OBJECTIVE -We studied the relationships of diabetic ulcer wound fluid matrix metalloproteinases (MMPs), tissue inhibitors of metalloproteinases (TIMPs), and transforming growth factor-ß1 (TGF-ß1) with wound healing rate.RESEARCH DESIGN AND METHODS -The ulcers were cleansed to remove exudates, and wound fluids were collected for analysis of MMP-2 and -9, TIMP-1, and TGF-ß1.RESULTS -At presentation, MMP-9 and the MMP-9 -to-TIMP-1 ratio correlated inversely with the wound healing rate at 28 days (P Ͻ 0.001). MMP-9 and the MMP-9 -to-TIMP-1 ratio were lower in the 23 patients who achieved complete healing at 12 weeks versus the 39 who did not. The pro-MMP-9 concentration was predictive of healing within 12 weeks. Addition of cutoffs for TIMP-1 (Ͼ480 pg/ml) and TGF-ß (Ͼ115 pg/ml) further improved its predictive power (area under the curve 0.94).CONCLUSIONS -These findings suggest that a milieu with high MMP-9 may be indicative of inflammation and poor wound healing. Measurements of MMP-9, TIMP-1, and TGF-ß in wound fluid may help to identify ulcers at risk of poor healing.

Background Pressure offloading treatment is critical for healing diabetes-related foot ulcers (DFU). Yet the 2011 Australian DFU guidelines regarding offloading treatment are outdated. A national expert panel aimed to develop a new Australian guideline on offloading treatment for people with DFU by adapting international guidelines that have been assessed as suitable to adapt to the Australian context. Methods National Health and Medical Research Council procedures were used to adapt suitable International Working Group on the Diabetic Foot (IWGDF) guidelines to the Australian context. We systematically screened, assessed and judged all IWGDF offloading recommendations using best practice ADAPTE and GRADE frameworks to decide which recommendations should be adopted, adapted or excluded in the Australian context. For each recommendation, we re-evaluated the wording, quality of evidence, strength of recommendation, and provided rationale, justifications and implementation considerations, including for geographically remote and Aboriginal and Torres Strait Islander peoples. This guideline, along with five accompanying Australian DFU guidelines, underwent public consultation, further revision and approval by ten national peak bodies (professional organisations). Results Of the 13 original IWGDF offloading treatment recommendations, we adopted four and adapted nine. The main reasons for adapting the IWGDF recommendations included differences in quality of evidence ratings and clarification of the intervention(s) and control treatment(s) in the recommendations for the Australian context. For Australians with plantar DFU, we recommend a step-down offloading treatment approach based on their contraindications and tolerance. We strongly recommend non-removable knee-high offloading devices as first-line treatment, removable knee-high offloading devices as second-line, removable ankle-high offloading devices third-line, and medical grade footwear as last-line. We recommend considering using felted foam in combination with the chosen offloading device or footwear to further reduce plantar pressure. If offloading device options fail to heal a person with plantar DFU, we recommend considering various surgical offloading procedures. For people with non-plantar DFU, depending on the type and location of the DFU, we recommend using a removable offloading device, felted foam, toe spacers or orthoses, or medical grade footwear. The six new guidelines and the full protocol can be found at: https://diabetesfeetaustralia.org/new-guidelines/. Conclusions We have developed a new Australian evidence-based guideline on offloading treatment for people with DFU that has been endorsed by ten key national peak bodies. Health professionals implementing these offloading recommendations in Australia should produce better DFU healing outcomes for their patients, communities, and country.

Topical propolis is a well-tolerated therapy for wound healing and this pilot in human DFU indicates for the first time that it may enhance wound closure in this setting when applied weekly. A multi-site randomized controlled of topical propolis now appears to be warranted in diabetic foot ulcers.

