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The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This is the first guideline on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes published by the IWGDF. We followed the GRADE Methodology to devise clinical questions in the PACO (Population, Assessment, Comparison, Outcome) and PICO (Population, Intervention, Comparison, Outcome) format, conducted a systematic review of the medical literature, and developed recommendations with the rationale. The recommendations are based on the evidence from our systematic review, expert opinion when evidence was not available, and also taking into account weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to an intervention. We here present the 2023 Guidelines on the diagnosis and treatment of active Charcot neuro-osteoarthropathy in persons with diabetes mellitus and also suggest key future topics of research.

Aims: Offloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes-related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence-based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline. Materials and Methods: We followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient-Intervention-Control-Outcome) format, undertaking a systematic review and meta-analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability. Results: For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non-removable knee-high offloading device as the first-choice offloading intervention. If contraindications or patient intolerance to non-removable offloading exist, consider using a removable knee-high or ankle-high offloading device as the second-choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third-choice offloading intervention. If such a non-surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non-plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice. Conclusion: These offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes-related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

Charcot neuroarthropathy (CN) is a complication of neuropathy, in people with diabetes. Treatment requires the prolonged wearing of an offloading device, which can be challenging. The importance of understanding people's perspectives for promoting their engagement in self management is well known. However, no such studies have been done in CN. This qualitative study aimed to understand people's experiences of CN.Semi-structured interviews with a purposive sample of 14 participants with CN, recruited from a randomised controlled trial. We gathered opinions, thoughts and the meanings participants attributed to their experiences of CN and its physical, socio-economic and physiological effects and how this affected their families and relationships. We analysed the interviews using Inductive Thematic Analysis.Four analytic themes were identified: (1) 'Trapped at home isolated and missing social life and daily life routines'; (2) 'Disruption to people's roles, responsibilities, relationships and mobility, which people adapted to try and address and manage'; (3) 'Pain which participants related to the direct or indirect consequences of wearing the cast or boot'; and (4) 'Blame for developing CN, attributed to themselves and healthcare professionals'. Participants described guilt about needing more support, expressing frustration, low mood and low self-esteem.This study highlights experiential aspects of the previously unrecognised burden of CN. Its physical, social and emotional impacts on participants and their families are substantial and sustained. There is a need to raise clinical awareness of CN and its wider effects.ISRCTN74101606. Registered on 6 November 2017, http://www.isrctn.com/ISRCTN74101606?q=CADomfilters=sort=offset=1totalResults=1page=1pageSize=10searchType=basic-search.

Background Charcot neuroarthropathy is a complication of peripheral neuropathy associated with diabetes which most frequently affects the lower limb. It can cause fractures and dislocations within the foot, which may progress to deformity and ulceration. Recommended treatment is immobilisation and offloading, with a below knee non-removable cast or boot. Duration of treatment varies from six months to more than 1 year. Small observational studies suggest that repeated assessment with magnetic resonance imaging improves decision-making about when to stop treatment, but this has not been tested in clinical trials. This study aims to explore the feasibility of using serial magnetic resonance imaging without contrast in the monitoring of Charcot neuroarthropathy to reduce duration of immobilisation of the foot. A nested qualitative study aims to explore participants’ lived experience of Charcot neuroarthropathy and of taking part in the feasibility study. Methods We will undertake a two-arm, open study and randomise 60 people with a suspected or confirmed diagnosis of Charcot neuroarthropathy from five NHS, secondary care multidisciplinary Diabetic Foot Clinics across England. Participants will be randomised 1:1 to receive magnetic resonance imaging at baseline and remission up to 12 months, with repeated foot temperature measurements and X-rays (standard care plus), or standard care plus with additional three-monthly magnetic resonance imaging until remission up to 12 months (intervention). Time to confirmed remission of Charcot neuroarthropathy with off-loading treatment (days) and its variance will be used to inform sample size in a full-scale trial. We will look for opportunities to improve the protocols for monitoring techniques and the clinical, patient-centred and health economic measures used in a future study. For the nested qualitative study, we will invite a purposive sample of 10–14 people able to offer maximally varying experiences from the feasibility study to take part in semi-structured interviews to be analysed using thematic analysis. Discussion The study will inform the decision whether to proceed to a full-scale trial. It will also allow deeper understanding of the lived experience of Charcot neuroarthropathy, and factors that contribute to engagement in management and contribute to the development of more effective patient-centred strategies. Trial registration ISRCTN, ISRCTN74101606. Registered on 6 November 2017.

