Silver dressings are used for their antimicrobial properties but there is limited evidence of clinical benefit when managing diabetes-related foot ulcers (DFUs). We aimed to assess whether silver dressings in acute DFUs increased the proportion of ulcers healed compared with non-silver dressings. In this open-labelled, randomised controlled trial, consecutive individuals who presented to a tertiary multidisciplinary diabetic foot service with a DFU without osteomyelitis or tendon on view of <6 weeks’ duration were randomised 1:1 via a computer-generated randomisation process to receive Acticoat (Smith & Nephew, England) dressing (silver group) or dressing without silver (control group) in addition to standard care. Stratified randomisation was performed to ensure that the presence of peripheral arterial disease and infection were equally managed within the two groups. The primary outcome was the proportion of ulcers healed at 12 weeks. Secondary outcomes included time to heal and to 50% ulcer reduction, rates of osteomyelitis and amputation, and need for and duration of antibiotics. Seventy-six ulcers (55 participants) in the control group and 91 ulcers (63 participants) in the silver group were included. There was no difference in the proportion of ulcers healed by 12 weeks in the control vs silver group (75% vs 69%, p=0.49). After adjustment for presence of peripheral arterial disease, infection and initial ulcer size, silver dressing was not associated with odds of healing (OR 0.92; CI 0.26, 3.22; p=0.53). There was no difference in time to healing, progression to osteomyelitis, need for amputation, or duration of or need for antibiotic treatment. In individuals with acute DFUs without osteomyelitis or tendon on view, Acticoat silver dressings did not improve wound healing or reduce need for antibiotics compared with non-silver dressings. Australian New Zealand Clinical Trials Registry ACTRN12614001234606 Australian Diabetes Society—unrestricted research award

The modern era of radioiodine (I‐131) theranostics for metastatic differentiated thyroid cancer requires us to rationalize the role of traditional empiric prescription in nonmalignant thyroid disease. We currently practice empiric I‐131 prescription for treatment of hyperthyroidism. This study aims to assess outcomes after treatment of hyperthyroidism by empiric I‐131 prescription at our centre, evaluate factors that impact on outcomes and prescribing practice, and gain insight into whether there is a place for theranostically‐guided prescription in hyperthyroidism.

This study investigated cognitive functioning and understanding of peripheral neuropathy in a cohort of individuals with diabetes-related foot ulcers requiring hospitalization. The aim was to examine the association between cognition, understanding of peripheral neuropathy, and diabetic health variables. Thirty inpatients referred to the Diabetic Foot Unit Clinical Psychology service, at the Royal Melbourne hospital, were assessed using the Montreal Cognitive Assessment (MoCA) and the Patient Interpretation of Neuropathy (PIN) questionnaire. Relevant demographic and medical information was collected. In this predominantly middle-aged, male cohort, the average MoCA score (22.37, SD = 3.65) fell below the general population age-matched mean, and a quarter of the MoCA patient scores were consistent with those seen in early dementia samples (<20). There appeared to be several misperceptions regarding peripheral neuropathy, less accurate attributions of blame to self or practitioners, and more accurate attributions of control of ulcer management to practitioners. Correlation analysis indicated that individuals with stronger MoCA scores tended to provide more accurate answers on the Acute Foot Ulcer Onset PIN scale. Individuals with diabetes-related foot ulcers requiring hospitalization demonstrate reduced cognitive functioning and this may affect their understanding of peripheral neuropathy, particularly information regarding foot ulcer onset. Routine screening of cognitive functioning in this cohort may be useful so that health education and care management can be adjusted according to individual patients’ cognitive capabilities.

