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Background: Adequate nutrition is essential in individuals with diabetic foot ulceration (DFU); therefore, an assessment of dietary intake is critical. A lack of nutrients including protein, zinc and vitamins C and D have all been associated with poor wound healing. However, the comprehensive dietary intake of Australian adults with DFU is poorly understood. The aim of this cross‐sectional study was to describe the dietary intake of adults with DFU in an Australian setting. Methods: Participants (n = 115) with diabetes (type 1 and 2), a mean body mass index of 36 and current foot ulceration were recruited from across New South Wales, Australia. Dietary intake was assessed using the Australian Eating Survey, a self‐reported validated food frequency questionnaire. Results: The mean (SD) reported energy intake was 9.57 (±SD 4.43) MJ day–1. A mean protein intake of 104 (±SD 49) g day–1 is below recommended intake for wound healing; however, the mean protein intake contribution to energy (19%E) was within recommendations for normal populations. The mean carbohydrate intake (43%E) was within recommended ranges for healthy populations; however, the mean total fat intake (36%E) was above recommendations. Micronutrient intake was adequate, apart from folate, which was below the recommended intake, and sodium, vitamin C, vitamin A and selenium, which were above the recommended intake. Conclusions: A lack of adequate folate may have a negative impact on healing, with folate proposed to play a role in tissue repair. Wound management of individuals with DFU should include a regular assessment of dietary intake to recognise deficiencies in macro‐ and micronutrients, and subsequently address these inadequacies to optimise healing. Key points: This cross‐sectional study of 115 participants with active diabetic foot ulceration aimed to describe current dietary intake.Utilising a validated food frequency questionnaire, the Australian Eating Survey, it was found that mean protein intake was inadequate for wound healing (9.57 MJ day–1).Intake of folate was also inadequate, which may have implications for tissue repair.Wound management of individuals with diabetic foot ulceration should include an assessment of dietary intake to recognise deficiencies in macro‐ and micronutrient intake and subsequently address these to optimise healing outcomes. [ABSTRACT FROM AUTHOR]

Background: Dietary intake is a recognised contributor to healing in diabetes-related foot ulceration (DFU). However, it is currently unknown how individuals with DFU perceive their diet, and what is deemed an acceptable dietary intervention. Therefore, the aims of this study were to explore perceptions of diet quality, previous dietary advice, and dietary interventions in individuals with DFU, and secondly to determine acceptable dietary interventions in individuals with DFU to assist with wound healing. Methods: A qualitative study using reflexive thematic analysis was undertaken. Individuals with active or recent history of DFU were recruited from a high-risk foot service. Semi-structured interviews were undertaken. Results: Nineteen participants were included with three themes identified: A complex relationship with food, perceptions of food, diet and dietitians, and self-management. Dietary misconceptions were common. Self-perceived diet quality varied, with most unaware of how diet could impact wound healing. Many expressed barriers relating to food agency (purchasing, preparing, and accessing food). Participants expressed a strong preference for personalised, face-to-face dietary advice and nutritional supplementation. Conclusions: There is a need for personalised dietary re-education and assistance with food agency in this cohort to overcome commonly held misconceptions of diet and improve dietary intake to facilitate wound healing. [ABSTRACT FROM AUTHOR]

Australia has the second highest rate of non‐traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01–1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001–1.01) infection (OR 2.08, 95% CI 1.06–4.07) and presence of diabetes (OR 3.77, 95% CI 1.12–12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration. [ABSTRACT FROM AUTHOR]

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation. [ABSTRACT FROM AUTHOR]

Purpose of study: To investigate toe systolic blood pressure and/or toe-brachial pressure index in predicting healing post minor diabetic foot amputations. Key methods: A systematic search of EMBASE and PubMed (including Medline and The Cochrane Library) was conducted from database inception to 9 March 2020. Two authors independently reviewed and selected relevant studies. Quality was assessed with a modified Critical Appraisal Skill Programme checklist. Main results: Ten studies met the inclusion criteria. Nine studies investigating toe systolic blood pressure reported healing occurred at mean toe systolic blood pressure values ⩾30 mmHg, ranging between 30 and 83.6 mmHg. The meta-analysis (four studies) found toe systolic blood pressure <30 mmHg had 2.09 times the relative risk of non-healing post amputation, compared to toe systolic blood pressure ⩾30 mmHg (relative risk = 2.09, 95% confidence interval: 1.37–3.20, p = 0.001). Two studies investigating toe-brachial pressure index report successful healing where toe-brachial pressure index >0.2, with one study reporting a higher value of 0.8. Main conclusions: Successful post-amputation healing outcomes were reported at mean toe systolic blood pressure ⩾30 mmHg, and the results varied considerably between the studies. Further research should identify whether variables, including amputation level, method of wound closure and length of post-operative follow-up periods, affect the values of toe systolic blood pressure and toe-brachial pressure index observed in this review. [ABSTRACT FROM AUTHOR]