The National Diabetes Stakeholders Covid‐19 Response Group was formed in early April 2020 as a rapid action by the Joint British Diabetes Societies for Inpatient Care, Diabetes UK, the Association of British Clinical Diabetologists, and Diabetes Frail to address and support the special needs of residents with diabetes in UK care homes during Covid‐19. It was becoming obvious that the care home sector was becoming a second wave of Covid‐19 infection and that those with diabetes residing in care homes were at increased risk not only of susceptibility to infection but also to poorer outcomes. Its key purposes included minimising the morbidity and mortality associated with Covid‐19 and assisting care staff to identify those residents with diabetes at highest risk of Covid‐19 infection. The guidance was particularly created for care home managers, other care home staff, and specialist and non‐specialist community nursing teams. The guidance covers the management of hyperglycaemia by discussion of various clinical scenarios that could arise, the management of hypoglycaemia, foot care and end of life care. In addition, it outlines the conditions where hospital admission is required. The guidance should be regarded as interim and will be updated as further medical and scientific evidence becomes available.

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee-high offloading device is the first choice of offloading treatment. A removable knee-high and removable ankle-high offloading device are to be considered as the second- and third-choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth-choice offloading treatment. If non-surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

Aim The management of acute Charcot neuroarthropathy relies on off-loading which is costly and time-consuming. Published studies have used monitoring techniques with unknown diagnostic precision to detect remission. We performed a systematic review of techniques for monitoring response to offloading in acute Charcot neuroarthropathy. Materials and methods We included studies of off-loading which evaluated or described monitoring techniques in acute Charcot neuroarthropathy. PubMed, EMBASE, CINAHL and Cochrane databases were searched (January1993-July 2018). We extracted data from papers including study design, setting, population, monitoring techniques and treatment outcomes. We also extracted information on the cost, clinical applicability, sensitivity and specificity, safety and participant acceptability of the monitoring techniques. Results We screened 1205 titles, 140 abstracts and 45 full-texts, and included 29 studies. All studies were of low quality and at high risk of bias. In seven studies, the primary aim was to evaluate monitoring techniques: three evaluated magnetic resonance imaging, two thermography monitoring, one three-phase bone scanning and one Doppler spectrum analysis. The remaining 22 observational studies reported treatment outcomes and described the monitoring techniques used to assess the Charcot neuroarthropathy. Heterogeneity prevented the pooling of data. Very few studies included data on cost, clinical applicability, sensitivity and specificity, safety and patient acceptability of the monitoring techniques used. Conclusion Multiple techniques have been used to evaluate remission in acute Charcot neuroathropathy but uncertainty remains about their effectiveness. We recommend further research into the influences of different monitoring techniques on treatment outcomes.

Introduction The optimal management for patients with diabetes and peripheral vascular disease—intermittent claudication or critical limb ischemia (CLI)—remains undetermined. Methods In a single-center retrospective analysis, we compared 1- and 5-year amputation-free survival rates in patients undergoing angiography subsequently treated with medical therapy or revascularization. Results 78 patients were included, 56 with CLI (mean age 77 years); 22 with claudication (mean age 75 years). Of the CLI cohort, 30 patients were medically treated. Their 1-year amputation-free survival rate was similar to those treated with revascularization (46.7% versus 50.0%, respectively). 8 patients in the claudicant cohort were treated conservatively. The 1-year amputation-free survival rate was 75.0% for conservative treatment versus 78.6% in those revascularized. Within the CLI cohort, in those conservatively treated 20% underwent major, and 16.7% minor amputations, compared to 15.4% and 23.1% in those revascularized. At 5 years in the claudicant cohort, the amputation-free survival rate was 37.5% with medical treatment, versus 71.4% for those treated with revascularization. For CLI, the 5-year amputation-free survival rate was 10% for conservative treatment, versus 26.9% for revascularization. Conclusion We found similar rates of amputation at 1 year for patients treated medically or revascularized. However, at 5 years, the amputation-free survival rate was markedly higher in revascularized patients compared to those medically managed. Our study highlights the potential role of predicting life expectancy when considering treatment, with the option of surgical treatment offered to those in whom survival is predicted to be longer than 5 years. However, larger studies with matched cohorts are now needed to confirm these findings. Electronic supplementary material The online version of this article (doi:10.1007/s13300-015-0131-1) contains supplementary material, which is available to authorized users.

