Review Review MANAGING ULCERS: BEST PRACTICE Despite a wealth of evidence and clinical guidelines, the prevention and management of diabetic foot ulcers remains a challenge. This article aims to defi ne best practice through the exploration of ten key points taken from current evidence and guidelines in an attempt to help non-specialist practitioners to implement best practice when treating patients with .

Caroline McIntosh and Veronica Newton are Senior Lecturers in Podiatry, University of Huddersfi eld

The need for standardised care in diabetes has been highlighted by the development of numerous clinical guidelines and best practice statements from key sources such as the National Institute for Health Figure 1. Diabetic foot and Clinical Excellence (NICE, ulcer. 2004); the Department of Health (Dept of Health, 2001); the Scottish Intercollegiate Guidelines Network, (SIGN, 2001), and the Royal College to have an appreciation of the characterised by chronic of General Practitioners underlying disease process. hyperglycaemia. (Hutchinson et al, 2000) (Table 1). New evidence is constantly Diabetes mellitus occurs when There are two main types of emerging within the field there is inadequate uptake of diabetes: type 1 and type of diabetes care, making it glucose by the cells of the body 2. In people with type 1 difficult for the non-specialist resulting in raised blood glucose diabetes, the pancreas does practitioner to remain up-to- levels (Pocock and Richards, not produce enough . date with current best evidence. 2004). This is an autoimmune disease This review aims to identify the whereby the insulin producing basic requirements of diabetic Insulin, a hormone produced β-cells are destroyed by the foot examination and to define in the pancreas, regulates the body’s own immune system. best practice for effective storage and release of energy Without insulin, the storage and management of diabetic from food. Diabetes can occur release of energy from food foot ulceration through the due to failure of the pancreas cannot be regulated and high exploration of 10 key elements. to produce enough insulin or levels of glucose remain in the to the development of insulin bloodstream (hyperglycaemia) Diabetes mellitus resistance, both resulting in (Davey, 2004). To gain an understanding of high blood glucose levels affects approximately 15% of the complexities of diabetic (hyperglycaemia). Diabetes all people living with diabetes in foot ulceration, it is important is a progressive disease England and primarily affects the

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fundamental to establishing Table 1 ulcer risk and allowing strategies Clinical guidelines and best practice statements to be implemented to prevent ulceration (American Diabetes International Consensus on the Diabetic Foot (International Working Group on the Diabetic Foot, 1999) Association, 2004). If at-risk National Service Framework for Diabetes (Department of Health, 2001) individuals are identified early, Management of Diabetes: A National Clinical Guideline (Scottish Intercollegiate Guidelines Network [SIGN], 2001) diabetes-related foot problems : Prevention and Management of Foot Problems (National Institute for Health and Clinical Excellence are largely preventable. Table [NICE], 2004) 3 describes risk classifications. A traffic light system has been provided as a visual guide to younger population (<30 years of uncontrolled hyperglycaemia highlight risk status: green age) (Dept of Health, 2001). increases the risk of developing denotes low-risk foot, amber a number of chronic problems denotes at-risk to high-risk foot Type 2 diabetes affects associated with diabetes, and red denotes ulcerated foot. approximately 85% of all people namely vascular and neurological living with diabetes in England (Dept of Health, 2001). Type 2 Diabetes mellitus occurs Table 2 diabetes usually occurs later in when there is inadequate life; it is most common in people uptake of glucose by the Basic foot examination over the age of 40 years. In cells of the body resulting in people with type 2 diabetes, the raised blood glucose levels The examination should include: β-cells are not able to produce (Pocock and Richards, 2004). Use of a 10g monofilament to assess sensory status enough insulin, or there is a Palpation of foot pulses degree of complications. This is primarily Inspection of the feet for deformities where the cells in the body can due to damage of small blood Inspection of footwear for wear and tear and foreign not respond to the insulin that vessels (microvasculature objects that may traumatise the foot is produced by the β-cells. The disease). Initially changes are Source: NICE (2004) storage and release of energy reversible, but with prolonged from food is not regulated and exposure to high glucose levels hyperglycaemia occurs. damage can be irreversible Ten key points in effective and the likelihood of chronic management of diabetic foot Self-monitoring of blood glucose complications increases (Dept of ulceration levels is advocated to people Health, 2001). NICE (2004) guidelines state living with diabetes, with a level of that individuals presenting with 7mmols/l being the optimum. It is Standard diabetic foot ulceration should be referred also possible for trained healthcare examination to the diabetes specialist professionals to measure the All individuals with diabetes multidisciplinary team within 24 percentage concentration of should receive annual hours. The team members must glucose in red blood cells in a test assessment by trained then undertake a comprehensive

