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Regional variation of risk factors and clinical presentation of diabetic foot lesions.
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Abbas ZG, Lutale J, Archibald LK.
Rodent bites on the feet of diabetes patients in Tanzania.
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Abbas ZG, Archibald LK.
Epidemiology of the diabetic foot in Africa.
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35 The International Consensus on the Diabetic Foot N.C. Schaper and K. Bakker
INTRODUCTION More than 200 million people in the world have diabetes mellitus, and too many of these sub- jects suffer from diabetic foot ulcers, which may eventually lead to an amputation (Table 35.1).1 Given the high costs associated with these ulcers, this disorder is a major burden not only to the patient but also to the health care system.2,3 Although the pathways to ulceration and am- putation do not differ throughout the world, the prevalence of ulcers and amputations varies markedly between different countries.4, 6 These differences probably reflect variations in popu- lation characteristics and wound management strategies across geographic regions.5, 7 Usually, several mechanisms are involved simultaneously, stressing the need for a patient-oriented, mul- tidisciplinary, approach to reduce the number of ulcerations, amputations and associated health care costs.8, 10 Furthermore, a well-structured organisation with facilities for providing diabetic foot care should be present.11 For such an approach to be useful, concerted action by all persons working with diabetic subjects is required, and specific guidelines are needed to realise uni- formity in diabetic foot care.4 Unfortunately, lack of awareness, knowledge and skills by both patients and health care providers still results in insufficient prevention and management in too many patients.12
THE INTERNATIONAL WORKING GROUP ON THE DIABETIC FOOT In the last decade, guidelines on prevention and management of the diabetic foot have been formulated in several countries.
However, differences in specialists involved, aims and target groups resulted in different documents.
Furthermore, in several countries, the diabetic foot is not on the agenda of the policymakers in health care, and arguments are needed to reallocate resources.
Clearly, there was a need for an international consensus, which could be the starting point for the formulation of guidelines in different countries or geographical areas.
Also, from quite a different field, a need for consensus was expressed.
The number of scientists involved in research in the diabetic foot is steadily increasing, but in several areas different definitions of items such as an ulcer, osteomyelitis, ‘severe’ or ‘mild’ ischaemia were used by different
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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THE INTERNATIONAL CONSENSUS ON THE DIABETIC FOOT (1999) 387
Table 35.1 Foot facts12
r One in every six people with diabetes will have a foot ulcer during his/her lifetime. r Every year, 4 million people with diabetes will develop a foot ulcer. r Every 30 seconds a leg is lost due to diabetes, somewhere in the world. r Foot problems are the most common cause of admission to hospital, for people with diabetes. r In developing countries, foot problems may account for up to 40% of health care resources. r The direct cost of an amputation is estimated to be between US$30 000 and US$60 000. r Ulcers can be prevented, and up to 85% of amputations can be avoided.
specialists involved.13 Moreover, several ulcer classification systems have been promoted, but no system has found universal acceptance.
This lack of common language and a common ulcer classification system hampers both the formulation of unambiguous guidelines for daily practice and the uniform reporting of scientific data.
To fulfill these needs, the International Consensus on Guidelines of the Diabetic Foot has been developed by a group of independent experts, in close association with several international organisations involved in the care of subjects with diabetes mellitus.
The International Working Group on the Diabetic Foot (IWGDF) coordinates the produc- tion of consensus documents.
This worldwide organisation was instituted in 1996 and is, since 2000, also the Consultative Section on the Diabetic Foot of the International Diabetes Federation (IDF).
Currently, 82 countries from all continents are represented in this unique multidisciplinary team of experts on the diabetic foot, including general practitioners, diabetol- ogists, podiatrists, diabetic nurses and general, vascular and orthopaedic surgeons.
Since its creation, the IWGDF has produced ‘The International Consensus on the Diabetic Foot’ in 1999 and three supplements in 2003 on infection, classification and wound healing.14, 16 During the three meetings of the IWGDF, in 1997,1998 and in 2003, the consensus process, the documents produced and the implementation of the guidelines were discussed.
Moreover, several working groups on specific topics have met more frequently under the guidance of an editorial board.
All materials produced by the IWGDF can be ordered at the IDF office in Brussels, Belgium.
THE INTERNATIONAL CONSENSUS ON THE DIABETIC FOOT (1999) The aim of the 1999 consensus document was to provide guidelines for prevention and treat- ment that will reduce the impact of diabetic foot disease, with consideration of costs and using the principles of evidence-based medicine (Table 35.2).4 In the document, the basic concepts
Table 35.2 Documents produced by the IWGDF
r The International Consensus on the Diabetic Foot (1999) r Practical Guidelines on the Management and Prevention of the Diabetic Foot (1999) r Interactive CD-ROM (2003) with International Consensus on Diagnosing and Treating the Infected Diabetic Foot Report on wound healing and treatments Report on classification of foot ulcers for research purposes
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388 THE INTERNATIONAL CONSENSUS ON THE DIABETIC FOOT
in diabetic foot care are addressed, with clear description of the various diagnostic, preventive or therapeutic strategies.
Furthermore, the organisation of care and the implementation of the guidelines are described.
The document consists of three different texts, written for policymak- ers in health care, general foot care specialists and health care professionals, respectively.
The text for policymakers focuses on the socio-economic impact of the diabetic foot and the possi- bility to reduce this impact by well-targeted intervention strategies.
The Practical Guidelines on the Management and Prevention of the Diabetic Foot describes the basic principles of preven- tion and treatment.
All health care workers involved in the care of diabetic patients can use these guidelines.
The International Consensus on the Management and Prevention of the Diabetic Foot serves as a reference to The Practical Guidelines.
Furthermore, it summarises the strategies in management and prevention, gives a set of definitions of the essential topics in diabetic foot disease and can be used by the various specialists involved in diabetic foot care.
THE 2003 CONSENSUS DOCUMENT AND REPORTS After the successful launching of the consensus documents at the Third International Sympo- sium on the Diabetic Foot in 1999, the IWGDF decided in 2000 that additional documents were to be produced on the infected diabetic foot, wound healing and on an ulcer classification for research purposes. These topics were not covered in depth by the 1999 consensus document.
Infection Infection is a frequent complication of diabetic foot ulcers and is, in many patients, the pivotal event leading to amputation.
The IWGDF observed that there were worldwide large differences in the definition of infection, its diagnosis and its management.
Therefore, a working group of experts in the field was instituted, with B.A.
Lipsky (United States) as chairman.
This group produced a state-of-the-art consensus document on diagnosis and treatment of the infected diabetic foot, and moreover, it provides practical guidelines for daily practice.14 A summary of this consensus document and, in particular, of the practical guidelines is given below.
Wound Healing The aims of the wound care document were to provide a state of the art on wound healing, on barriers to healing and on treatments for diabetic foot ulcers; a summary of this document is given below.15 Unfortunately, it became clear to the working group, with K.G.
Harding (United Kingdom) as chairman, that the evidence base to produce practical guidelines on wound care is lacking.
The current document should therefore be seen as a progress report; however, the IWGDF hopes that within the next few years more solid data will become available.
Given the great need for practical, evidence-based guidelines, the present consensus process will be continued, and hopefully within the next few years practical guidelines will be produced on this topic, in combination with a shorter version of the current document.
Classification More than ten different systems have been developed to classify diabetic foot ulcers for daily clinical practice, and different centres of excellence use different classification systems;