AimTo investigate the effect of a novel glucose alert system, comprising the Melbourne Glucose Alert Pathway and glucose-alert-capable networked blood glucose meters, on nursing and hospital medical officer responses to adverse glycaemia. MethodsA prospective, pre- and post-observational study was undertaken in non-critical care wards of a tertiary hospital over 4 months (n=148 or 660 patient-days). The intervention consisted of two components designed to promote a consistent staff response to blood glucose measurements: (1) a clinical escalation pathway, the Melbourne Glucose Alert Pathway, and (2) networked blood glucose meters, which provide a visual alert for out-of-range blood glucose measurement. All consecutive inpatients with diabetes were assessed for diabetes management and capillary blood glucose. The primary outcome was documented nursing and medical staff action in response to episodes of adverse glycaemia (blood glucose >15 mmol/l or <4 mmol/l). Secondary outcomes consisted of glycaemic measures. ResultsIn response to episodes of adverse glycaemia, nursing action increased (proportion with nursing action: 45% to 73%; P<0.001), and medical action increased (proportion with medical action: 49% to 67%; P=0.011) with the glucose alert system in place. Patient-days with hyperglycaemia (any blood glucose value >15 mmol/l: 24% vs 16%; P=0.012) and patient-days with mean blood glucose >15 mmol/l (7.4% vs 2.6%; P=0.005) decreased. There was no difference in hypoglycaemia incidence. ConclusionsUse of a novel glucose alert system improved health professional responses to adverse glycaemia and decreased hyperglycaemia in the hospital setting.

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.

Introduction: On any given day in Australia, the national burden of diabet es - re lated foot disease (DFD) is significant : • 300,000 people are at - risk of developing DFD • 50,000 people are living with DFD • 12, 5 00 people are living with a diabetes - related amputation • 1 , 000 people are in hospital because of DFD • 12 people will undergo a diabetes - related amputation • 4 people will die because of DFD • $ 4 million will be spent managing DFD To reduce this large national burden, the following three priorities should be addressed for people with, or at - risk of, DFD : A. Access to affordable and effective care B. Provision of safe quality care C. Research and development to improve patient outcomes.

Foot ulcers are one of the most feared complication s of diabetes. From the patient’s perspective the burden of disease is high due to factors such a s loss of mobility, pain, (fear of) amputation, the need for frequent outpatient visits, hospitalisation and invasive procedures. The longer the ulcer persists, the more quality of life is lost. From a health care perspective these patients use a lot of resources, and need expensive, multidisciplinary care with many disciplines involved. For health care workers it is frequently difficult to understand all the different aspects that have to be addressed in order to effectively treat these patients. In the last decades much progress has been made in this area. With relative simple tools, as for instance described in the Guidance documents of the International Working Group on the Diabetic Foot (IWGDF), each patient should be systematically evaluated. Subsequently, we can define who is at risk for a poor outcome, who needs urgent treatment, what treatment should be offered and which disciplines should be involved . Several studies have shown that a multidisciplinary approach can achieve a 45-85% reduction in amputation rates and in several countries amputation rates are progressively going down. But, even in well performing countries still too many patients lose part of their leg. We clearly need initiatives to improve the quality of care in this area and the Australian Diabetic Foot Ulcer Minimum Dataset is a major step forward that can help to reduce the burden of disease. The implementation of this easy-to-use document can have a major impact on the quality of care in Australia as it was developed using the evidence based approach of the IWGDF and in consultation with relevant stakeholders. By developing a common language for all the different disciplines involved, standardises evaluation of ea ch patient, defining process and outcome benchmarks, each participating clinic will have ins truments to improve the care for its patients.

BackgroundDiabetic foot infections are an important cause of hospitalization, health expenditure and mortality. Bone biopsy is the gold standard for diagnosing diabetic foot osteomyelitis but it is not routinely performed in most centres. Instead, a combination of history, examination, biochemical and radiological findings are used to make the diagnosis.Case ReportHere, we report a case mimicking diabetic foot osteomyelitis, where the histology was crucial in acquiring the correct diagnosis.ConclusionThe absence of ulceration in cases of presumed diabetic foot osteomyelitis should raise suspicion of potential rare mimics of osteomyelitis and bone biopsy should be considered to further evaluate the underlying etiology prior to any definitive surgical management.