Trauma, in the form of pressure and/or friction from footwear, is a common cause of foot ulceration in people with diabetes. These practical recommendations regarding the provision of footwear for people with diabetes were agreed upon following review of existing position statements and clinical guidelines. The aim of this process was not to re-invent existing guidelines but to provide practical guidance for health professionals on how they can best deliver these recommendations within the Australian health system. Where information was lacking or inconsistent, a consensus was reached following discussion by all authors. Appropriately prescribed footwear, used alone or in conjunction with custom-made foot orthoses, can reduce pedal pressures and reduce the risk of foot ulceration. It is important for all health professionals involved in the care of people with diabetes to both assess and make recommendations on the footwear needs of their clients or to refer to health professionals with such skills and knowledge. Individuals with more complex footwear needs (for example those who require custom-made medical grade footwear and orthoses) should be referred to health professionals with experience in the prescription of these modalities and who are able to provide appropriate and timely follow-up. Where financial disadvantage is a barrier to individuals acquiring appropriate footwear, health care professionals should be aware of state and territory based equipment funding schemes that can provide financial assistance. Aboriginal and Torres Strait Islanders and people living in rural and remote areas are likely to have limited access to a broad range of footwear. Provision of appropriate footwear to people with diabetes in these communities needs be addressed as part of a comprehensive national strategy to reduce the burden of diabetes and its complications on the health system.

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ata from the Australian Institute of Health and Welfare (AIHW) suggest that one Australian loses a lower limb every 3 hours as a direct result of diabetes-related foot disease (DRFD). 1 Further data suggest there has been a 30% increase in diabetes-related amputations in Australia over the past decade, with 8% of diabetes-related deaths being attributable to foot disease. 1,2 These statistics are especially disappointing given the exponential growth in knowledge, research and published guidelines on managing DRFD. 3,4 In order to reduce this significant burden, several complementary measures are therefore urgently required.To allow for long-term surveillance of DRFD in Australia, it is paramount that data collection is initiated at a national level. The health system does not currently allow for collection of information from both public and private sectors, and ignores the large group of people managed solely in the community. Effective allocation of resources and care coordination are likely to be hindered by this lack of data, as are identification of at-risk patient groups and development and evaluation of preventive strategies. Solutions for improving data collection would include creation of specific Medicare item numbers for DRFD and development of web-based data collection forms and databases.The inclusion of chronic disease management items in the Medicare Benefits Schedule (MBS) is acknowledged as a step forward in the fight against DRFD. Reports suggest that 1.3 million consultations were provided by podiatrists under this program in 2004-2008, accounting for 34% of all consultations. 5 It is important to note, however, that this funding arrangement does not allow for more frequent follow-up for individuals with acute DRFD complications or needing intensive secondary prevention due to previous ulceration and/or amputation. Recurrence rates for foot ulceration range from 20%-80% annually, with many of these ulcers leading to amputation. 6 Improved access to publicly funded specialised foot care services, and increasing the number of rebates available under the MBS, are seen as cost-effective necessities for people with current or past foot complications. The cost of this would be recouped by preventing future hospitalisations and amputations.Improved access to appropriately skilled health care providers and multidisciplinary teams is required, and could be achieved if Australian health care policymakers adopt a standardised national model of care for DRFD. This model must sustain a continuum of care between community-based health care and local hospitals. Research supports the resourcing and implementation of well defined treatment pathways provided under a multidisciplinary model of care. 7,8 A standardised national service model would also support a national network of interdisciplinary DRFD clinics, in turn facilitating the development of a national database to assist with referral pathways, data collection, initiation of quality improvement programs and benchmarking across organisations. Such a mod...

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Appropriate assessment and management of diabetes-related foot ulcers (DRFUs) is essential to reduce amputation risk. Management requires debridement, wound dressing, pressure off-loading, good glycaemic control and potentially antibiotic therapy and vascular intervention. As a minimum, all DRFUs should be managed by a doctor and a podiatrist and/or wound care nurse. Health professionals unable to provide appropriate care for people with DRFUs should promptly refer individuals to professionals with the requisite knowledge and skills. Indicators for immediate referral to an emergency department or multidisciplinary foot care team (MFCT) include gangrene, limb-threatening ischaemia, deep ulcers (bone, joint or tendon in the wound base), ascending cellulitis, systemic symptoms of infection and abscesses. Referral to an MFCT should occur if there is lack of wound progress after 4 weeks of appropriate treatment.