Caring for the diabetic foot in primary care

Non-insulin dependent diabetes mellitus (NlDDM) is a common condition affecting 10% of the world population, a further 1 0-lS% of adults aged over 40 years having pre-diabetes and thus carrying an increased high risk of progression to the condition2 Major complications in NlDDM are mainly of vascular nature, the renal, ophthalmic, and nervous (peripheral and autonomic) complications ariSing mainly secondary to microvascular complications while macrovascular pathology being responsible to cerebrovascular, peripheral vascular and coronary heart pathology. Foot ulcers in diabetics are common and seriousl , and likely to increase in the coming years with increasing incidence of diabetes in the community4. As the diabetic foot syndrome leads to amputations, disability and reduced quality of life5, lower extremity complications in persons with diabetes have become an increasingly Significant public health concern in both the developed and developing world6 Indeed the prevalence of the diabetic foot varies between 9% to lS% according to the population studied,7,8 with an estimated annual incidence lying between 1-4% and a lifetime risk of lS%9,10 Viewed differently the risk oflower limb amputation in a diabetic is SO-lOO times that of the general populationll claiming about SO% of non- traumatic, lower extremity amputations. 12 The Public Health impact of these numbers is significant. While in the U.K. this is estimated to cost the NHS around £12.9 million per annum, 1l in the United States an estimated 4% of patients diagnosed with diabetes account for 46% of annual hospitalisations for foot ulcers.14 Equally of concern is the high mortality of patients with diabetic foot ulcers. Five-year mortality rates in these patients have been reported between 43% and SS%, spiralling up to 74% in patients with lower-extremity amputation. These rates are higher than those for several types of cancer including prostate, breast, colon, and Hodgkin's disease. 15 In patients previously hospitalized with a diabetic foot, mortality is often related to cardiovascular disease. In one study the cause of death was mainly due to acute myocardial ischaemia (24.2%), infection (21.2%) and cerebrovascular accident 00.6%), the prevalence of cardiovascular disease calculated at 70.1 %16 Thus new-onset diabetic foot ulcers should be considered as a marker for significantly increased mortality and should be aggressively managed locally, systemically, and psychologically. 17 Maltese Family Doctor l[-Tabib tal-Familja A number of factors are involved in the development and maintenance of a diabetic foot ulcer. These include polyneuropathy, mechanical overload, peripheral arterial disease and infection. 18 In up to 8S% foot ulcers precede amputations in diabetic patients. 19 Since evolution of the disease is slow, it is possible to implement prevention and control measures,20 but as patient outcomes (such as amputation and death) occur erratically, widespread adoption of auditing this aspect of diabetic care emerges as crucial. Indeed, examination of the feet in a diabetes clinic setting is notoriously known to leave much to be desired but good results may be attained if appropriate measures are taken. Despite treatment up to 15% of ulcers fail to heal within 6 months in established specialised ulcer clinics, hence the importance of prevention.peer-reviewe