The postexercise ankle–brachial index (ABI) is recommended in patients with normal resting ABI when peripheral artery disease (PAD) is suspected. The aims of this study were to determine the comparative diagnostic accuracy of the resting and postexercise ABI for detecting PAD, and, the effect of the presence of diabetes on these. Three methods of interpretation currently in use were also investigated: a reduction in postexercise ABI by >20% compared to resting ABI, an ABI value of ≤0.90 postexercise, or a reduction in systolic ankle pressure of >30 mmHg postexercise. This retrospective study used colour duplex ultrasound (CDU) as the reference standard. In 278 limbs (whole group), the resting ABI had an overall area under the curve (AUC) of 0.71, with the postexercise ABI yielding a similar diagnostic accuracy of AUC 0.72. In the non-diabetes group (n=171), the resting ABI had an overall AUC of 0.74 and the postexercise ABI had a similar AUC of 0.76. In the diabetes group (n=107), overall accuracy was reduced compared to the non-diabetes group, with the resting ABI having an overall AUC of 0.65 and the postexercise ABI yielding a similar accuracy with an AUC of 0.64. The overall diagnostic accuracy of the postexercise ABI for diagnosing PAD was not greatly improved compared to resting ABI. Given the lower overall diagnostic accuracy in the diabetes group, both the resting and the postexercise ABI results in diabetes populations should be interpreted with caution. There is a risk of undiagnosed disease if relying on these results alone to determine lower limb vascular status. [ABSTRACT FROM AUTHOR]

Background: The resting systolic toe pressure (TP) is a measure of small arterial function in the periphery. TP is used in addition to the ankle-brachial index when screening for peripheral arterial disease (PAD) of the lower limb in those with diabetes, particularly in the presence of lower limb medial arterial calcification. It may be used as an adjunct assessment of lower limb vascular function and as a predictor of wound healing. The aim of this study was to determine the diagnostic accuracy of TP for detecting PAD in people with and without diabetes. Methods: This was a retrospective case-control study. Two researchers extracted information from consecutive patient records, including TP measurements, colour Duplex ultrasound results, demographic information, and medical history. Measures of diagnostic accuracy were determined by receiver operating curve (ROC) analysis, and calculation of sensitivity, specificity, and positive and negative likelihood ratios. Results: Three hundred and nintey-four participants with suspected PAD were included. In the diabetes group (n = 176), ROC analysis of TP for detecting PAD was 0.78 (95%CI: 0.69 to 0.84). In the control group (n = 218), the ROC of TP was 0.73 (95%CI: 0.70 to 0.80). TP had highest sensitivity when anatomical distribution of disease was both proximal and distal (diabetes group: 79.49%, the control group: 82.61%). TP yielded highest sensitivity in mild disease (50-75% stenosis) in diabetes group, (81.82%) and moderate disease (>75% stenosis) in control group (80.77%). Conclusions: Our findings indicate that TPs are useful to assist in diagnosing PAD in clinical practice, however, results should be interpreted with caution due to the small probability of PAD being present with a negative test. [ABSTRACT FROM AUTHOR]

The toe–brachial index (TBI) is used as an adjunct to the ankle–brachial index (ABI) for non-invasive lower limb vascular screening. With increasing evidence suggesting limitations of the ABI for diagnosis of vascular complications, particularly in specific populations including diabetes cohorts, the TBI is being used more widely. The aim of this review was to determine the sensitivity and specificity of the TBI for detecting peripheral artery disease (PAD) in populations at risk of this disease. A database search was conducted to identify current work relating to the sensitivity and specificity of toe–brachial indices up to July 2015. Only studies using valid diagnostic imaging as a reference standard were included. The QUADAS-2 tool was used to critically appraise included articles. Seven studies met the inclusion criteria. Sensitivity of the TBI for PAD was reported in all seven studies and ranged from 45% to 100%; specificity was reported by five studies only and ranged from 16% to 100%. In conclusion, this review suggests that the TBI has variable diagnostic accuracy for the presence of PAD in specific populations at risk of developing the disease. There was a notable lack of large-scale diagnostic accuracy studies determining the diagnostic accuracy of the TBI in detecting PAD in different at-risk cohorts. However, standardised normal values need to be established for the TBI to conclusively determine the diagnostic accuracy of this test. [ABSTRACT FROM AUTHOR]