called HbA1C. practitioners as part of ongoing assessment to establish a diabetes care (NICE, 2004). The management plan tailored to

HbA1C is a measure of how minimum requirements of a basic meet the needs of the individual, much glucose is attached to foot examination are detailed in while conforming to best practice the haemoglobin part of the Table 2. in diabetes. Figure 2 shows the red blood cell (glycosylated 10 key elements in effective haemoglobin) and is usually Following a basic foot management of diabetic foot expressed as a percentage. examination, the risk status for ulceration. Levels of 6.5–7.5% are ulceration can be established. optimum figures. Early identification of risk factors Each point will now be explained The effect of prolonged, for diabetic foot ulceration is and then considered in relation

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fat, sugar and salt, high in fruit Table 3 and vegetables and moderate in bread, potatoes, cereals, Classification of risk status pasta and rice. Everyone with diabetes should receive dietary Low-risk No complications: annual review recommended information and support. A state- At-risk foot Neuropathy or absent pulses or bone/joint deformity such as bunion formation or toe deformities: registered dietician can provide 3–6 month review recommended specific dietary advice that takes High-risk foot Neuropathy or absent pulses or bone/joint deformity/previous ulcer: a 1–3 month review with into account lifestyle and cultural an individualised management plan is recommended preferences (Diabetes UK, 2006). Ulcerated foot Urgent treatment

From: International Working Group on the Diabetic Foot (1999); NICE (2004) 2. Identify aetiological factors Patient assessment should include evaluation of their to the current evidence base The same studies showed vascular and neurological and clinical guidelines, and that patients with intensive status, skin assessment and recommendations made to blood glucose (i.e. with more a thorough medical and social facilitate the practitioner in frequent glucose monitoring history to establish the cause implementing best practice. points throughout the day), of the wound. The International who controlled their diabetes Working Group on the Diabetic 1. Advocate tight glycaemic with either sulphonylureas or Foot (IWGDF, 1999) suggests control insulin, had fewer microvascular most ulcers on the diabetic foot NICE guidelines (2002) for complications. The UK can be classified as neuropathic, patients with type 2 diabetes Prospective Diabetes Study ischaemic or neuroischaemic. recommend self-monitoring and (UKPDS) Group (1998) also management of blood glucose demonstrated an increased risk The IWGDF (1999) and NICE

with HbA1C measurements by of cardiovascular events such as (2004) suggest that the most a healthcare professional at myocardial infarction and strokes frequent cause of diabetic foot

2–6 monthly intervals. A level of when HbA1C concentrations rise ulceration is ill-fitting shoes, 6.5–7.5% is a measure of good above the normal range. which may be too small, too big glycaemic control (McIntosh or excessively worn and advise et al, 2001). High glycaemic Use of combination therapy meticulous routine examination levels can detrimentally affect (treatment with more than one of footwear in all patients. the tissue electrolyte balance type of oral hypoglycaemic) Practitioners should examine and white blood cell activity for management of type 2 them for wear and tear and and hence prolong infection diabetes can optimise glycaemic foreign objects such as small and delay healing, which is control further by increasing stones, glass fragments, drawing why controlling blood sugar in sites of action of drug therapy, pins, pet hairs, etc that may the absence of other disease leading to reduced episodes of traumatise the foot (NICE, 2004). processes aids normal healing. hyperglycaemia (NICE, 2002). Therefore, the practitioner should Underlying complications in It has been demonstrated in always advocate tight glycaemic the diabetic foot are vascular randomised controlled trials control for patients with type 2 changes resulting in ischaemic that prolonged episodes of diabetes. ulceration and neurological hyperglycaemia increase the changes resulting in neuropathic risk of developing both macro- Glycaemic control can be ulceration. Edmonds and Foster (large) and micro- (small) vessel further reinforced by dietary (1999) argue that it is rare to disease (Diabetes Control and advice to encourage patients see pure ischaemic changes Complications Research Group, to play a role in controlling their without neuropathic alterations. 1993; UK Prospective Diabetes diabetes. A healthy diet for Approximately 50% of people Study [UKPDS] Group, 1998). people with diabetes is low in who present at diabetic foot