The optimal way to manage diabetic foot osteomyelitis remains uncertain, with debate in the literature as to whether it should be managed conservatively (ie, nonsurgically) or surgically. We aimed to identify clinical variables that influence outcomes of nonsurgical management in diabetic foot osteomyelitis. We conducted a retrospective study of consecutive patients with diabetes presenting to a tertiary center between 2007 and 2011 with foot osteomyelitis initially treated with nonsurgical management. Remission was defined as wound healing with no clinical or radiological signs of osteomyelitis at the initial or contiguous sites 12 months after clinical and/or radiological resolution. Nine demographic and clinical variables including osteomyelitis site and presence of foot pulses were analyzed. We identified 100 cases, of which 85 fulfilled the criteria for analysis. After a 12-month follow-up period, 54 (63.5%) had achieved remission with nonsurgical management alone with a median (interquartile range) duration of antibiotic treatment of 10.8 (10.1) weeks. Of these, 14 (26%) were admitted for intravenous antibiotics. The absence of pedal pulses in the affected foot (n = 34) was associated with a significantly longer duration of antibiotic therapy to achieve remission, 8.7 (7.1) versus 15.9 (13.3) weeks ( P = .003). Osteomyelitis affecting the metatarsal was more likely to be amputated than other sites of the foot ( P = .016). In line with previous data, we have shown that almost two thirds of patients presenting with osteomyelitis healed without undergoing surgical bone resection.

Aims: Glycaemic variability – the visit-to-visit variation in HbA1c – plays a possible role in the development of micro and macrovascular disease in patients with diabetes. Whether HbA1c variability is a factor determining wound healing in diabetic foot ulcers remains unknown. We aimed to determine whether HbA1c variability is associated with foot ulcer healing time. Methods: A retrospective analysis of patients presenting to our specialist multidisciplinary foot clinic between July 2013 and March 2015, with at least three HbA1c measurements within five years of presentation and more than two follow-up reviews. HbA1c variation was measured by magnitude of standard deviation. Results: 629 new referrals were seen between July 2013 and March 2015. Of these, 172 patients had their number of days to healing recorded and sufficient numbers of HbA1c values to determine variability. The overall geometric mean days to heal was 91.1 days (SD 80.8 to 102.7). In the low HbA1c variability group the geometric mean days to heal was 78.0 days (60.2 to 101.2) vs 126.9 days (102.0 to 158.0) in the high Hb1Ac variability group (p=0.032). Those with low HbA1c (< 58 mmol/mol) and low variability healed faster than those with high HbA1c and high variability (73.5 days [59.5 to 90.8] vs 111.0 days [92.0 to 134.0], p=0.007). Additionally, our results show that time to healing is more dependent on the mean HbA1c than the variability in HbA1c (p=0.007). Conclusions/interpretation: Our data suggest that there was a significant association between HbA1c variability and healing time in diabetic foot ulcers.

The hypothesis laid out in this thesis states that the early changes seen on an MR imaging in those with early Charcot neuroarthopathy may be due to mitochondrial dysfunction. In a Charcot foot, there is movement between bones. In an attempt to prevent this movement, the small muscles of the foot contract continuously when the foot is weight bearing. This contraction takes energy in the form of ATP. However, the reduction of glucose transport into the muscle cells due to insulin resistance / insufficiency, leads to reduction in the ATP producing capacity of the mitochondria. The ATP depletion affects the cell membrane gradient leading to mitochondrial and cellular swelling. These early cellular changes could then be picked up with MR imaging as muscle oedema.

Medication to aid weight loss and weight loss surgery are becoming more commonly available for people with diabetes. As a result of profound weight loss, diabetes may go into remission and many biochemical and physical parameters improve. However, some of the end organ damage associated with diabetes may not improve, peripheral neuropathy being an example. We present three cases in people with diabetes and preexisting peripheral neuropathy who had lost significant weight. They became more mobile and developed a Charcot foot despite their diabetes improving significantly. People who have lost significant weight should continue to monitor their feet because the risks of foot disease remain even if diabetes goes into remission. (J Am Podiatr Med Assoc 104(5): 522-525, 2014) Weight gain is intimately related to the likelihood of developing prediabetes and type 2 diabetes, 1 and subsequent weight loss contributes to diabetes remission. 2 As the prevalence of obesity increases, health-care providers are seeking strategies to either treat those who are already obese, or come up with successful strategies to prevent weight gain. Bariatric surgery has been widely advocated as part of the strategy for treating the increasing burden of obesity and type 2 diabetes, and may be used earlier in the natural history of the disease over the next few years. 3 The combination of peripheral vascular disease and distal neuropathy predisposes one to the development of foot ulcers. 4 In addition, a combination of shear stress and pressure as a result of trauma or changes in the biomechanics of the foot can result in the development of foot ulcers. 5

