Update on the inaugural Sydney Diabetic Foot Conference 2013

The first International Diabetic Foot Conference in Australia was hosted at Liverpool Hospital in Sydney during May 30-31, 2013. In response to the growing diabetes epidemic globally and more locally to Australia, the conference provided the perfect bridge for interaction between the multidisciplinary team members involved in diabetes care and the opportunity to assimilate the most up-to-date evidence-based medicine from some of the most respected researchers in the field.

Queensland’s high risk foot database : tracking the length and width of Queensland’s foot ulcers

Background Foot ulcers are a leading cause of avoidable hospital admissions and lower extremity amputations. However, large clinical studies describing foot ulcer presentations in the ambulatory setting are limited. The aim of this descriptive observational paper is to report the characteristics of ambulatory foot ulcer patients managed across 13 of 17 Queensland Health & Hospital Services. Methods Data on all foot ulcer patients registered with a Queensland High Risk Foot Form (QHRFF) was collected at their first consult in 2012. Data is automatically extracted from each QHRFF into a Queensland high risk foot database. Descriptive statistics display age, sex, ulcer types and co-morbidities. Statewide clinical indicators of foot ulcer management are also reported. Results Overall, 2,034 people presented with a foot ulcer in 2012. Mean age was 63(±14) years and 67.8% were male. Co-morbidities included 85% had diabetes, 49.7% hypertension, 39.2% dyslipidaemia, 25.6% cardiovascular disease, 13.7% kidney disease and 12.2% smoking. Foot ulcer types included 51.6% neuropathic, 17.8% neuro-ischaemic, 7.2% ischaemic, 6.6% post-surgical and 16.8% other; whilst 31% were infected. Clinical indicator results revealed 98% had their wound categorised, 51% received non-removable offloading, median ulcer healing time was 6-weeks and 37% had ulcer recurrence. Conclusion This paper details the largest foot ulcer database reported in Australia. People presenting with foot ulcers appear predominantly older, male with several co-morbidities. Encouragingly it appears most patients are receiving best practice care. These results may be a factor in the significant reduction of Queensland diabetes foot-related hospitalisations and amputations recently reported.

Reduction in the incidence of diabetes lower extremity amputations in Queensland : 2005-2010

Background Lower extremity amputation is a common end stage complication among people with diabetes. Since 2006, the Queensland Diabetes Clinical Network has implemented programs aimed at reducing diabetes-related amputations. The aim of this retrospective observational study was to determine the incidence of diabetes lower extremity amputations in Queensland from 2005 to 2010. Methods Data on all Queensland diabetes-related lower extremity amputation admissions from 2005-2010 was obtained using diabetes amputation-related ICD-10-AM (hospital discharge) codes. Queensland diabetes amputation incidences were calculated for both general and diabetes populations using population data from the Australian Bureau of Statistics and National Diabetes Services Scheme respectively. Chi-squared tests were used to assess changes in amputation incidence over time. Results Overall, 4,443 admissions for diabetes-related amputation occurred; 32% (1,434) were major amputations. The diabetes-related amputation incidence among the general population (per 100,000) reduced by 18% (18.2 in 2005, to 15.0 in 2010, p < 0.001); major amputations decreased by 24% (6.6 to 4.7, p < 0.01). The incidence among the diabetes population (per 1,000) reduced by 40% (6.7 in 2005, to 4.0 in 2010, p < 0.001); major amputations decreased by 45% (2.3 to 1.2, p < 0.001). Conclusion This paper appears to be the first to report a significant reduction in diabetes amputation incidence in an Australian state. This decrease has coincided with the implementation of several diabetes foot clinical programs throughout Queensland. Whilst these results are encouraging in the Australian context, further efforts are required to decrease to levels reported internationally.

Is the clinical Queensland High Risk Foot Form valid or reliable for research?

Background High-risk foot complications such as neuropathy, ischaemia, deformity, infections, ulcers and amputations consume considerable health care resources and typically result from chronic diseases. This study aimed to develop and test the validity and reliability of a Queensland High Risk Foot Form (QHRFF) tool. Methods Phase one involved developing a QHRFF using an existing diabetes high-risk foot tool, literature search, expert panel and several state-wide stakeholder groups. Phase two tested the criterion-related validity along with inter- and intra-rater reliability of the final QHRFF. Three cohorts of patients (n = 94) and four clinicians, representing different levels of expertise, were recruited. Validity was determined by calculating sensitivity, specificity and positive predictive values (PPV). Kappa and intra-class correlation (ICC) statistics were used to establish reliability. Results A QHRFF tool containing 46-items across seven domains was developed and endorsed. The majority of QHRFF items achieved moderate-to-perfect validity (PPV = 0.71 – 1) and reliability (Kappa/ICC = 0.41 – 1). Items with weak validity and/or reliability included those identifying health professionals previously attending the patient, other (non-listed) co-morbidity, previous foot ulcer, foot deformity, optimum offloading and optimum footwear. Conclusions The QHRFF had moderate-to-perfect validity and reliability across the majority of items, particularly identifying individual co-morbidities and foot complications. Items with weak validity or reliability need to be re-defined or removed. Overall, the QHRFF appears to be a valid and reliable tool to assess, collect and measure clinical data pertaining to high-risk foot complications for clinical or research purposes.

