NHS evidence update on diabetic foot problems

NHS evidence update on diabetic foot problems

Currently, the prevalence of diabetes mellitus (DM) has the character of a global epidemic, and with the growth of the patient population, the prevalence of late diabetic complications will undoubtedly increase. One of the most dangerous chronic complications of diabetes is diabetic foot syndrome (SDS), in which ulcerative defects are the most common manifestation. A severe outcome of ulcerative foot injury is amputation of the lower limb, which is performed 10-30 times more often in patients with diabetes compared to the entire population. After the first amputation, the risk of repeated amputation and death increases significantly. Despite the existence of developed protocols and standards, the desired high efficiency of treatment of ulcers in SDS is currently not achieved. Treatment of SDS in most cases remains long, time-consuming and high-cost. In this regard, there is a need to create alternative medical technologies that complement existing basic approaches to the treatment of SDS and, within the framework of multidisciplinary medical care, reduce the healing time of ulcers, thus reducing the risk and frequency of lower limb amputations. The presented literature review is devoted to the description of the current practice and prospects for the use of innovative methods of treatment of patients with SDS.

Introduction

Currently, the prevalence of diabetes mellitus (DM) has the character of a global epidemic, and with the growth of the patient population, the prevalence of late diabetic complications will undoubtedly increase. One of the most dangerous chronic complications of diabetes is diabetic foot syndrome (SDS), in which ulcerative defects are the most common manifestation.

A multicenter study organized by the European Study Group on Diabetes and the Lower Extremity (Eurodiale) shows that among first — time patients, 51% of cases are diagnosed with neuropathic SDS (27% of them with infected ulcers), 31% with neuroishemic form and signs of ulcer infection, and 18% with ischemic. Ulcers can form on any part of the foot, but about half are formed on the plantar surface (including the toes) and the rest in other areas.1,2

A severe outcome of ulcerative foot injury is amputation of the lower limb, which is performed 10-30 times more often in patients with diabetes compared to the entire population. After the first amputation, the risk of repeated amputation and death increases significantly. Despite the existence of developed protocols and standards, the desired high efficiency of treatment of ulcers in SDS is currently not achieved. Treatment of SDS in most cases remains long, time-consuming and high-cost. According to a Eurodiale study involving 1,000 people with SDS, observed in specialized clinics in several European countries, the median time for healing ulcers in the forefoot area was 147 days, in the middle-188 days and in the heel area-237 days.1,3

When foot ulcers occur in patients with DM, there is a significant increase in financial costs, which are approximately 5.4 times higher in the first year of treatment than the cost of a patient without VTS, and 2.8 times higher in the second year. A study on the average cost of treatment for SDS, conducted in the United States back in 1999, showed that outpatient treatment of a single ulcer over a two-year period is $28,000. The average cost of inpatient treatment of SDS without amputations in 1997 was $ 16580, with amputations within the foot $ 25241 and $ 31436 in the case of high amputation of the lower limb.In 2012, the financial burden of this complication of diabetes is clearly shown in the United States, as the annual direct cost of treating SDS is comparable to the cost per year for one of the five most expensive cancers, such as breast, rectum, lung, prostate, and leukemia, at $17 billion.In this case, the amounts are indicated without indirect costs for patients, such as the impact on the physical, psychological and social well-being. It is known that the presence of a long-term non-healing foot ulcer negatively affects the emotional state of patients, causing a sense of fear, anger, decreased self-esteem and, as a result, social isolation.4-7

In this regard, there is a need to create alternative medical technologies that complement existing basic approaches to the treatment of SDS and, within the framework of multidisciplinary medical care, reduce the healing time of ulcers, thus reducing the risk and frequency of lower limb amputations.

The presented literature review is devoted to the description of the current practice and prospects for the use of innovative methods of treatment of patients with SDS.

Standard treatment tactics

Multi-factor and multidisciplinary approach in the treatment of SDS

The principles of treatment of SDS are formulated in The “international agreement on diabetic foot” based on the results of numerous multicenter randomized controlled trials (RCTS). However, in General practice, the importance of their compliance is often underestimated by both the patient and the doctor, and the first necessary step towards success is a clear understanding that treatment aimed at achieving complete healing of ulcers in SDS is associated with significant difficulties. Currently, in Russia, the most trained doctors in this field are specialists of the Diabetic foot offices, who are aware of advanced therapies, and individual training of patients with an introduction to the problems of treatment of SDS and ways to solve them, optimally motivates the patient and sets up cooperation with the doctor.

The basis for the treatment of patients with SDS is a scientifically proven, multi-factorial approach that includes therapeutic measures aimed at accelerating the healing of ulcers and preserving the lower limb:

  • unloading the affected limb,
  • proper regular ulcer care,
  • prevention and control of infection,
  • normalization of carbohydrate metabolism,
  • if necessary, restore blood supply to the limb.

Only by complex modification of all factors simultaneously achieve the necessary conditions for ulcer healing, and ignoring any of them during treatment leads to a change in the ulcer condition, slowing or stopping epithelization.2

Optimally, the tasks of treating SDS can only be solved in a specialized clinic, which has a cohesive, coordinated team that is engaged not only in treatment, but also in screening and prevention of this complication, and includes such specialists as:

  • Diabetologist
  • The doctor’s office “Diabetic foot” (podiatr)
  • Dressing the nurse
  • Technician for individual production of discharge dressings
  • Traumatologist-orthopedist
  • Purulent Department surgeon
  • The angiosurgeon
  • X-ray endovascular surgeon
  • Rehabilitation specialist
  • Physiotherapist
  • Microbiologist
  • Doctor of ultrasonic diagnostics
  • Radiologist

However, it is extremely difficult to implement a multi-factor approach to providing medical care in modern conditions, and not only in Russia. There is still a lack of structural coherence in the treatment of patients with SDS in many countries, insufficient funding for this area of medicine, resulting in losses due to amputations and closing the vicious circle of the burden of SDS, and there is still a low availability of revascularizing surgery on the lower extremities, sometimes based on insufficient competence of doctors and/or lack of confidence in a positive result. As a result, according to Swedish researchers, only 30% of these patients use a multidisciplinary approach to saving a limb. 8

Badenoch
Douglas Badenoch
I am an information scientist with an interest in making knowledge from systematic research more accessible to people who need it. This means you. I've been attempting this in the area of Evidence-Based Health Care since 1995. So far the results have been mixed. For some reason we expected busy clinicians to search databases and appraise papers instead of seeing patients. We also expected publishers to make the research freely available to the people who paid for it.. Ha! Hence The National Elf service.

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