Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis.

BACKGROUND: Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU. METHODS: We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed. RESULTS: From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers. CONCLUSIONS: Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

Incidence and predictors of recurrent and other new diabetic foot ulcers: a retrospective cohort study.

AIMS: To estimate progression rates, evaluate risk factors for progression, and study rate ratios for progression among people with a healed diabetic foot ulcer according to whether the healed ulcer was neuropathic, neuro-ischaemic or critically ischaemic. METHODS: We conducted a retrospective cohort study in all individuals with a healed diabetic foot ulcer treated at the Steno Diabetes Centre Copenhagen foot clinic in the period 2010 to 2016. The outcome of interest was recurrent/other new diabetic foot ulcers. RESULTS: A total of 780 people had a healed diabetic foot ulcer in the study period (2010-2016). The participants were followed for 1249 person-years [median (Q1-Q3) 1.04 (0.38-2.46) person-years] in total. One-third (33.1%) developed a recurrent/other new diabetic foot ulcer per year. Male gender, people with Type 2 diabetes and smokers had a statistically significantly higher risk of progression to a recurrent/other new diabetic foot ulcer compared to participants without these risk factors. Participants with neuro-ischaemic or critically ischaemic diabetic foot ulcers had statistically significantly higher progression rates than participants with neuropathic diabetic foot ulcers. CONCLUSIONS: Focus should be on preventing future recurrent/other new diabetic foot ulcers especially in people with ischaemia.

ESCMID guideline for the diagnosis and treatment of biofilm infections 2014.

Biofilms cause chronic infections in tissues or by developing on the surfaces of medical devices. Biofilm infections persist despite both antibiotic therapy and the innate and adaptive defence mechanisms of the patient. Biofilm infections are characterized by persisting and progressive pathology due primarily to the inflammatory response surrounding the biofilm. For this reason, many biofilm infections may be difficult to diagnose and treat efficiently. It is the purpose of the guideline to bring the current knowledge of biofilm diagnosis and therapy to the attention of clinical microbiologists and infectious disease specialists. Selected hallmark biofilm infections in tissues (e.g. cystic fibrosis with chronic lung infection, patients with chronic wound infections) or associated with devices (e.g. orthopaedic alloplastic devices, endotracheal tubes, intravenous catheters, indwelling urinary catheters, tissue fillers) are the main focus of the guideline, but experience gained from the biofilm infections included in the guideline may inspire similar work in other biofilm infections. The clinical and laboratory parameters for diagnosing biofilm infections are outlined based on the patient's history, signs and symptoms, microscopic findings, culture-based or culture-independent diagnostic techniques and specific immune responses to identify microorganisms known to cause biofilm infections. First, recommendations are given for the collection of appropriate clinical samples, for reliable methods to specifically detect biofilms, for the evaluation of antibody responses to biofilms, for antibiotic susceptibility testing and for improvement of laboratory reports of biofilm findings in the clinical microbiology laboratory. Second, recommendations are given for the prevention and treatment of biofilm infections and for monitoring treatment effectiveness. Finally, suggestions for future research are given to improve diagnosis and treatment of biofilm infections.

[Accidents caused by inflatable bouncers in 0-19 year-olds in Denmark in 1993]. / Ulykker med hoppepuder hos 0-19-årige i Danmark i 1993.

The paper describes the epidemiology of accidents caused by inflatable bouncers. The estimated number of bouncers and bouncing castles in DK was 300-350 in 1993. The data were extracted from the Danish part of the EHLASS project ("the European Home and Leisure Accident Surveillance System). The project registers injuries in five Danish casualty wards, covering a total uptake area of 14.2% of the Danish population. In 1993, there were 91 injuries caused by inflatable bouncers, 37% of them in boys, and 63% in girls. Seventy-nine percent of the injuries were caused by falling, 19% by contact with an object or another person and 2% stress injuries. The type of injury were: bruises 42%, fractures 31%, distorsions 23%, and tendon/muscle strains 3%. The location of the fractures were: one in the spine, two in the clavicle, all other (25) were located in the limbs. Four patients had to be admitted for further observation or treatment. The average cost per injury was 839 dKr., or aprox 150 US$. It does not seem necessary to take special precautions or make restrictions in the use of this new playground article.

[Clinical result after Leeds-Keio reconstruction of the anterior cruciate ligament]. / Det kliniske resultat efter Leeds-Keio ligamentrekonstruktion af forreste korsbånd.

Seventeen patients with rupture of the anterior cruciate ligament and chronic instability were treated with the Leeds-Keio Dacron ligament system. The post-operative treatment included 15 weeks of immobilisation (five weeks with fixed knee, five weeks with 30-80 degrees of flexion and five weeks with 0-90 degrees of flexion). Muscular exercise were started after 5 weeks. They were submitted to clinical examination approximately 30 months (13-50) after implantation. The Lysholm-scoring was: excellent-good: 70%, fair: 6%, poor: 24%. These rather disappointing results could be explained by the regime: poor muscular strength and rehabilitation, long preoperative observation period and long post-operative immobilisation. We found a high frequency of rupture of the Leeds-Keio ligament system (18%) and fear, with reference to the literature, that it might increase with time. Rupture and loss of tension result in loss of stability and reactive synovitis. Though the material is small, we conclude that this regime can not be recommended.

[Acute compartment syndrome after a brief march]. / Akut kompartmentsyndrom efter kort march.

A case of acute anteriolateral compartmental syndrome in an 18-year old male conscript, caused by moderate physical strain is reported. It is questioned, with reference to literature, whether elevation and observation of mild cases is appropriate treatment.