The prevalence of symptomatic venous thromboembolism in patients requiring total contact casting for neuropathic foot complications

Declan Doherty, Andy Bridgen, Aaron Barber and Frank Webb

The total contact cast (TCC) is considered the gold-standard treatment for plantar neuropathic ulceration and acute Charcot neuroarthropathy. There is little evidence on the risk of venous thromboembolism (VTE) associated with TCC treatment. It is widely accepted that routine VTE chemoprophylaxis is not required for neuropathic patients treated with a TCC. Aims: This study aimed to investigate the rate of symptomatic VTE in neuropathic patients with a TCC and to provide up-to-date information to guide future practice. Methods: A retrospective service evaluation was undertaken. The PASCOM-10 online database was utilised for data collection within a communitybased podiatric surgery unit. Patients treated with a TCC or TCC with Bohler walker for plantar ulceration or Charcot neuroarthropathy between 2019 and 2021 were identified. Data were reviewed to ascertain if any evidence of symptomatic VTE had been recorded during casting. Results: A total of 53 casting episodes in 40 patients were included. All patients had a diagnosis of peripheral neuropathy. The mean length of time in a cast was 51 days (range 14–161 days). No episodes of total contact casting resulted in a symptomatic VTE. Conclusion: The use of TCC did not increase the prevalence of VTE in this patient cohort. Larger, prospective studies are warranted to further investigate VTE risk in neuropathic patients treated with a TCC and the theorised VTE protective mechanisms in this patient population.

Citation: Doherty D, Bridgen A, Barber A, Webb F (2022) The prevalence of symptomatic venous thromboembolism in patients requiring total contact casting for neuropathic foot complications. The Diabetic Foot Journal 25(4): 50–6

Key words

- Bohler walker - Charcot neuroarthropathy - Total contact cast - Ulceration - Venous thromboembolism

Article points

1. There is little evidence on the risk of venous thromboembolism (VTE) associated with a total contact cast (TCC).

2. This study aimed to investigate the rate of symptomatic VTE in neuropathic patients with a TCC.

3. The use of TCC did not increase the prevalence of VTE in this patient cohort.

Authors

Declan Doherty is Trainee in Podiatric Surgery, Buxton Hospital, Buxton, Derbyshire, UK; Andy Bridgen is Senior Lecture in Podiatry and Postgraduate Course Leader, University of Huddersfield, Huddersfield, UK; Aaron Barber is Lead Podiatrist in Diabetes, Diabetes Centre, Barnsley Hospital, Barnsley, UK; Frank Webb is Consultant Podiatric Surgeon, Buxton Hospital, Buxton , UK.

Phage therapy for diabetic foot infection

Matthew J Young, Lesley ML Hall and Joshua D Jones

      The treatment of diabetic foot infections (DFIs) represents a costly and growing challenge to the NHS. DFIs can be difficult to treat for a variety of reasons, including late presentation of advanced infection, and antibiotic tolerance or resistance. Bacteriophage (phage) are ubiquitous viruses that infect and kill bacteria in a species-, sometimes even strain-, specific manner. Phages have been used to treat bacterial infection since 1919, but their use in the geopolitical West ceased in the 1930s due to a variety of factors, including the mass production of antibiotics. The modern antibiotic resistance crisis has driven renewed interest in phage therapy and 2,241 patients with mostly with antibiotic refractory infections have been treated since 2000, 79% of whom improved. This includes at least 310 patients with chronic wound infections, among whom 86.1% achieved clinical resolution or improvement of infection. Reassuringly, the available evidence suggests that phage therapy is safe and without notable side effects. Some phages also possess enzymes capable of degrading the biofilms that afford antibiotic tolerance to bacteria and underpin many chronic infections. Phages also act independent of antibiotic resistance, allowing the treatment of even pan-resistant bacteria, and topical or local application to DFIs means antimicrobial activity is independent of a patient’s peripheral perfusion. Presently only an option when antibiotics are not meeting a patient’s clinical needs, future integration of phage therapy at all levels of DFI care will radically transform the outlook for DFIs in the UK. Reducing the number of serious infections and amputations will not only benefit patients but will deliver vast savings to the NHS and reduce the amount of antibiotics used, making phage therapy a tangible response to the antibiotic resistance crisis.

Citation: Young MJ, Hall LML, Jones JD (2022) Phage therapy for diabetic foot infection. The Diabetic Foot Journal 25(4): 30–7

Key words - Bacteriophage  - Diabetic foot infection  - Phage therapy

Article points

1. Bacteriophages (phages) are viruses that infect and kill bacteria that can be used to treat infections, known as phage therapy.

2. The available evidence suggests that phage therapy is safe and effective for the treatment of wound infections.

3. Phage therapy has the potential to transform the care of diabetic foot infections.

Authors

      Matthew J. Young is Consultant Physician, Royal Infirmary of Edinburgh, Edinburgh, UK; Lesley ML Hall is Consultant Physician, Diabetes and Endocrinology, Queen Elizabeth University Hospital, Glasgow, UK; Joshua D Jones is Consultant Physician, Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, UK; Clinical Microbiology, Ninewells Hospital, NHS Tayside, Dundee, UK

Early-onset type 2 diabetes: Clinical implications, diagnosis and management

David Morris

There is strong evidence that early-onset type 2 diabetes (commonly defined as that occurring in people under the age of 40 years) is a more aggressive condition than late-onset type 2 diabetes. The longer period of exposure to the risk factors of hyperglycaemia, hypertension and hyperlipidaemia and the more rapid progression of disease itself renders the individual more vulnerable to developing both microvascular and macrovascular complications at an earlier age. Early recognition and management of type 2 diabetes in younger people and public health messaging aimed at prevention of type 2 diabetes will be crucial to dealing with the problem. This article outlines the diagnosis, clinical implications and management of early-onset type 2 diabetes, with a particular focus on younger adults (rather than children and adolescents), in whom the condition is more common, and who are likely to be managed in primary care.

