Advanced Practicing Podiatrists - High Risk Foot Group News

Journal Club - 16th July 2025

Fri, 25 Jul 2025 02:29:40 GMT

Article Title: Cognition and quality of life in patients with a diabetes-related foot ulcer

Journal: Journal of Tissue Viability

Issue/Page No: 34

Discussion Date: 16th July 2025

Study objective, hypothesis and question?	Study Objective: The study aimed to compare cognitive function and quality of life (QoL) in individuals with diabetes and a diabetes-related foot ulcer (DFU) to a control group with diabetes but no active foot ulceration. Hypothesis: The study hypothesized that individuals with DFU would demonstrate significantly poorer cognitive function and QoL compared to controls without DFU. Research Question: The study sought to answer whether cognitive function and QoL are impaired in individuals with diabetes and DFU compared to those with diabetes but no active foot ulceration, and whether cognitive impairment is associated with reduced QoL in this population.
Rationale and relevance of the question? (Why was the study done?)	Rationale: Diabetes-related foot ulceration (DFU) is a common complication of diabetes that significantly impacts quality of life (QoL) and may lead to recurrent ulceration or lower limb amputation. Cognitive impairment is also associated with diabetes, affecting memory, executive functioning, and other cognitive domains. These impairments may hinder adherence to complex treatment regimens required for DFU management. Despite evidence linking cognitive dysfunction and QoL in other contexts, limited studies have assessed both factors together in patients with DFU. Understanding this relationship is crucial for improving patient care and adherence to treatment protocols. Relevance: The question is relevant because: 1. Impact on Patient Outcomes: Cognitive impairment may adversely affect adherence to DFU treatment regimens, potentially delaying wound healing and increasing the risk of complications. 2. Quality of Life: DFU is known to reduce QoL, and understanding the role of cognitive dysfunction in this reduction can help target interventions to improve overall well-being. 3. Holistic Care: Integrating cognitive assessments into DFU management could optimize adherence and improve patient outcomes. 4. Educational Materials: Tailoring educational resources to the cognitive abilities of DFU patients may enhance their understanding and compliance with treatment plans. This study provides insights into the psychological burdens of DFU, emphasizing the need for comprehensive care that addresses both physical and cognitive challenges.
Relevance of this topic/question to FH Podiatrists? (Is it urgent or essential reading for a podiatrist working in an acute hospital?	Relevance to Podiatrists: 1. Improved Patient Management: Podiatrists play a key role in managing diabetes-related foot ulcers (DFU). Understanding the link between cognitive impairment and treatment adherence can help them tailor interventions to improve patient compliance with offloading devices, wound care, and other protocols. 2. Holistic Care: Podiatrists can incorporate cognitive and quality of life (QoL) assessments into routine care for DFU patients. This enables them to identify patients who may require additional support or targeted interventions to address cognitive challenges. 3. Enhanced Education Strategies: Podiatrists can adapt educational materials and communication strategies to suit the cognitive abilities of patients with DFU, ensuring that instructions are clear and actionable. 4. Prevention of Complications: By recognizing cognitive impairment as a potential barrier to adherence, podiatrists can proactively address this issue, potentially reducing the risk of recurrent ulceration, delayed healing, and lower limb amputation. 5. Collaborative Care: Podiatrists can work closely with other healthcare professionals, such as endocrinologists and psychologists, to provide comprehensive care that addresses both physical and psychological factors affecting DFU patients. This study highlights the importance of considering cognitive function and QoL in DFU management, offering podiatrists valuable insights to optimize patient outcomes.