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clinics have neuropathy, and The duration of diabetes and disease; therefore, a 2–6- 50% have neuroischaemic feet the severity of hyperglycaemia monthly review is recommended (Edmonds and Foster, 1999). have a strong association with (Hutchinson et al, 2000). Other common causes of the development of vascular diabetic foot ulceration include complications below the 4. Manage arterial risk factors previous ulceration. Recurrence knee (Diabetes Control and The presence of arterial disease rates of diabetic foot ulceration Complications Trial Research is a risk factor for foot ulceration are high. For example, Pound et Group, 1993; UKPDS Group, in the diabetic foot. Arterial risk al (2005) identifi ed that 40% of 1998). Measurement of PVD factor management is essential patients developed a recurrent/ extends from simple pulse to ensure effective control of new ulcer within four months of palpation of the foot pulses the underlying issues in type 2 the original ulcer healing. Another (dorsalis pedis and posterior diabetes. These are identifi ed common cause is trauma in tibial) to more sophisticated as hypertension, dyslipidaemia, an insensate foot as a result of assessment by specialist coronary heart disease, smoking, peripheral neuropathy. practitioners, i.e. using Doppler hyperglycaemia, renal disease ultrasound to obtain the ankle and sedentary lifestyle (UKPDS Foot deformities can give rise to brachial pressure index (ABPI) Group, 1998). abnormal sites of high pressure and the toe brachial pressure on the foot, resulting in tissue index (TBPI). Prevalence of hypertension in breakdown and foot ulceration. type 2 diabetes is higher than

Socioeconomic status is also an HbA1C measurement is a predictor that in the general population. important consideration because of the rate of development of Hypertension (defi ned by a of the related poor access micro- and macro-vascular blood pressure greater than to health care and education associated with low status (IWGDF, 1999).

3. Establish and quantify 1. Advocate tight glycaemic control vascular status 10. Offer structured 2. Identify Patients with diabetes mellitus education and aetiological factors are more prone to peripheral empowerment vascular disease (PVD) than the non-diabetic population 9. Engage 3. Establish (Shaw and Boulton, 2001). This multidisciplinary and quantify includes proximal vessel disease team approach vascular status (affecting the lower abdomen Managing and thigh), and more distal diabetic foot ulceration vessel disease (affecting calf and using best practice foot) (SIGN, 2001). 4. Manage 8. Employ off-loading arterial risk factors Practitioners should establish strategies and quantify the number of risk factors associated with: peripheral vascular 7. Establish and 5. Rapid management quantify neurological of infection disease (PVD); hypertension; complications dyslipidaemia; coronary and pain 6. Identify wound characteristics heart disease; smoking; hyperglycaemia; renal disease; and sedentary lifestyle (American Diabetes Association, 2003; NICE, 2004). Figure 1. Ten key elements in effective management of diabetic foot ulceration.