Objective: To look at haematological and biochemical variables as predictors of outcomes in people admitted to hospital with a diabetic foot ulcer (DFU) without the use of technology or devices. In particular, to see if there was a relationship between admission blood cell and protein levels, and the likelihood of angioplasty, amputation, and death at one year after admission. Method: A five-year retrospective analysis of patients admitted to a tertiary multidisciplinary specialist diabetic foot clinic looking at admission C-reactive protein (CRP), white cell count (WCC), neutrophil count and HbA1c and their relationship to likelihood of angioplasty, minor or major amputation, and death at one year after admission. Results: We identified 206 patients, in whom there was 1 year mortality rate of 6.3%. Raised WCC and CRP levels were significantly associated with major amputation (p=0.0035 and pConclusion: Commonly measured haematological and biochemical markers were useful predictors of outcomes for patients admitted to hospital for acute foot wounds. In addition, we found a much lower 1 year mortality and shorter length of hospital stay than previously recorded, possibly due to the introduction of a multidisciplinary weekly ward round.

Background Few data describe the natural history of Charcot neuroarthropathy treated with a total contact plaster cast (TCC). Methods A 5 year retrospective analysis of 50 patients presenting with an acute CN, Assessing time to clinical resolution into appropriate footwear and assessing if initial immobilisation device influenced resolution time. Results During the study period 42 patients (84%) of patients went into remission, 2 died during their treatment, 4 had major amputations, in 2 patients treatment was ongoing. 36 patients were treated with combination offloading devices, 6 were treated with one modality only. Median time to resolution for patients initially treated with a TCC was not significantly shorter than for those treated with a removable below knee boot. 34.9% required re-casting due to clinical deterioration in the removable device. Conclusions More precise measures of resolution of CN are needed to assess the impact of initial treatment modality on time to resolution.

Objectives People with diabetes stay in hospital for longer than those without diabetes for similar conditions. Clinical coding is poor across all specialties. Inpatients with diabetes often have unrecognized foot problems. We wanted to look at the relationships between these factors. Design A single day audit, looking at the prevalence of diabetes in all adult inpatients. Also looking at their feet to find out how many were high-risk or had existing problems. Setting A 998-bed university teaching hospital. Participants All adult inpatients. Main outcome measures (a) To see if patients with diabetes and foot problems were in hospital for longer than the national average length of stay compared with national data; (b) to see if there were people in hospital with acute foot problems who were not known to the specialist diabetic foot team; and (c) to assess the accuracy of clinical coding. Results We identified 110 people with diabetes. However, discharge coding data for inpatients on that day showed 119 people with diabetes. Length of stay (LOS) was substantially higher for those with diabetes compared to those without (± SD) at 22.39 (22.26) days, vs. 11.68 (6.46) ( P < 0.001). Finally, clinical coding was poor with some people who had been identified as having diabetes on the audit, who were not coded as such on discharge. Conclusion Clinical coding – which is dependent on discharge summaries – poorly reflects diagnoses. Additionally, length of stay is significantly longer than previous estimates. The discrepancy between coding and diagnosis needs addressing by increasing the levels of awareness and education of coders and physicians. We suggest that our data be used by healthcare planners when deciding on future tariffs.

