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ABU DHABI, United Arab Emirates — New clinical-practice recommendations for the diabetic foot, issued earlier this year by the International Diabetes Federation, are designed to help all healthcare professionals and most specifically general practitioners and family-care doctors to identify early those patients who need referral to specialist care.
Introducing these latest guidelines here at the International Diabetes Federation (IDF) Congress 2017, Dr Edward Jude of Tameside Hospital NHS Foundation Trust, the United Kingdom, noted that 80% of diabetic-foot cases worldwide are seen by primary-care doctors, yet they lack understanding about what they should be assessing and at what point they should refer a patient.
Prof Johan Wens, a GP who also works at the University of Antwerp, Belgium, speaking in the same session, concurred. "GPs need to be educated that a delay in people with diabetic foot can lead to loss of a limb and it's urgent that they are referred."
However, with most GPs having only around 10 minutes to see each patient, on average — although this depends to some extent on where in the world they work — the meeting attendees agreed that this is a huge stumbling block.
The new 70-page IDF document — Clinical Practice Recommendations on the Diabetic Foot 2017: A guide for healthcare professionals — divides topics, by increasing severity, into diabetic peripheral neuropathy, peripheral arterial disease, ulcers, diabetic-foot infection, and Charcot neuro-osteoarthropathy (Charcot foot).
It is designed with the goal of having GPs intervene at risk category 1 or 2, to help them identify, assess, and treat diabetic-foot patients earlier in the "window of presentation" between when neuropathy is diagnosed and prior to an ulcer developing, Dr Jude noted.
The old way of simply "looking for ulcers" means patients are referred far too late, delegates heard.
Too Complex for GPs? There's a Pocket Guide, Too
However, the chair of the session, Dr William Jeffcoate of Nottingham University Hospitals Trust, United Kingdom, said he felt this 70-page document "is too complicated for primary-care or any other healthcare professional not working in diabetic-foot disease."
The authors were keen to stress, however, that they have also produced a pocket chart. This Z card consists of just 2 pages and can be printed off, or a hard copy ordered from the IDF website for just €2, Dr Jude explained.
This short document enables doctors to put patients into one of four risk categories based on the results of assessment and then advises them on future decisions depending on the risk category assigned.
Nevertheless, Prof Wens observed there remains much work to do — looking for relevant clinical trials he found there is little research into the feasibility and implementation of diabetic-foot guidelines in primary care, despite the fact that at least 10 such guidelines exist around the world, including the ADA ones and these latest from IDF.
And there are still sections missing from all of these guidelines, he said, including training for healthcare professionals on the diabetic foot.
"It's very confusing for primary-care practitioners — when to do this and how to do this," he observed.
The 3-Minute Diabetic Foot Exam: Look at, Touch the Feet, Ask Questions
Podiatrist Lawrence B Harkless, DPM, of the Western University of Health Sciences, Pomona, California, concurred with the other speakers that PCPs "are very busy" and the foot "is way down on their list."
Having trained family-medicine residents on podiatric medicine, he has some simple tips for doctors and he cited the "3-minute exam," which can help raise a red flag for any patients at risk of ulcer; details of this were published in 2014 (J Fam Pract. 2014;63:646-656).
First of all, doctors have to take a quick but thorough medical history, and they have to actually look at and touch the foot, he stressed.
"Just by observing the skin — if you see discolored skin, mycotic nails, hyperpigmentation, bleeding under the toenail, maceration, and calluses, which precede ulcers," these are all warning signs, he explained.
It's also vital to palpate, touching the foot and ankle, looking at capillary refill time, temperature changes, pedal pulse, etc.
Looking at and feeling the foot also give clues for any signs of vascular disease, he added — these include an absence of hair, atrophy of skin or subcutaneous tissue (the "baked-potato" look), edema, pallor, and cold temperature.
"Every complication in diabetes is related to blood flow," Dr Harkless told Medscape Medical News. "So if you do an assessment of the vasculature, and if they have any signs or symptoms in terms of the skin, discoloration, nails, callus — because ulcers are preceded by callus — that's enough to send to the specialist.
"Also, do they have neuropathy?" he added. That is, on neurologic exam, is the patient responsive to the Ipswich Touch test or to a monofilament test?
And is there any deformity and/or limited joint mobility — and if so, how long has it been present? Is the mid-foot hot, red, or swollen? Is there any malalignment on gait analysis?
Teach Your Patients Foot Care
He also recommends that doctors teach their patients daily foot care. It's important to make sure that they or a family member can visually examine both feet soles and between the toes, that they keep the feet dry and report any new lesions, discolorations, or swelling to a healthcare professional.
Patients also need to be advised about the risk of walking barefoot, even indoors, and it's vital they have appropriate footwear and not shoes that are too small and/or rub.
Finally, they need to comprehend that general health is important — including the role of smoking cessation, for example. And it's key that their doctor explain to them the importance of keeping their blood glucose under control and how this, in turn, helps to prevent neuropathy or prevent progress if already present, including protection of the feet, he concluded.
International Diabetes Federation Congress 2017. December 6, 2017; Abu Dhabi, United Arab Emirates.
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