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140/90mmHg) is present in 5. Rapid management of infection can then be modified with more than 80% of people with Practitioners must remain vigilant reference to clinical response type 2 diabetes. The incidence for signs of infection and, if and microbiological test results. of microvascular (small vessel) in doubt, patients should be and macrovascular (large vessel) referred urgently to the specialist Additionally, it is important to disease increase incrementally foot care multidisciplinary maintain good metabolic control with increasing systolic blood team for assessment. Current blood glucose measures of pressure. Therefore, it is guidelines promote aggressive approximately 7 mmols/l, or

essential to reduce the blood management of infection with HbA1c <7% would be considered pressure to near-normal levels. appropriate systemic antibiotic desirable and would optimise Guidelines suggest patients therapy (IWGDF, 1999; NICE, cardiovascular function to should aim for near-normal 2004). improve the chances of wound

levels — HbA1c <7% and blood healing (Cutting et al, 2005; pressure <140/<80mmHg (UK A major challenge for diabetes Edmonds, 2005). Prospective Diabetes Study care providers is the prompt (UKPDS) Group, 1998). recognition of infection in the A recent study aimed to diabetic foot. Clinical diagnosis develop further criteria for Lipid changes are regularly seen in of infection relies on the early recognition of infection patients with diabetes, as insulin is important signs associated with in the diabetic foot (Cutting et a key regulator of lipid metabolism. infection: pain or discomfort, al, 2005). The signs identified Typical lipid changes in type 2 swelling, warmth and erythema include cellulitis, lymphangitis, diabetes are: (Edmonds et al, 2004). However, purulent exudate and pus/ 8An increase in triglycerides in the diabetic foot these signs abscess. 8A decrease in high-density can be absent even in the lipoprotein-cholesterol (HDL-C) presence of infection as a result 6. Identify wound characteristics 8An increase in small, low-density of neuropathy and a reduced In a chronic diabetic foot lipoprotein (LDL) particles. arterial supply. wound, the cellular processes are disrupted and abnormal All these changes are associated functions may be due to a variety with an increased risk of A major challenge for of intrinsic (e.g. cellular level) or atherosclerosis; an underlying diabetes care providers is extrinsic (e.g. mechanical forces) disease process that increases the prompt recognition of factors, acting on their own or in the clinical risk of diabetic infection in the diabetic foot. combination. The philosophy of foot ulceration (NICE, 2002). wound bed preparation (WBP) is Lipid-lowering therapy has Wound infection is associated now widely accepted as a useful demonstrated a relative risk with delayed wound healing, strategy to assist the practitioner reduction in major cardiovascular and in the neuroischaemic when implementing care plans events in patients with or without foot can rapidly give rise to for patients with complex type 2 diabetes (Robless et al, spreading infection (cellulitis) wounds (Watret, 2005). 2001). that can progress to tissue death (necrosis). NICE (2004) Sibbald et al (2000) defined Other factors, such as coronary guidelines stipulate that wound wound bed preparation as ‘a heart disease, smoking, management should employ changing paradigm that links hyperglycaemia, renal disease the use of intensive systemic treatment to the cause and and a sedentary lifestyle should antibiotic therapy for non- focuses on three components of be managed on an individual healing/progressive ulcers with local wound care, ‘debridement, basis in accordance with the signs of infection. SIGN (2001) wound-friendly moist interactive National Service Framework suggests treatment with a dressings and bacterial (2001), NICE guidelines and broad-spectrum antibiotic in balance’. WBP principles other international guidelines conjunction with appropriate attempt to assist the clinician in (Table 1). debridement. Antibiotic regimens understanding and identifying