Objective: The primary aim of this pilot observational study was to assess the reduction in wound depth and area achieved with a new negative pressure wound therapy (NPWT) system in diabetic patients with foot ulcers and post-amputation wounds. Secondary aims were to assess pain levels, extent of exudate removal, and ease of use of the system for both the patient and care giver. Method: Patients in both acute and home care settings were enrolled into this 4-week study. Dressings were changed three times per week. Wound area and depth, exudate removal and pain severity were evaluated at each dressing change. At the final visit, the investigators and patients were surveyed with respect to equipment and dressings used in the study. Results: Sixteen patients were enrolled into the study. Data relating to 14 patients with a variety of post-amputation wounds were included in the intention-to-treat (ITT) analysis. The post-amputation wounds showed a general trend for a reduction in the median wound surface area between baseline (22.9cm2; range 0.5-55) and the final visit (15.3cm2; range 2.4-63.5). This equates to a median change (calculated from the percentage change in wound area for each patient individually) of -41% (range -82% to +15%). There was also a general trend in reduction in the median depth between baseline (17mm; range 0-35) to final visit (5mm; range 0-35). One patient presented with a foot ulcer that demonstrated a 50% reduction in depth from baseline to the final assessment. The device effectively managed wound exudate and most patients reported low pain levels during therapy. Ease of use of the system was rated very highly by investigators and patients. Conclusion: This pilot study indicates that the use of the new NPWT system can be expected to have a positive effect on the healing of post-amputation wounds and foot ulcers in patients with diabetes. The findings demonstrate that the system is easy to use, effectively controls exudate and minimises pain and inconvenience for patients being treated with NPWT. Declaration of interest: This study was sponsored by Mölnlycke Heath Care (Gothenburg, Sweden) and Medela AG (Baar, Switzerland). The authors have no other conflicts of interest that are directly relevant to the content of this manuscript.

Aims: To identify which factors predict the need for minor or major amputation in patients attending a multidisciplinary diabetic foot clinic. Methods: A retrospective analysis of patients who attended over a 27 month period were included. Patients had to have attended ≥3 consecutive consultant led clinic appointments within 6 months. Data was collected on HbA1c, clinic attendance, blood pressure, peripheral arterial disease (PAD), and co-morbidities. Patients were followed up for 1 year. Results: 165 patients met the inclusion criteria. 121 were male. 33 patients had amputations. There was an association between poor glycaemic control at baseline and risk of amputation when adjusted for other factors, with those patients having HbA1c ≤58 at less risk of amputation with an odds of 0.14 (0.04 to 0.53) of amputation(p = 0.0036). Other statistically significant factors predictive of amputation were: missing clinic appointments (p = 0.0079); a high Charlson index (p = 0.03314); hypertension (p = 0.0216). No previous revascularisation was protective against amputation (p = 0.0035). However PAD was not seen to be statistically significant, although our results indicated a lower risk of amputation with no PAD. Overall, 34.9% (n = 58) of patients had good glycaemic control (HbA1c

Introduction : Podiatrists form an integral part of the multidisciplinary foot team in the treatment of diabetic footrelated complications. A set of unforeseen circumstances within our specialist diabetes foot service in the United Kingdom caused a loss of 50% of our non-operative podiatry team for almost 7 months during 2010. Some of this time was filled by non-specialist community non-operative podiatrists. Methods : We assessed the economic impact of this loss by examining data for the 5 years prior to this 7-month interruption, and for the 2 years after ‘normal service’ was resumed. Results : Our data show that the loss of the non-operative podiatrists led to a significant rise in the numbers of admissions into hospital, and hospital length of stay also increased. At our institution a single bed day cost is £275. During the time that the numbers of specialist non-operative podiatry staff were depleted, and for up to 6 months after they returned to normal activities, the extra costs increased by just less than £90,000. The number of people admitted directly from specialist vascular and orthopaedic clinics is likely to have increased due to the lack of capacity to manage them in the diabetic foot clinic. Our data were unable to assess these individuals and did not look at the costs saved from avoiding surgery. Thus the actual costs incurred are likely to be higher. Conclusions : Our data suggest that specialist non-operative podiatrists involved in the treatment of the diabetic foot may prevent unwarranted hospital admission and increased hospitalisation rates by providing skilled assessment and care in the outpatient clinical settings. Keywords : diabetes; foot clinic; podiatrist; economic value; multidisciplinary team (Published: 10 September 2013) Citation: Diabetic Foot & Ankle 2013, 4 : 21757 - http://dx.doi.org/10.3402/dfa.v4i0.21757