Biomechanical characteristics of peripheral diabetic neuropathy : a systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure

Background: Diabetic peripheral neuropathy is an important cause of foot ulceration and limb loss. This systematic review and meta-analysis investigated the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and dynamic plantar pressures. Methods: Electronic databases were searched systematically for articles reporting the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and plantar pressures. Searches were restricted to articles published between January 2000 and April 2012. Outcome measures assessed included spatiotemporal parameters, lower limb kinematics, kinetics, muscle activation and plantar pressure. Meta-analyses were carried out on all outcome measures reported by ≥3 studies. Findings: Sixteen studies were included consisting of 382 neuropathy participants, 216 diabetes controls without neuropathy and 207 healthy controls. Meta-analysis was performed on 11 gait variables. A high level of heterogeneity was noted between studies. Meta-analysis results suggested a longer stance time and moderately higher plantar pressures in diabetic peripheral neuropathy patients at the rearfoot, midfoot and forefoot compared to controls. Systematic review of studies suggested potential differences in the biomechanical characteristics (kinematics, kinetics, EMG) of diabetic neuropathy patients. However these findings were inconsistent and limited by small sample sizes.; Interpretation: Current evidence suggests that patients with diabetic peripheral neuropathy have elevated plantar pressures and occupy a longer duration of time in the stance-phase during gait. Firm conclusions are hampered by the heterogeneity and small sample sizes of available studies. Interpretation: Current evidence suggests that patients with diabetic peripheral neuropathy have elevated plantar pressures and occupy a longer duration of time in the stance-phase during gait. Firm conclusions are hampered by the heterogeneity and small sample sizes of available studies.

Evaluating the impact of high risk foot training on undergraduate podiatry students

Background Diabetes is the leading cause of high risk foot (HRF) complications, admissions and lower limb amputation. Best practice training of podiatrists is known to have a beneficial impact on such outcomes; however, there has been a paucity of studies into undergraduate diabetes podiatry training. The primary aim of this paper was to investigate the changes in final year podiatry students’ confidence, knowledge and clinical practice in the management of HRF complications. Methods This was a prospective longitudinal study of final year podiatry students (n=25) at the Queensland University of Technology. All participants throughout 2011 undertook an intervention of a series of “hands on” HRF workshops, on-campus clinics and external clinical rotations. Outcome measures included customised confidence and knowledge surveys in HRF management across four time points. A timed simulated case scenario was used to evaluate changes in clinical practice at two time points. Friedman and Wilcoxon Signed Rank Tests were used to calculate differences between time points Results Overall improvements between the first and last time points were demonstrated in 20/21 confidence items (p<0.001), 12/27 clinical practice items (p<0.05) and 3/12 knowledge items (p<0.001). Although 8/12 knowledge items recorded high baseline scores of over 80%. Conclusions Overall, it appears student confidence and clinical practice improved with the introduction of designated HRF activities, whilst knowledge remained high. This suggests “hands on” practice and not didactic lectures improve students’ clinical confidence and practice. Results from the 2012 student cohort will also be presented at this conference.

Australian Diabetes Foot Network : practical guideline on the provision of footwear for people with diabetes

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.

The genome organization and affinities of an Australian isolate of carrot mottle umbravirus

The genomic sequence of an Australian isolate of carrot mottle umbravirus (CMoV-A) was determined from cDNA generated from dsRNA. This provides the first data on the genome organization and phylogeny of an umbravirus. The 4201-nucleotide genome contains four major open reading frames (ORFs). Analysis suggests that ORF2 encodes an RNA-dependent RNA polymerase, that ORF4 encodes a movement protein, and that the virus has no coat protein gene. The functions of ORFs 1 and 3 remain unknown. ORF2 is probably translated following ribosomal frameshifting. ORFs 3 and 4 are probably translated from a subgenomic mRNA. Sequence comparisons showed CMoV-A to be closely related to pea enation mosaic RNA2 NA2), but also to have affinities with the Bromoviridae. These findings shed light on the relationships between the luteoviruses, PEMV, and the umbraviruses and on the relationships between the carmo-like viruses and the Bromoviridae.

