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      Prevention, assessment, diagnosis and management of diabetic foot based on clinical practice guidelines : A systematic review

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          Abstract

          Aim:

          Diabetic foot complications are the main reason for hospitalization and amputation in people with diabetes and have a prevalence of up to 25%. Clinical practice guidelines are recommendations based on evidence with the aim of improving health care. The main aim of this study was to carry out a systematic review of the levels of the evaluation and treatment strategies that appear in the clinical practice guidelines focus on diabetic foot or diabetes with diabetic foot section. Another objective of this study was to perform an analysis of the levels of evidence in support of the recommendations made by the selected clinical practice guidelines.

          Methods:

          A systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and a quality assessment by the Appraisal of Guidelines for Research and Evaluation (AGREE II) were performed. The databases checked were “NICE”, “Cinahl”, “Health Guide”, “RNAO”, “Sign”, “PubMed”, “Scopus” and “NCG”. The search terms included were “diabetic foot”, “guideline(s)”, “practice guideline(s)” and “diabetes.”

          Results:

          Twelve articles were selected after checked inclusion criteria and quality assessment. A summary and classification of the recommendations was completed.

          Conclusions:

          The heterogeneity of levels of evidence and grades of recommendation of the CPGs included regarding the management, approach and treatment of DF makes it difficult to interpret and assume them in clinical practice in order to select the most correct procedures. Despite this and according to the detailed study of the guidelines included in this work, it can be concluded that the highly recommendable interventions for DF management are debridement (very high level of evidence and strongly recommended), foot evaluation (moderate level of evidence and fairly recommended) and therapeutic footwear (moderate level of evidence and fairly recommended).

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          Most cited references54

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          Literature review on the management of diabetic foot ulcer.

          Leila Yazdanpanah, Morteza Nasiri, Sara Adarvishi (2015)
          Diabetic foot ulcer (DFU) is the most costly and devastating complication of diabetes mellitus, which affect 15% of diabetic patients during their lifetime. Based on National Institute for Health and Clinical Excellence strategies, early effective management of DFU can reduce the severity of complications such as preventable amputations and possible mortality, and also can improve overall quality of life. The management of DFU should be optimized by using a multidisciplinary team, due to a holistic approach to wound management is required. Based on studies, blood sugar control, wound debridement, advanced dressings and offloading modalities should always be a part of DFU management. Furthermore, surgery to heal chronic ulcer and prevent recurrence should be considered as an essential component of management in some cases. Also, hyperbaric oxygen therapy, electrical stimulation, negative pressure wound therapy, bio-engineered skin and growth factors could be used as adjunct therapies for rapid healing of DFU. So, it's suggested that with appropriate patient education encourages them to regular foot care in order to prevent DFU and its complications.
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            Diabetic peripheral neuropathy: current perspective and future directions.

            Randhir Singh Deswal, Navpreet Kaur, L T Kishore (2014)
            Diabetic neuropathy is a heterogeneous group of disorders with extremely complex pathophysiology and affects both somatic and autonomic components of the nervous system. Neuropathy is the most common chronic complication of diabetes mellitus. Metabolic disruptions in the peripheral nervous system, including altered protein kinase C activity, and increased polyol pathway activity in neurons and Schwann cells resulting from hyperglycemia plays a key role in the development of diabetic neuropathy. These pathways are related to the metabolic and/or redox state of the cell and are the major source of damage. Activation of these metabolic pathways leads to oxidative stress, which is a mediator of hyperglycemia induced cell injury and a unifying theme for all mechanisms of diabetic neuropathy. The therapeutic intervention of these metabolic pathways is capable of ameliorating diabetic neuropathy but therapeutics which target one particular mechanism may have a limited success. Available therapeutic approaches are based upon the agents that modulate pathogenetic mechanisms (glycemic control) and relieve the symptoms of diabetic neuropathy. This review emphasizes the pathogenesis, presently available therapeutic approaches and future directions for the management of diabetic neuropathy. Copyright © 2013 Elsevier Ltd. All rights reserved.
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              The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy.

              Yuzhe Feng, Felix J V Schlösser, Bauer Sumpio (2009)
              The purpose of this systematic review is to evaluate current evidence in the literature on the efficacy of Semmes Weinstein monofilament examination (SWME) in diagnosing diabetic peripheral neuropathy (DPN). The PubMed database was searched through August 2008 for articles pertaining to DPN and SWME with no language or publication date restrictions. Studies with original data comparing the diagnostic value of SWME with that of one or more other modalities for DPN in patients with diabetes mellitus were analyzed. Data were extracted by two independent investigators. Diagnostic values were calculated after classifying data by reference test, SWME methodology, and diagnostic threshold. Of the 764 studies identified, 30 articles were selected, involving 8365 patients. There was great variation in both the reference test and the methodology of SWME. However, current literature suggests that nerve conduction study (NCS) is the gold standard for diagnosing DPN. Four studies were identified which directly compared SWME with NCS and encompassed 1065 patients with, and 52 patients without diabetes mellitus. SWME had a sensitivity ranging from 57% (95% confidence interval [CI], 44% to 68%) to 93% (95% CI, 77% to 99%), specificity ranging from 75% (95% CI, 64% to 84%) to 100% (95% CI, 63% to 100%), positive predictive value (PPV) ranging from 84% (95% CI, 74% to 90%) to 100% (95% CI, 87% to 100%), and negative predictive value (NPV) ranging from 36% (95% CI, 29% to 43%) to 94% (95% CI, 91% to 96%). There is great variation in the current literature regarding the diagnostic value of SWME as a result of different methodologies. To maximize the diagnostic value of SWME, a three site test involving the plantar aspects of the great toe, the third metatarsal, and the fifth metatarsals should be used. Screening is vital in identifying DPN early, enabling earlier intervention and management to reduce the risk of ulceration and lower extremity amputation.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Medicine (Baltimore)
                Journal ID (iso-abbrev): Medicine (Baltimore)
                Journal ID (publisher-id): MEDI
                Title: Medicine
                Publisher: Wolters Kluwer Health
                ISSN (Print): 0025-7974
                ISSN (Electronic): 1536-5964
                Publication date Collection: August 2019
                Publication date (Electronic): 30 August 2019
                Volume: 98
                Issue: 35
                Electronic Location Identifier: e16877
                Affiliations
                [a ]Department of Nursing and Podiatry
                [b ]Department of Physiotherapy, University of Málaga, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos 29071, Málaga, Spain.
                Author notes
                [∗ ]Correspondence: María Ruiz-Muñoz, Arquitecto Francisco Peñalosa, s/n. Ampliación campus de Teatinos 29071, office 2.14, Málaga, Spain (e-mail: marumu@ 123456uma.es ).
                Article
                Publisher ID: MD-D-19-02958 Accession ID: 16877
                DOI: 10.1097/MD.0000000000016877
                PMC ID: 6736276
                PubMed ID: 31464916
                SO-VID: 13289168-846e-45b8-a91c-92574f75b7fa
                Copyright © Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

                History
                Date received : 23 April 2019
                Date revision received : 26 July 2019
                Date accepted : 25 July 2019
                Categories
                Subject: 4300
                Subject: Research Article
                Subject: Systematic Review and Meta-Analysis
                Custom metadata
                OPEN-ACCESS TRUE

                Keywords: diabetes,diabetes complications,evidence,guideline,review
                Data availability:
                Keywords: diabetes, diabetes complications, evidence, guideline, review

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