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exudate that can cause Table 4 excessive hydration (maceration) and damage to the surrounding Clinical application of TIME principles skin (White and Cutting, 2004). Tissue management (non-viable or deficient) Assess the amount of viable and non-viable tissue. The presence of slough and necrotic tissue can delay healing and In the absence of any strong the need for regular debridement should be considered evidence for the most (Watret, 2005) appropriate dressing choice, Infection and/or inflammation Diabetic foot ulcers are prone to infection NICE (2004) recommends that Moisture imbalance Wound assessment should encompass analysis of wound practitioners should use wound exudate, e.g. volume, consistency etc (Gray and White, 2004) dressings that best match Edges of the wound (non-advancing or undermined) Closure of diabetic foot ulcers is delayed in the presence of clinical experience, patient non-viable tissue such as a callus. Frequent debridement by preference, and the anatomical a skilled podiatrist is needed to promote proliferation of healthy location of the wound, while granulation tissue to facilitate normal wound healing also considering cost. (Watret, 2005) 7. Establish and quantify the underlying molecular and case debridement may further neurological complications cellular abnormalities that traumatise compromised tissues. and pain prevent the wound from healing. Symptoms of diabetic peripheral WBP involves optimising the neuropathy (neurological As many as 50% of patients local wound environment for damage to the nerves in attending a diabetic foot healing. The acronym TIME the upper and lower limbs) clinic will have one or which stands for Tissue (non- are diverse, with symptoms more of the symptoms of viable or deficient), Infection/ ranging from painless to painful, peripheral neuropathy (Baker inflammation, Moisture affecting many nerve pathways. et al, 2005). (imbalance) and Edge (non The key clinical features of advancing or undermined), is peripheral neuropathy in the leg often discussed in conjunction While debridement is and foot are: with the principles of WBP and recognised as an important 8Motor neuropathy which has been suggested in papers adjunct to stimulate healing presents as muscle wasting by Schultz et al (2004) and in the neuropathic foot and diminished or absent Watret (2005) as a systematic (Edmonds et al, 2004), reflexes approach to facilitate wound wound debridement must 8Sensory neuropathy which management (Table 4). be undertaken with caution presents as diminished or in the sensitive ischaemic absent sensation of touch, Regular wound debridement foot to prevent any additional pain, temperature and is recommended to remove pain during treatment and to vibration necrotic tissue and callus, prevent any further trauma to 8Autonomic neuropathy which reduce pressure, allow a full vascular-compromised tissues. presents as a foot with dry inspection of the wound bed If in any doubt as to whether skin, warm to the touch, pink and stimulate wound healing in debridement is appropriate, a in colour with abnormally the diabetic foot (Leaper, 2002; referral must be made to the bounding pulses due to Edmonds et al, 2004; Watret, diabetes multidisciplinary team thermoregulation defects. 2005). NICE (2004) guidelines for further assessment. support this view and advise It is widely recognised that that dead tissue should be Effective wound management peripheral neuropathy is a carefully removed from foot should also aim to maintain major contributory factor in the ulcers to facilitate healing, unless a moist wound environment development of foot ulceration. surgical revascularisation of to promote healing while As many as 50% of patients the vessels is required in which preventing excess wound attending a diabetic foot

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clinic will have one or more of has been shown in trials to suggested as the ‘gold the symptoms of peripheral reduce symptoms of painful standard’ in off-loading (Baker et al, 2005). neuropathy (SIGN, 2001). foot ulcers (SIGN, 2001; NICE, Ulcer prevalence and the risk of It is important to remember 2004). However, in the presence amputation can be reduced if that glycaemic control, ethnic of ischaemia and/or infection, people diagnosed with sensory background, duration of the TCC can be contraindicated neuropathy are offered foot care disease, and cardiovascular because of inaccessibility to education, podiatry and, where factors are all associated with the wound (Edmonds et al, required, therapeutic footwear increased risk of complications 2004) and, therefore, other (Dept of Health, 2001). (NICE, 2004). commercially available designs of RCWs should be considered, Pain in the insensate foot 8. Employ off-loading strategies such as the Aircast pneumatic is a sign of deep structure Removal of pressure, known as walker. disruption, including infection off-loading, can be achieved by of the bone and its marrow a number of strategies, including Therapeutic footwear is (osteomyelitis) or Charcot avoidance of weight bearing, the frequently prescribed as a arthropathy changes (Sibbald, use of irremovable and removable management strategy in 2003), both of which require cast walkers, half shoes, orthotic the primary and secondary prompt management to prevent devices and therapeutic footwear. prevention of diabetic foot adverse outcomes such as Armstrong et al (2001) suggest ulceration and as an adjunct tissue necrosis and severe that the central goal of any to aid healing when ulceration deformity, respectively. programme designed to heal is present. Maciejewski et al Patients with painful active foot ulceration is effective (2004) reviewed evidence for diabetic neuropathy may reduction of pressure. In the the effectiveness of therapeutic benefit from prescription of presence of neuropathy, diabetic shoes in preventing ulceration a tricyclic antidepressant, patients generally develop foot and found several studies that e.g. amitriptyline, which ulceration over sites of high reported statistically significant pressure and shear on the sole protective benefits from (plantar aspect) of the foot therapeutic footwear. However, primarily related to normal walking used alone, therapeutic Key Points (Armstrong et al, 2003). footwear may not provide sufficient pressure relief to off- 8 There is an urgent need for standardised care in diabetes. A randomised controlled load effectively, and should 8 With new evidence constantly trial investigated off-loading be used in combination with emerging, it is difficult for the strategies for diabetic foot orthotic devices. A thorough non-specialist to keep up-to-date ulcers (Armstrong et al, 2001). assessment of the structure with current best practice. Findings suggest that the total and mechanics of the foot 8 To understand the complexities contact cast (TCC), a type needs to be undertaken by a of diabetic foot ulceration, an appreciation of the underlying of below-knee walking cast podiatrist and/or orthotist before disease process is necessary. made from either plaster of insole prescription (McIntosh 8 There are two main types of Paris or fibreglass, healed a and Newton, 2005) and diabetes: type 1 and type 2. higher proportion of wounds in patients requiring off-loading 8 The non-specialist can play a a shorter amount of time than devices should be referred key role in the early detection removable cast walkers (RCWs) to the specialist diabetes of problems and prompt referral to the diabetes foot care that can be removed to facilitate multidisciplinary team for further multidisciplinary team. dressing changes. Armstrong assessment. 8 Amputation risk is decreased et al (2001) suggest that it is when patients receive care perhaps the removability of 9. Engage multidisciplinary from specialist foot care the RCW that is its biggest team approach multidisciplinary teams. detriment in healing times. The aim of the multidisciplinary The TCC has therefore been team, as described in the

