Treatment of diabetic foot ulcers: review of the literature with regard to the TIME clinical decision support tool.

OBJECTIVE: The aim of this clinically orientated paper is to offer an overview of diabetic foot ulcer (DFU) dressings generally, and more specifically, their use in the treatment of DFUs. METHOD: The TIME clinical decision support tool (CDST) has been used as a clinical tool that can help clinicians bring together the different aspects of dressings for DFU treatment into a holistic approach to patient care. RESULTS: DFUs are often difficult to heal, are painful and impact negatively on the individual's quality of life. Most DFU dressings are designed to support the healing of hard-to-heal wounds and represent one part of the management of DFUs. Apart from providing a moist environment, absorbing increased exudate, enhancing granulation and assisting in autolysis, the dressings need to be cost-effective. Wound dressing selection is based on clinical knowledge that ensures the dressing is most appropriate for the individual and the wound, taking into account the comorbidities that the individual may have. CONCLUSION: This paper has highlighted how the use of the TIME CDST model can enhance clinical care and is a further tool clinicians should consider when developing and executing DFU treatment plans. Future research needs to focus on large multicentre studies using robust methodologies, given the current gaps in the evidence, to determine the effectiveness of dressing products for DFUs.

Effectiveness of combined modulated ultrasound and electric current stimulation to treat diabetic foot ulcers.

OBJECTIVE: The use of combined ultrasound and electrostimulation (CUSECS) as an adjunct therapy for diabetic foot ulcers (DFUs) is a relatively new concept. This study aimed to investigate if combined ultrasound and electrostimulation is an effective adjunctive treatment for hard-to-heal DFUs when compared with standard wound care. METHODS: A randomised controlled pilot study design was used. Patients with hard-to-heal DFUs from two centres were sequentially randomised. For 8 weeks, the experimental group received CUSECS and standard wound care treatment twice a week. The control group received standard wound care treatment once a week. Wound changes were documented using photography, which also facilitated wound size measurement. Self-efficacy, economic cost, quality of life and reoccurrence rates were analysed as secondary objectives. RESULTS: The experimental group (n=6) achieved a higher rate of mean wound healing (mean difference (MD): 0.49) when compared to the control group (n=5, MD: 0.01). Two participants completed full healing in the experimental group and one in the control group. There were no statistically significant findings because of the small sample size. There were no direct adverse reactions to this therapy. Quality of life scores improved in the treatment group. There was no significant change in self-efficacy scores. Costs were higher in the experimental group; however, the healing rate was quicker, which could be extrapolated to cost reductions over time. CONCLUSION: Results suggest that CUSECS may be a useful adjunctive therapy for treatment of hard-to-heal DFUs. Further large-scale studies are needed to ascertain the effectiveness of CUSECS. The findings here are inconclusive but indicate that CUSECS may offer promise as a treatment.

The tip of the iceberg: an overview of diabetic foot disease.

Diabetic foot disease is the leading cause of lower-extremity amputation globally and imposes a significant burden for healthcare services and patients alike. The main pathology is ulceration, due to neuropathy or peripheral arterial disease. The most frequent sign is ulceration on the foot. Ulceration needs to be referred to the multidisciplinary diabetic foot team promptly for a comprehensive management plan to be developed. Delay in referral is associated with poor outcomes. Management of diabetic foot ulceration is multifaceted, including offloading, revascularisation, infection control, debridement, glycaemic control and wound care. Management plans need to be patient focused and developed collaboratively across primary and secondary care settings.

Time to revisit the skills and competencies required to work in rural general hospitals.

OBJECTIVES: To determine the structure and demographic of medical teams working in Rural General Hospitals (RGHs) in Scotland, and to gain insight into their experiences and determine their opinions on a remote and rural medical training pathway. DESIGN: Structured face-to-face interviews. Interviews were partially anonymised, and underwent thematic analysis. SETTING: Medical departments of the six RGHs in Scotland 2018-2019. PARTICIPANTS: 14 medical consultants and 23 junior doctors working in RGHs in Scotland. Inclusion criteria: Present at time of site visit, medical consultant in an RGH or junior doctor working in an RGH who provides care for medical patients. Exclusion criteria: Doctors on leave or off shift. Medical consultants with less than one month of experience in post. Non-medical specialty consultants e.g. surgical or anaesthetic consultants. RESULTS: Of 21 consultant posts in the RGHs, only eight are filled with resident consultants, the remainder rely on locums. Consultants found working as generalists rewarding and challenging, and juniors found it to be a good training experience. Consultants feel little professional isolation due to modern connectivity. The majority of consultants (12/14) and all junior doctors favour a remote and rural medicine training pathway encompassing a mandatory paediatrics component, and feel this would help with consultant recruitment and retention. CONCLUSION: RGHs medical departments are reliant on locum consultants. The development of a remote and rural training medical training pathway is endorsed by the current medical teams of RGHs and has the potential to improve medical consultant staffing in RGHs.

