The challenge of service planning and development without adequate data: The case for orthotic services.

The UK National Health Service (NHS) employs a group of 14 separate allied health professions. Prosthetics and orthotics are the smallest of these professions. Although small, orthotics is integral to many clinical care pathways and has shown to provide an essential impact on a range of clinical conditions in the health service priority lists. Previous reports acknowledged the lack of data on the UK prosthetic and orthotic workforce, appointment outcomes and cost and the service users accessing such services and thus the challenges that it poses for effective service delivery. There is still a paucity of relevant data or initiatives to support the service provision. The work within this paper has taken the first step to address this gap, presenting a summary of the information relating to appointments and costs, and provides a discussion on the implications of variations across the NHS orthotic services within England in terms of spend, staffing and skill mix for orthotic services and service users and the need for further data on service users and the UK prosthetic and orthotic workforce.

The Diabetic Foot Attack: "'Tis Too Late to Retreat!"

The "diabetic foot attack" is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of "time is tissue" and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.