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National Service Framework for long-term complications, Glossary (Department of Health, 2001) eating a balanced diet and and NICE (2004) guidelines, taking regular activities or is to minimise the impact of exercise to promote optimal the long-term complications of health. Furthermore, this care diabetes. This is done through should be patient-centred Charcot arthropathy or Charcot neuroarthropathy: is a chronic, progressive, degenerative disease of osseous early identification of risk factors so that services can match (bone) tissue. It is suggested that this results from and effective management, thus individual care with individual autonomic neurological dysfunction causing rapid maximising the quality of life for needs (Department of Health, changes in bone density that can cause severe foot those with diabetes. Evidence 2001). deformity suggests that amputation risk is Dyslipidaemia: an excess of lipids (a type of fat) in the reduced when patients receive blood care from specialist foot care Diabetes mellitus is a chronic multidisciplinary teams (Foster condition that can impact High-density lipoprotein (HDL): this is a type of cholesterol sometimes referred to as the ‘good’ type of and Edmonds, 2002). on almost every aspect of cholesterol. Low levels of HDL in the bloodstream have someone’s life. been correlated with the development of heart disease Diabetes mellitus is a chronic condition that can impact Insensate: lacking physical sensation on almost every aspect of Since its publication in 2001, Ischaemia: blood deficiency and relative tissue hypoxia someone’s life. Individuals living the National Service Framework usually as a result of arterial disease/obstruction with diabetes will require the for Diabetes has contributed Low-density lipoprotein (LDL): this is a type of support of numerous health to the attempt to structure cholesterol, sometimes referred to as the ‘bad’ type professionals at differing education to prevent some of of cholesterol. The higher the value of LDL in the stages, e.g. at first diagnosis the devastating complications bloodstream above the normal values, the higher the and in the short- and long-term associated with diabetes. The risk of vascular disease management of complications. National Service Framework Lymphangitis: a state of inflammation of the lymphatic The need for a multidisciplinary recommends structured vessels seen radiating from a site of infection team approach is outlined education to improve patients’ within section 12 of the National knowledge and understanding Monofilament: instrumentation used in neurological testing to assess sensory perception Service Framework for Diabetes of their condition, thus enabling (Department of Health, 2001) them to undertake effective Neuroischaemia: pathophysiological changes (the and within the NICE (2004) and self-care (Dept of Health, disordered physiological processes associated with SIGN (2001) guidelines. The aim 2005). A number of structured disease or injury) resulting in neurological and vascular is to ensure that people with education programmes have signs/symptoms diabetes receive integrated health recently been introduced Neuroischaemic: denotes pathological changes in both and social care, with effective to educate patients and neurological and vascular systems communication between all encourage those living with Neuropathy: pathological changes in the nerves affect- healthcare providers involved diabetes to manage their ing structure and function in order to achieve an optimal own diabetes and foot care individualised care package. independently. These include: Triglycerides: a type of circulating fat (obtained from the diet). Elevations of this type of fat in the blood- 8The expert patient programme stream have been correlated with the development of 10. Offer structured education 8Dose Adjustment For Normal arterial disease and empowerment Eating for type 1 diabetes Standard 3 of the National (DAFNE) Service Framework for Diabetes 8Diabetes Education and Self (DoH, 2001) aims to encourage Management for Ongoing and are able to offer help support people with diabetes to self Newly Diagnosed for type 2 and advice to people living manage their diabetes on a diabetes (DESMOND). with diabetes. day-to-day basis, in terms These programmes provide of achieving good glycaemic a national network of health Lifestyle management can help control to reduce the risk factors professionals and patients who improve the patient’s quality