Soybean dwarf luteovirus contains the third variant genome type in the luteovirus group

Complementary DNAs covering the entire RNA genome of soybean dwarf luteovirus (SDV) were cloned and sequenced. Computer analysis of the 5861 nucleotide sequence revealed five major open reading frames (ORFs) possessing conservation of sequence and organisation with known luteovirus sequences. Comparative analyses of the genome structure show that SDV shares sequence homology and features of gene organisation with barley yellow dwarf virus (PAV isolate) in the 5' half of the genome, yet is more closely related to potato leafroll virus in its 3' coding regions. In addition, SDV differs from other known luteoviruses in possessing an exceptionally long 3' terminal sequence with no apparent coding capacity. We conclude from these data that the SDV genome represents a third variant genome type in the luteovirus group.

Characterisation of the subgenomic RNAs of an Australian isolate of barley yellow dwarf luteovirus

We have characterised the subgenomic RNAs of an Australian isolate of BYDV-PAV. Northern blot analyses of infected plants and protoplasts have shown that this isolate synthesises three subgenomic RNAs. Precise mapping of the transcription start sites of all three subgenomic RNAs and translational analyses of subgenomic RNA 2 and 3 have revealed a number of features. First, the transcription start site of subgenomic RNA 1 in this isolate differs markedly from the start site determined for an Illinois isolate of BYDV-PAV. Second, the start sites of subgenomic RNA 1 and 2 occur at a sequence that closely resembles the 5' end sequence of the genomic RNA (5'AGUGAAGA). Third, subgenomic RNA 2 appears to express ORF 6 of BYDV-PAV but the gene product is truncated due to the appearance of a new stop codon in the sequence. Last, subgenomic RNA 3, which is abundantly transcribed and encapsidated by the virus particle, appears to have no coding ability. We postulate that this novel subgenomic RNA has a regulatory function.

Putative full-length clones of the genomic DNA segments of subterranean clover stunt virus and identification of the segment coding for the viral coat protein

Subterranean clover stunt disease is an economically important aphid-borne virus disease affecting certain pasture and grain legumes in Australia. The virus associated with the disease, subterranean clover stunt virus (SCSV), was previously found to be representative of a new type of single-stranded DNA virus. Analysis of the virion DNA and restriction mapping of double-stranded cDNA synthesized from virion DNA suggested that SCSV has a segmented genome composed of 3 or 4 different species of circular ssDNA each of about 850-880 nucleotides. To further investigate the complexity of the SCSV genome, we have isolated the replicative form DNA from infected pea and from it prepared putative full-length clones representing the SCSV genome segments. Analysis of these clones by restriction mapping indicated that clones representing at least 4 distinct genomic segments were obtained. This method is thus suitable for generating an extensive genomic library of novel ssDNA viruses containing multiple genome segments such as SCSV and banana bunchy top virus. The N-terminal amino acid sequence and amino acid composition of the coat protein of SCSV were determined. Comparison of the amino acid sequence with partial DNA sequence data, and the distinctly different restriction maps obtained for the full-length clones suggested that only one of these clones contained the coat protein gene. The results confirmed that SCSV has a functionally divided genome composed of several distinct ssDNA circles each of about 1 kb.

A satellite RNA of barley yellow dwarf virus contains a novel hammerhead structure in the self-cleavage domain

An RNA molecule with properties of a satellite RNA was found in an isolate of barley yellow dwarf virus (BYDV), RPV serotype. It is 322 nucleotides long, single-stranded, and does not hybridize to the viral genome. Dimers of the RNA, which presumably represent replicative intermediates, were able to self-cleave into monomers. In vitro transcripts from cDNA clones were capable of self-cleavage in both the plus (encapsidated) and minus orientations. The sequence flanking the minus strand cleavage site contained a consensus " hammerhead" structure, similar to those found in other self-cleaving satellite RNAs. Although related to the hammerhead structure, sequences flanking the plus strand termini showed differences from the consensus and may be folded into a different structure containing a pseudoknot. © 1991.

Sequence and identification of the barley yellow dwarf virus coat protein gene

The nucleotide sequence of the coat protein gene of barley yellow dwarf virus (BYDV, PAV serotype) was determined, and the amino acid sequence was deduced. The open reading frame, encoding a protein of relative molecular mass (Mr) 22,047, was confirmed as the coat protein gene by comparison with amino acid sequences of tryptic peptides derived from dissociated virions. In addition, a fragment of this gene expressed in Escherichia coli produced a product which was recognized by antibodies prepared against purified BYDV virions. An overlapping reading frame encoding an Mr 17,147 protein is contained completely within the coat protein gene. © 1988.