Aim: To determine the effectiveness of the percutaneous isolated limb procedure (PILP) for the delivery of the antibiotic Timentin to the lower limb of individuals with diabetes, peripheral vascular disease and significant infection. Method: Over two separate clinical studies, 11 individuals with a significant diabetes-related foot infection were recruited to receive ticarcillin / clavulanic acid (Timentin) using PILP. Patients had an antegrade femoral artery catheter, retrograde Venous Recovery Catheter and Venous Support Device inserted under local anaesthetic. The catheters were connected with an oxygenator, heater and paediatric cardiac perfusion pump to create a lower limb circuit, with a proximal external tourniquet to isolate the limb circulation. Systemic and circuit antibiotic levels were determined during the procedure. Results: No alteration in vital signs or biochemical parameters from the limb or systemic circulation were recorded during the procedure or during the 28-day follow-up. Ticarcillin concentrations in the limb circulation were more than 20-fold higher than that determined in the systemic circulation at the 15 min time point (circuit 140.8 ± 9.9 μg/mL vs systemic 6.7 ± 1.7 μg/mL, p<0.0001). The higher concentration was maintained within the circuit (8-fold) throughout the 30 min procedure (at 30 min, circuit 87.6 ± 12.3 μg/mL vs systemic 10.3 ± 2.5 μg/mL, p<0.0001). Conclusions: The significantly higher concentrations of Timentin maintained within the PILP circuit compared to the systemic circulation indicate it is a safe and effective method of isolated antibiotic delivery in individuals with diabetes, peripheral vascular disease and significant lower limb infection.

Opinions vary amongst health professionals regarding appropriate management of blisters on the feet in both the healthy and at-risk patient. The literature in this area is sparse, and what literature there is varies considerably regarding recommendations for blister management. Suggested treatments range from no intervention and leaving the blister intact to removal of fluid whilst keeping the overlying skin intact, or de-roofing the blister. The lack of evidence in this field creates differences of opinion and tension between health care professionals and suggests that further investigation is required in order to develop guidelines for best clinical practice. This review article aims to evaluate the current literature and expert professional opinion for the management of blisters in the acute setting, with the aim of developing evidence-based guidelines.

Recommendations to improve national diabetes-related foot disease (DRFD) care • National data collection on incidence and outcomes of DRFD. • Improved access to care, through the Medicare Benefits Schedule, for people with diabetes who have a current or past foot complication. • Standardised national model for interdisciplinary DRFD care. • National accreditation of interdisciplinary foot clinics and staff. • Subsidies for evidence-based treatments for DRFD, including medical-grade footwear and pressure off-loading devices. • Holistic diabetes care initiatives to “close the gap” on inequities in health outcomes for Aboriginal and Torres Strait Islander peoples.

Aim: To trial medical-grade honey wound dressings on dry, clinically infected diabetic foot ulcers in an acute high-risk foot service (HRFS).Method: Five clinicians trialled medical-grade honey wound gel and medical-grade honey alginate on appropriate diabetic foot wounds and completed a simple evaluation form for each application including patient tolerability.Results: Clinician ease of use, Clinician overall satisfaction and Patient comfort was rated as "high" in the majority of applications (66-93%).Conclusion: Honey wound dressings did not lead to deterioration in diabetic foot wounds and were rated highly by clinicians and patients with regards to ease of use, overall outcome and tolerability.

OBJECTIVE To determine the microbiological profile of diabetes-related foot infections (DRFIs) and the impact of wound duration, inpatient treatment, and chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS Postdebridement microbiological samples were collected from individuals presenting with DRFIs from 1 January 2005 to 31 December 2007. RESULTS A total of 653 specimens were collected from 379 individuals with 36% identifying only one isolate. Of the total isolates, 77% were gram-positive bacteria (staphylococci 43%, streptococci 13%). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated from 23%; risk factors for MRSA included prolonged wound duration (odds ratio 2.31), inpatient management (2.19), and CKD (OR 1.49). Gram-negative infections were more prevalent with inpatient management (P = 0.002) and prolonged wound duration (P < 0.001). Pseudomonal isolates were more common in chronic wounds (P < 0.001). CONCLUSIONS DRFIs are predominantly due to gram-positive aerobes but are usually polymicrobial and increase in complexity with inpatient care and ulcer duration. In the presence of prolonged duration, inpatient management, or CKD, empiric MRSA antibiotic cover should be considered.