The Complete Genome Sequence of the Staphylococcus Bacteriophage Metroid.

Phages infecting bacteria of the genus Staphylococcus play an important role in their host's ecology and evolution. On one hand, horizontal gene transfer from phage can encourage the rapid adaptation of pathogenic Staphylococcus enabling them to escape host immunity or access novel environments. On the other hand, lytic phages are promising agents for the treatment of bacterial infections, especially those resistant to antibiotics. As part of an ongoing effort to gain novel insights into bacteriophage diversity, we characterized the complete genome of the Staphylococcus bacteriophage Metroid, a cluster C phage with a genome size of 151kb, encompassing 254 predicted protein-coding genes as well as 4 tRNAs. A comparative genomic analysis highlights strong similarities - including a conservation of the lysis cassette - with other Staphylococcus cluster C bacteriophages, several of which were previously characterized for therapeutic applications.

Comparative Microbiological and Whole-Genome Analysis of Staphylococcus aureus Populations in the Oro-Nasal Cavities, Skin and Diabetic Foot Ulcers of Patients With Type 2 Diabetes Reveals a Possible Oro-Nasal Reservoir for Ulcer Infection.

Patients with type 2 diabetes are at higher risk for periodontal disease and diabetic foot ulcer infections (DFUIs), the latter of which are predominantly caused by staphylococcal bacteria. Staphylococci have also been detected in the mouth, nose and gums (the oro-nasal cavity) of patients with periodontal disease and can move between the mouth and nose. The present study investigated if the oro-nasal cavity and/or periodontal pockets (PPs) in diseased gum tissue can provide a microbial reservoir for DFUIs. Eighteen patients with type 2 diabetes and at least three natural teeth (13 patients with ulcers and 5 patients without ulcers) underwent non-invasive microbiological sampling of PP, oro-nasal, skin and ulcer sites. Staphylococci were recovered using selective chromogenic agar, definitively identified and subjected to DNA microarray profiling, whole-genome sequencing and core-genome multilocus sequence typing (cgMLST). Staphylococcus aureus and Staphylococcus epidermidis were recovered from both the oro-nasal and ulcer sites of 6/13 and 5/13 patients with ulcers, respectively. Molecular typing based on the staphylococcal protein A (spa) gene and DNA microarray profiling indicated that for each patient investigated, S. aureus strains from oro-nasal and ulcer sites were identical. Comparative cgMLST confirmed that isolates from multiple anatomical sites of each individual investigated grouped into closely related, patient-distinct clusters (Clusters 1-7). Isolates belonging to the same cluster exhibited an average of 2.9 allelic differences (range 0-11). In contrast, reference genomes downloaded from GenBank selected as representatives of each sequence type identified in the present study exhibited an average of 227 allelic differences from the most closely related isolate within each cluster.

POINT: podiatry for international diabetic foot teams.

FOREWORD: The Point Project is an initiative between the two organisations: D-Foot International and the International Federation of Podiatrists (FIP-IFP). Both organisations promote the role of evidence-based foot care for patients with and at risk of diabetes. This collaborative work highlights the podiatric skills needed in order to deliver comprehensive evidence-based care to patients with diabetic foot disease. The statements along with the relevant skills and behaviours are based upon the guidance documents produced by the International Working Group on the Diabetic Foot (IWGDF), thus meaning while this is a consensus document it is also evidence-based. Representatives from both organisations with a multidisciplinary membership met early in 2017 to discuss the different areas of practice and to define which skills and behaviours were required at different levels of practice. Using the TRIEpodD-document (UK) and IWGDF guidance as the basis for discussion, the team identified which knowledge, skills and behaviours could be considered podiatric in nature. Once identified as podiatric, we discussed at which level of podiatric practice they could apply. The members of the team came from a variety of locations which represented practice at the different levels. Following the initial meeting, further discussions took place via email in order to consolidate initial discussions and complete the document. Cognisant of the large volume of guidance in relation to all areas of practice, this document is aimed to assist clinicians by pointing them in the direction in which they need to develop services rather than being a set of rules which must be followed. The POINT team feels that this document supports clinicians globally on three levels: As a benchmarking tool for existing teams to critically reflect upon their practice and identify where quality improvements can be made As a tool for clinicians who wish to establish a diabetic foot team to highlight the skills needed in order to provide care across the breadth of diabetic foot practice highlighting the specific roles in which podiatrists can help For national and local decision makers, to identify which skills can be provided by podiatrists to promote the development of the profession. While this is a consensus relating to podiatric skills, the team is aware that, in the absence of podiatrists, skills will be provided by other health professionals. We support this practice and while such professionals can not be considered podiatrists, they are providing podiatric skills to the diabetic foot team. The delivery of the relevant skill to the patient is the important factor, not the health professional is delivering it. The development of this document is merely the first step to identifying areas where skills need to be developed. Both D-Foot and FIP-IFP are committed to developing podiatric skills further across the globe. The aims and objectives of the two organisations are mutually beneficial to those suffering from diabetic foot disease. People with diabetes deserve the best care that they can receive, irrespective of the resources available. By working together we have been able to identify the podiatric knowledge, skills and behaviours required to provide evidence-based care. The next step is to work together to ensure consistent delivery of these globally for the benefit of those suffering the debilitating consequences of diabetic foot disease.