Citation: Morris D (2022) Early-onset type 2 diabetes: Clinical implications, diagnosis and management. Journal of Diabetes Nursing 26: [Early view publication]

Article points

Article points

1. The incidence of early-onset type 2 diabetes is increasing, with important individual health and socioeconomic consequences.

2. Individuals with early-onset type 2 diabetes experience more rapid progression of microvascular and cardiovascular complications than those with type 1 diabetes and those who develop type 2 diabetes in later years.

3. The presence of islet cell autoantibodies is predictive of future insulin requirement and the development of other autoimmune diseases.

4. If there is uncertainty about the type of diabetes in a child or young adult, it is safer to manage as type 1 diabetes and treat with insulin.

5. A holistic approach to earlyonset type 2 diabetes is essential. Socioeconomic status and psychological issues need to be taken into account.

Key words

- Children and young people - Early-onset type 2 diabetes

Author

David Morris, Specialist Doctor in Diabetes, Royal Shrewsbury Hospital; Clinical Undergraduate Tutor, Keele University; and retired GP

Depression — the ‘elephant in the room’ for the under-utilisation of foot self-care in diabetes?

Andrew Hill

      Much evidence indicates that foot self-care behaviours, specifically, remain underutilised in the prevention of diabetic foot ulcers (DFUs). Adherence to care is a multidimensional phenomenon, determined by the interplay of several factors, including: social and economic, patient-related, health-system-related and conditionrelated factors. Of particular interest and relevance may be the role that depression plays in the context of foot self-care in diabetes, which is discussed in this article. Diabetes-associated depression is well established phenomenon and the prevalence of depression amongst people with diabetes is known to be in the range of 10%–15% — which is twice the rate of people without diabetes. Furthermore, the outcomes for diabetes and depression are worse when they appear together. The mechanisms of their co-existence are multiple and complex and likely involve sociological, psychological and physiological elements. Their co-existence also appears to heavily influence the likelihood of individuals to undertake self-care behaviour that may help to avert the worst of the diabetes-related complications, such as DFU and amputation

Citation: Hill A (2022) Depression — the ‘elephant in the room’ for the under-utilisation of foot self-care in diabetes. The Diabetic Foot Journal 25(4): 16–21

Key words

- Foot care practices - Patient and public involvement - Risk identification - Risk reduction

Article points

1. Adherence to foot selfcare behaviours is a multidimensional phenomenon, determined by the interplay of several factors, including: social and economic, patient related, health-system-related, and condition-related.

2. Depression is well known to co-exist in many people with diabetes — especially those who have suffered diabetesrelated complications, such a foot ulceration and amputation.

3. The co-existence of diabetes and depression appears to heavily influence the likelihood of individuals to undertake self-care behaviour that may help to avert the worst of the diabetes-related complications, such as DFU and amputation.

Authors

Andrew Hill is Senior Lecturer and Programme Lead, The SMAE Institute, Maidenhead, UK

CGM for children and young people with type 1 diabetes: NICE criteria and effects of decision fatigue and alarm fatigue

Imogen Stamford

Research has shown that use of continuous glucose monitoring (CGM) is associated with improved time in range, improved HbA1c, and decreased risk of long-term complications secondary to type 1 diabetes. There are, however, several barriers that can lead to discontinuation of CGM, including pain, skin reactions, concerns around accuracy, sensor loss, interference with daily activity, and alarm fatigue. This review paper will outline the impact of decision fatigue and alarm fatigue in children and young people using CGM.

Citation: Stamford I (2022) CGM for children and young people with type 1 diabetes: NICE criteria and effects of decision fatigue and alarm fatigue. Diabetes Care for Children & Young People 12: [Early view publication]

Article points

1. While the advantages of continuous glucose monitoring (CGM) are well recognised, as practitioners it is important to be aware of the implications of CGM use.

2. People with diabetes can never have a day without checking and responding to ever-changing glucose levels, which puts them at an increased risk of developing decision fatigue.

3. It is important for practitioners to support patients in creating balance between setting alarm limits that are narrow enough to ensure patient safety, but not so narrow that alarms will be repeatedly triggered can lead to the risk of alarms being ignored.

Key words

- Alarm fatigue - Continuous glucose monitoring - Decision fatigue - Type 1 diabetes

Author

Imogen Stamford, Paediatric Diabetes Specialist Nurse, Oxford University Hospitals NHS Foundation Trust

The Wound Microbiome

Ellen K. White and Elizabeth A. Grice

Department of Dermatology, University of Pennsylvania, Perelman School of Medicine, Philadelphia,

Pennsylvania 19104, USA

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      Breach of the skin barrier and subsequent wound healing occur in the context of microbial communities of bacteria, fungi, and viruses. These polymicrobial communities are dynamic and important components of the wound environment and are associated with differential healing outcomes. Here, we highlight both culture-dependent and -independent methods that have furthered our understanding of the wound microbiome. We discuss common themes that have developed from such studies about the microbial inhabitants of diverse wound types.We additionally explore the wide range of microbial mechanisms that influence healing, from invading pathogens to beneficial commensals. These insights can be leveraged to better predict healing outcomes and derive novel microbial-based therapies for chronic wounds.

Editors: Xing Dai, Sabine Werner, Cheng-Ming Chuong, and Maksim Plikus Additional Perspectives on Wound Healing: From Bench to Bedside available at www.cshperspectives.org Copyright © 2022 Cold Spring Harbor Laboratory Press; all rights reserved Advanced Online Article. Cite this article as Cold Spring Harb Perspect Biol doi: 10.1101/cshperspect.a041218