Aim: Adequate nutritional intake is an essential component for timely wound healing. The present research aimed to identify the frequency of inadequate dietary intake, including the specific nutritional elements most frequently lacking, in a group of patients admitted with diabetes-related foot complications.Methods: Consecutive patients admitted to a diabetic foot unit underwent a dietary assessment, which included the retrospective collection of a seven-day food history for the period just prior to admission. The collected data were entered into FoodWorks, and comparisons were made with recommendations made by national guidelines.Results: Thirty-five patients underwent nutritional assessment, 74% male and 26% having impaired renal function. Protein consumption was in excess of daily recommended intake, and although the overall fat intake as a percentage of total calories consumed was in keeping with national guidelines, the intake of saturated fat was inappropriately high. Of the 12 micronutrients assessed, niacin and vitamin C were appropriately consumed by all; average intake of potassium, phosphorus and thiamine approached recommended levels, while the intake of magnesium, calcium, zinc, riboflavin, folate and vitamin A all fell short of recommended daily requirements. No dietary differences were identified between individuals with normal and abnormal renal function, but deficiencies in calcium and iron were identified only in women.Conclusion: Dietary deficiencies of macronutrients were not identified in individuals admitted with diabetes-related foot complications, but many patients were found to be consuming well below the daily recommended daily intake of one or more of the micronutrients deemed necessary for normal wound healing.

BACKGROUND:Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group.METHODS:One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors.RESULTS:Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end-stage kidney failure.CONCLUSION:Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end-stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.

Admission rates for diabetes-related foot complications to an Australian hospital were assessed by comparing the frequently used method of retrospectively identifying patients according to International Classification of Diseases (ICD) codes with that of prospectively identifying patients at the time of admission. The aim was to determine the true admission rate of diabetes-related foot complications and to assess the ability of ICD discharge codes to accurately represent the clinical severity of each identified admission. The retrospective study of ICD codes identified approximately one-third of the patients admitted during the prospective studies. Furthermore, ICD codes allocated in the prospective studies failed to accurately represent the clinical condition in 61% of cases and the corresponding Weighted Inlier Equivalent Separations weighting resulted in a $215,000/year deficit for admissions to a single hospital.

Background Foot ulceration affects 15-20% of people with diabetes. It is a major precursor to amputation in this patient group, and early and appropriate treatment provides the greatest opportunity for healing. The use of silver for its antimicrobial properties has re-emerged, and modern wound dressings that release a sustained amount of free silver ions, are now widely used in wound management.Objectives To evaluate the effects of silver-containing dressings and topical agents on infection rates and healing of diabetes related foot ulcers.Search strategy Searches were made of the Cochrane Wounds Group Specialised Register (August 2005), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library Issue 3 2005) MEDLINE (1966 to October week 2 2004), EMBASE (1980 to October week 2 2004) and CINAHL (1982 to October week 2 2004). The Journal of Wound Care (Volume 12/13 Issues 1-10) was hand-searched. Manufacturers, researchers and local and international wound groups were contacted in order to identify unpublished trials. Web sites for wound groups and World Wide Wounds (www.worldwidewounds.com) were searched.Selection criteria Randomised controlled trials and non-randomised controlled clinical trials were considered for inclusion. Studies were included if they involved participants with Type 1 or Type 2 diabetes and related foot ulcers, met the requirements for randomisation, allocation and concealment where appropriate, and compared the intervention with a placebo or a sham dressing, an alternative non silver based dressing or no dressing, and reported outcomes that represent healing rate or infection.Data collection and analysis Two authors independently evaluated the papers identified by the search strategy against the inclusion criteria but identified no trials eligible for inclusion in the review. It was not possible to perform planned subgroup and sensitivity analysis in the absence of data. In future, if eligible trials become available, a random effects model will be applied for meta-analysis in the presence of statistical heterogeneity (estimated using the I-2 statistic). Dichotomous outcomes will be reported as risk ratios with 95% confidence intervals (CI), and continuous outcomes as weighted mean differences (WMD) with 95% CI. Statistical significance will be set at P value < 0.05 for all outcomes and the magnitude of the effect will be estimated by calculating the number needed to treat (NNT) with 95% CI.Main results No studies were identified that met with the inclusion criteria Authors' conclusions Despite the widespread use of dressings and topical agents containing silver for the treatment of diabetic foot ulcers, no randomised trials or controlled clinical trials exist that evaluate their clinical effectiveness. Trials are needed to determine clinical and cost-effectiveness and long term outcomes including adverse events.

Aims  To design a multidisciplinary, evidenced‐based, clinical guideline for the assessment, investigation and management of inpatients with acute diabetes related foot complications.