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ScHARR, University of Sheffield, edn. Oxford University Press, Oxford bed – debridement, bacterial balance Sheffield 606–8 and moisture balance. Ostomy Wound Manage 46: 14–35 NICE (2002) Management of Type 2 Pound N, Chipchase S, Treece K, Game Diabetes – Managing Blood Glucose F, Jeffcoate W (2005) Ulcer-free survival Sibbald GR (2003) Wound diagnosis. Levels. National Institute for Health and following management of foot ulcers in Pisa Satellite Symposium — Wound Clinical Excellence, London diabetes. Diabet Med 22(10): 1036–9 Pain Management: An Interdisciplinary Case-Based Approach. Proceedings NICE (2002) Management of Type 2 Robless P, Mikhailidis DP, Stansby G from European Wound Management Diabetes — Management of Blood (2001) Systematic review of antiplatelet Association (EWMA) Conference, Pressure and Blood Lipids. National therapy for prevention of myocardial Saturday 24 May 2003, Pisa Institute for Health and Clinical infarction, stroke or vascular death Excellence, London in patients with peripheral vascular Scottish Intercollegiate Guidelines disease. Br J Surg 88(6): 787–800 Network (2001) Section 7: Management NICE (2004) Type 2 Diabetes: Prevention of diabetic foot disease. In: and Management of Foot Problems. Schultz G, Barillo, Mozingo, and Chin, Management of Diabetes: A National Clinical Guideline 10. National Institute (2004) The Wound Bed Advisory Board Clinical Guide. Scottish Intercollegiate for Health and Clinical Excellence, Members Wound bed preparation and a Guidelines Network, Edinburgh (http:// London brief history of TIME. Int Wound J 1: 19 www.sign.ac.uk/guidelines/fulltext/55/ Plank J, Haas W, Rakovac I, Görzer Shaw JE, Boulton AJM (2001) The section7.html) (Last accessed 4 May E, Sommer R, Siebenhofer A, Pieber diabetic foot. In: Beard JD, Gaines 2006) TR (2003) Evaluation of the impact PA, eds. Vascular and Endovascular UK Prospective Diabetes Study (UKPDS) of chiropodist care in the secondary Surgery. 2nd edn. WB Saunders, Group (1998) Intensive blood-glucose prevention of foot ulcerations in diabetic London: 105–26 control with sulphonylureas or insulin subjects. Diabetes Care 26(6): 1691–5 Sibbald RG, Williamson D, Orsted compared with conventional treatment Pocock G. Richards CD. (2004) Human HL, Campbell K, Keast D, Krasner D, and risk of complications in patients with WCS SUBS 1/2 page AD NEW 27/5/05 7:25 pm Page 1 Physiology. The Basics of Medicine. 2nd Sibbald D (2000) Preparing the wound type 2 diabetes. UKPDS

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