Evaluating the prognostic performance of bedside tests used for peripheral arterial disease diagnosis in the prediction of diabetic foot ulcer healing.

INTRODUCTION: Diabetic foot ulceration (DFU) is a common and challenging complication of diabetes. Risk stratification can guide further management. We aim to evaluate the prognostic performance of bedside tests used for peripheral arterial disease (PAD) diagnosis to predict DFU healing. RESEARCH DESIGN AND METHODS: Testing for Arterial Disease in Diabetes (TrEAD) was a prospective observational study comparing the diagnostic performance of commonly used tests for PAD diagnosis. We performed a secondary analysis assessing whether these could predict DFU healing. Follow-up was performed prospectively for 12 months. The primary outcome was sensitivity for predicting ulcer healing. Secondary endpoints were specificity, predictive values, and likelihood ratios for ulcer healing. RESULTS: 123 of TrEAD participants with DFU were included. In 12 months, 52.8% of ulcers healed. The best negative diagnostic likelihood ratio (NDLR) was observed for the podiatry ankle duplex scan (PAD-scan) monophasic or biphasic with adverse features(NDLR 0.35, 95% CI 0.14-0.90). The highest positive likelihood ratios were observed for toe brachial pressure index of ≤0.2 (positive diagnostic likelihood ratio (PDLR) 7.67, 95% CI 0.91-64.84) and transcutaneous pressure of oxygen of ≤20 mm Hg (PDLR 2.68, 95% CI 0.54-13.25). Cox proportional hazards modeling demonstrated significantly greater probabilities of healing with triphasic waveforms (HR=2.54, 95% CI 1.23-5.3, p=0.012) and biphasic waveforms with non-adverse features (HR=13.67, 95% CI 4.78-39.1, p<0.001) on PAD-scan. CONCLUSIONS: No single test performed well enough to be used in isolation as a prognostic marker for the prediction of DFU healing. TRIAL REGISTRATION NUMBER: NCT04058626.

Arterial spectral waveform analysis in the prediction of diabetic foot ulcer healing.

OBJECTIVE: We assessed the association between (1) severity of vessel wall calcification, (2) number of patent vessels at the ankle and (3) arterial spectral waveform features, as assessed on a focused ankle Duplex ultrasound (DUS), and healing at 12-months in a cohort of patients who had their diabetic foot ulcers conservatively managed. RESEARCH DESIGN AND METHODS: Scans performed on 50 limbs in 48 patients were included for analysis. Patient health records were prospectively reviewed for 12-months to assess for the outcome of ulcer healing. RESULTS: We identified that the number of waveform components, peak systolic velocity, systolic rise time and long forward flow as well as the number of vessels patent at the ankle on DUS, may be useful independent predictors of healing, as noted by the trend towards statistical significance. CONCLUSION: Arterial spectral waveform features may be useful in predicting the chance of diabetic foot ulcer healing.

Effectiveness of a multicenter training programme to teach point-of-care vascular ultrasound for the detection of peripheral arterial disease in people with diabetes.

BACKGROUND: The primary aim of this study was to evaluate the effectiveness of a training programme to teach a focused bedside ultrasound scan (PAD-scan; Podiatry Ankle Duplex Scan) for the detection of arterial disease in people with diabetes. METHODS: Five podiatrists and one diabetologist across two hospitals were enrolled in a structured training programme consisting of a training course (1-day), supervised scanning (5-weeks), independent scanning (3-weeks) and a final evaluation of performance (1-day).Time, technical skills (Duplex Ultrasound Objective Structured Assessment of Technical Skills tool (DUOSATS); minimum score = 6, maximum score = 26) and accuracy (level of agreement with vascular scientist PAD-scan assessment) were assessed for every supervised scan and again for the final evaluation of performance. RESULTS: A total of 90 PAD-scans in 65 patients were performed during the supervised phase. Participants demonstrated significant improvements in median time (19 min(IQR 13.9-25.5) vs 9.3 min (IQR 7.3-10.5);p = 0.028) and DUOSATS scores (17.5 (IQR 16.8-21) vs 25 (IQR 24-25.3); p = 0.027). At the final evaluation, participants completed scans in 5.4 min (IQR 5.3-5.9), achieved full DUOSAT scores and perfect agreement with the vascular scientist. CONCLUSION: A structured training programme, integrated into diabetic foot clinics, was effective in teaching the PAD-scan.