Aims To develop an antibiotic foot formulary for the empirical treatment of diabetes-related foot infections presenting to our service. Subsequently, to asses costs associated with the introduction of our protocol, in particular to assess the effect on admissions avoidance and any cost savings achieved. Methods We reviewed several existing antibiotic protocols. We analysed data on costs related to treatment and admission rates prior to and after the introduction of the protocol. Results We rationalized our antibiotic protocol and adapted the Infectious Disease Society of America guideline by introducing a category of ‘moderate infection—borderline admission’ to our classification. This enabled the administration of outpatient intramuscular antibiotics. After introducing the rationalized protocol, our average antibiotic prescribing costs for a 3-week course of treatment fell from £17.12 to £16.42. Over 22 months of follow-up, 26 episodes were eligible for treatment with intramuscular antibiotics. Over the same time period, 121 people were admitted directly from the foot clinic. The costs saved as a result of avoided or delayed admission for those 26 episodes was over £76 000. For 12 people who required subsequent admission, their length of hospital stay was significantly shorter than those admitted directly [9.25 days (range 2–25) vs. 16.11 (2–64), P = 0.045]. Conclusions By modifying the Infectious Disease Society of America classification and adopting a protocol to administer outpatient oral and intramuscular antibiotics, we have led to substantial cost savings, shorter hospital admissions and also have developed a successful admissions avoidance strategy.

OBJECTIVE To promote foot screening of inpatients with diabetes, we simplified sensory testing to lightly touching the tips of the first, third, and fifth toes (the Ipswich Touch Test [IpTT]). RESEARCH DESIGN AND METHODS Respective performances of the IpTT and 10-g monofilament (MF) were compared with a vibration perception threshold of ≥25 V indicating at-risk feet in 265 individuals. The IpTT and MF were also directly compared. RESULTS With ≥2 of 6 insensate areas signifying at-risk feet, sensitivities and specificities, respectively, were IpTT (77 and 90%), MF (81 and 91%); positive predictive values were IpTT (89%), MF (91%); and negative predictive values were IpTT (77%), MF (81%). Directly compared, agreement between the IpTT and MF was almost perfect (κ = 0.88, P < 0.0001). Interrater agreement for the IpTT was substantial (κ = 0.68). CONCLUSIONS The IpTT performs well against a recognized standard for ulcer prediction. Simple to teach, reliable, without expense, and always at hand, it should encourage uptake of screening and detection of high-risk inpatients requiring foot protection.

A 43-year-old man with a 28-year history of type 1 diabetes presented to our foot clinic in February 2008 with a fractured left second proximal phalanx due to trauma. His diabetes control was poor, with an HbA1c of 79 mmol/mol (9.4%) [reference range

In this article, we describe a case of a man without diabetes with a long history of amiodarone use. He presented with a foot deformity and plantar ulceration. Examination showed him to have a symmetrical peripheral neuropathy and findings consistent with a Charcot foot. Extensive investigations failed to find other causes for his neuropathy, other than his amiodarone use. We believe that this is the first reported case of a neuropathic foot deformity and ulceration occurring with amiodarone use, and we feel that it is important to point out the association of this commonly used antiarrythmic drug with this form of neuropathic osteoarthropathy. Level of Clinical Evidence: 4

Aim: To assess the association of inflammatory markers and the risk of developing contrast-induced nephropathy (CIN) in patients with diabetes undergoing lower limb angiography. Methods: This was a retrospective study of 77 patients undergoing lower limb angiography. We measured renal function and markers of inflammation, in particular neutrophil and lymphocyte count and C-reactive protein (CRP) levels, before and at 24, 48 and 72 hours after administration of contrast medium. Results: Those with pre-existing renal disease were at increased risk of CIN. We found no relationship between baseline renal function and CRP. There was a reduction in haemoglobin and lymphocyte count that is currently unexplained. Conclusions: While several traditional risk factors for CIN have been identified, further work is needed to determine the significance of changes in other haematological parameters.

OBJECTIVE To promote foot screening of inpatients with diabetes, we simplified sensory testing to lightly touching the tips of the first, third, and fifth toes (the Ipswich Touch Test [IpTT]). RESEARCH DESIGN AND METHODS Respective performances of the IpTT and 10-g monofilament (MF) were compared with a vibration perception threshold of ≥25 V indicating at-risk feet in 265 individuals. The IpTT and MF were also directly compared. RESULTS With ≥2 of 6 insensate areas signifying at-risk feet, sensitivities and specificities, respectively, were IpTT (77 and 90%), MF (81 and 91%); positive predictive values were IpTT (89%), MF (91%); and negative predictive values were IpTT (77%), MF (81%). Directly compared, agreement between the IpTT and MF was almost perfect (κ = 0.88, P < 0.0001). Interrater agreement for the IpTT was substantial (κ = 0.68). CONCLUSIONS The IpTT performs well against a recognized standard for ulcer prediction. Simple to teach, reliable, without expense, and always at hand, it should encourage uptake of screening and detection of high-risk inpatients requiring foot protection.