Exploring the prevalence and management of wounds in an urban area in Ireland.

AIM: This study explores the prevalence and management of wounds within an urban setting in Ireland. METHOD: It employs a cross-sectional survey design, using a predesigned, validated data-collection instrument. FINDINGS: The point prevalence of wounds was 3.7% (n=445), with surgical wounds being the most prevalent (43%; n=189). Wound care was provided across a wide variety of clinical settings, with the majority of patients (60%; n=271) managed in the acute care setting. Most dressings were changed 2-3 times a week (60%; n=271). The mean dressing time was 15 minutes (SD: 12.4 minutes), varying from 2 minutes to 90 minutes. The mean nurse travel time was 3 minutes (SD: 6.5 minutes), varying from 0-60 minutes. Among participants managed using silver and iodine dressings, 53% (n=10, silver) and 78% (n=50, iodine) were prescribed for wounds described as being not infected. Alginate dressings were used incorrectly in 75% of cases, foam dressings in 63% of cases and Hydrofiber dressings in 63% of cases. CONCLUSION: Wound management within the explored geographical area is an important clinical intervention. This study identified areas of practice that need to be addressed, primarily those related to the topical management of the wound and use of offloading. The data has been used to inform practice, education, and further research in this important clinical specialty.

Importance of cytomegalovirus viraemia in risk of disease progression and death in HIV-infected patients receiving highly active antiretroviral therapy.

BACKGROUND: Before highly active antiretroviral therapy (HAART) became available, cytomegalovirus was a major cause of opportunistic infection in HIV-infected patients and was associated with accelerated progression to AIDS and death. We have investigated whether cytomegalovirus viraemia remains a significant risk factor for progression of HIV disease and death in the era of HAART. METHODS: 374 patients whose CD4-cell count had ever been below 100 per microL were enrolled in a prospective study. Serial blood samples were tested for cytomegalovirus by PCR. Rates of new cytomegalovirus disease, new AIDS-defining disorders, and death were calculated over a median follow-up of 37 months after stratification according to baseline and most recent cytomegalovirus PCR status at any point during follow-up. FINDINGS: Of 2969 PCR assays, 375 (12.6%) were positive for cytomegalovirus DNA. 259 (69.3%) patients were persistently negative for cytomegalovirus by PCR; 15 were persistently positive; and 100 were intermittently positive and negative. In multivariate models, cytomegalovirus PCR-positive status as a time-updated covariate was significantly associated with increased relative rates of progression to a new AIDS-defining disorder (2.22 [95% CI 1.27-3.88] p=0.005) and death (4.14 [1.97-8.70] p=0.0002). INTERPRETATION: Detection of cytomegalovirus in blood by PCR continues to identify patients with a poor prognosis, even in the era of HAART. Randomised controlled clinical trials of drugs active against cytomegalovirus are needed to investigate whether this virus is a marker or a determinant of HIV disease progression.

Rapid reconstitution of humoral immunity against cytomegalovirus but not HIV following highly active antiretroviral therapy.

OBJECTIVE: To determine the kinetics of reduction in human cytomegalovirus (HCMV) load and specific anti-glycoprotein B (gB) immune responses in patients with concurrent HCMV DNAaemia following the initiation of highly active antiretroviral therapy (HAART). DESIGN: Sequential analysis of eleven patients with HCMV DNAaemia who received HAART and eleven control patients with HCMV DNAaemia. METHODS: HCMV load was measured by quantitative competitive polymerase chain reaction and anti-gB, anti-HIV Env and Gag responses by an end-point dilution immunofluorescence assay using recombinant antigens expressed in insect cells. Estimates of the efficacy of the reconstituting immune system at controlling HCMV replication were based on previous dynamic models. RESULTS: In patients initiating HAART, HCMV DNA levels in blood declined rapidly, with a median half-life of 5.2 days, consistent with an efficacy of the reconstituting immune system at inhibiting HCMV replication of 52.8-85% (median, 61%). Commensurate with this decrease, a significant increase in anti-gB titres was observed in the post-HAART period (corresponding to an average fourfold increase in titre by 1 month rising to an eightfold increase at month 3; = 0.01). No changes in titre were observed in the control group or for anti-HIV Gag antibody levels, while anti-HIV Env antibody levels decreased after HAART. CONCLUSIONS: In patients with HCMV DNAaemia, reconstitution of humoral immunity to HCMV gB occurs rapidly following the initiation of HAART. These changes contrast with the patterns observed for anti-HIV humoral immune responses.