee pain, low back pain, and calf muscle pain) than the control group (p < 0.05). However, there were no significant differences in the (between before and after) numbers of taut bands, trigger points, and tender points of calf muscle and degree of ankle range of motion between the two groups. CONCLUSION: Stretching calf muscle with calf stretching box can increase compliance, decrease calf muscle tightness and decrease complications when compared with the conventional exercise method.

Decreased health-related quality of life in patients with diabetic foot problems.

PURPOSE: The aim of this study was to investigate health-related quality of life (HRQoL) in patients with diabetic foot problems and compare the HRQoL between diabetic patients with: 1) diabetic foot problems (DF), including diabetic foot ulcer (DFU) or amputation (AMPU); 2) other diabetic complications (COM), such as diabetic retinopathy (DR), end-stage renal disease (ESRD), or coronary artery disease (CAD); and 3) no diabetic complication (CON). PATIENTS AND METHODS: A total of 254 diabetic patients were studied in a cross-sectional setting. HRQoL was evaluated using Thai version of the Euro Quality of Life Questionnaire (EuroQoL), with five dimensions and five-level scale (EQ-5D-5L). Utility scores were calculated using time trade-off methods. RESULTS: A total of 141 patients in the DF group (98 DFU and 43 AMPU groups), 82 in the COM group (27 DR, 28 ESRD, and 27 CAD groups), and 31 in the CON group were interviewed. The mean age was 63.2±12.1 years, body mass index was 24.9±4.7 kg/m2, mean hemoglobin A1c was 7.7±2.1%, duration of diabetes was 13.1±9.9 years, and the mean utility scores were 0.799±0.25. After having DF, 21% of patients had lost their jobs. The COM group had lower utility scores than the CON group. Among the diabetic complications, the DF group had the lowest mean utility scores as compared to the COM and CON groups (0.703±0.28 in the DF group, 0.903±0.15 in the COM group, and 0.961±0.06 in the CON group, P<0.01). There was no difference in the mean utility scores between DFU and AMPU groups. Patients in the DF group reported moderate-to-severe problem in all dimensions more than the other groups. CONCLUSION: DF have the greatest negative impact on HRQoL. Therefore, diabetic foot care should be emphasized in clinical practice to prevent foot complications.