What methodological approach (design, analysis, etc.) has been used? (RCT, Case control, case study series, meta analysis etc.)	Methodological Approach: The study employed a cross-sectional case-control design to compare cognitive function and quality of life (QoL) between individuals with diabetes and an active diabetes-related foot ulcer (DFU) and a control group with diabetes but no active foot ulceration. Below are the key elements of the methodology: 1. Study Setting and Duration: o Conducted at Blacktown Hospital, Sydney, Australia. o Data collection occurred between December 2022 and August 2024. 2. Participants: o Cases: 42 adults with diabetes and an active DFU. o Controls: 40 age- and sex-matched individuals with diabetes but no DFU. o Inclusion criteria: Adults aged over 18 years, proficient in English, and no self-reported vision impairment. o Participants provided informed written consent. 3. Sampling: o Convenience sampling was used. o Frequency matching ensured balance in age and sex distribution between groups. 4. Data Collection: o Participants attended a single testing session where cognitive function and QoL were assessed. o Additional demographic and clinical information was collected, including age, sex, education level, diabetes duration, smoking status, and socioeconomic status. 5. Assessment Tools: o Cognitive Function: Measured using the Trail Making Test (TMT), which assesses rote memory (TMT-A) and executive functioning (TMT-B). o Quality of Life: Measured using the EuroQol EQ-5D-5L questionnaire, which evaluates mobility, self-care, usual activities, pain, and anxiety/depression. 6. Statistical Analysis: o Mann-Whitney U tests, logistic regression, and correlation analyses were used to evaluate differences and associations between cognitive function and QoL. o Continuous data were tested for normality using the Kolmogorov-Smirnov test. o Logistic regression assessed the relationship between cognitive function and the presence of DFU, controlling for variables like age, sex, education level, and diabetes duration. Key Features: • Validated Tools: Both the TMT and EQ-5D-5L are globally recognized and validated for assessing cognitive function and QoL. • Standardized Protocol: A single researcher administered all tests to minimize bias. • Ethical Approval: The study was approved by the Western Sydney Local Health District Human Research Ethics Committee. This methodological approach ensured robust comparisons between the case and control groups, providing valuable insights into the relationship between cognitive function, QoL, and DFU.
What were the results of the study? (What did the investigators find?)	Results of the Study: 1. Cognitive Function: • Trail Making Test (TMT): o Individuals with DFU took significantly longer to complete the TMT compared to controls. o TMT Total Time: Median time for DFU group was 179.0 seconds vs. 95.0 seconds for controls (p < 0.001, r = 0.57). o TMT-A (Rote Memory): Median time for DFU group was 48.0 seconds vs. 34.0 seconds for controls (p < 0.001, r = 0.45). o TMT-B (Executive Functioning): Median time for DFU group was 122.5 seconds vs. 58.5 seconds for controls (p < 0.001, r = 0.58). o Longer TMT completion times were associated with 4.13 increased odds of having a DFU (p < 0.001). 2. Quality of Life (QoL): • EuroQol EQ-5D-5L: o Median QoL score for DFU group was 0.88 vs. 0.96 for controls (p = 0.005, r = 0.31). o Visual Analogue Scale (VAS): Mean score for DFU group was 62.6 vs. 70.3 for controls (p = 0.05). o Lower QoL scores were moderately correlated with longer TMT times (p = 0.01, r = 0.29). 3. Logistic Regression: • Longer TMT times significantly increased the odds of having a DFU: o TMT Total Time: Odds ratio = 4.13 (95% CI 1.90–8.95, p < 0.001). o TMT-A: Each 1-minute increase in time was associated with 29 times increased odds of DFU (p = 0.005). o TMT-B: Each 1-minute increase in time was associated with 6.5 times increased odds of DFU (p < 0.001). 4. Key Findings: • Individuals with DFU demonstrated significantly poorer cognitive function (rote memory and executive functioning) compared to controls. • QoL was significantly lower in the DFU group, with a notable association between cognitive impairment and reduced QoL. • Cognitive impairment was identified as a significant risk factor for DFU, independent of age, sex, diabetes duration, and education level. Conclusion: The study highlights that individuals with DFU experience significant cognitive impairments and poorer QoL compared to those with diabetes but no DFU. These findings emphasize the need to integrate cognitive assessments into DFU management to improve adherence and patient outcomes.
Strengths & weaknesses of this study? Are the results valid? Look at study design, appropriateness of the method(s), population and sample size, appropriate study conduct, data gathering, subject follow‐up, influences of bias, methods of analysis, discussion, currentness and comprehensiveness of the listed references	Strengths of the Study: 1. Validated Tools: o The study used globally recognized and validated tools for assessing cognitive function (Trail Making Test) and quality of life (EuroQol EQ-5D-5L), ensuring reliability and accuracy of measurements. 2. Matched Case-Control Design: o Age- and sex-matching between cases and controls reduced confounding variables, allowing for more robust comparisons. 3. Standardized Protocol: o A single researcher administered all tests, minimizing interviewer bias and ensuring consistency in data collection. 4. Ethical Approval: o The study adhered to ethical guidelines, with informed consent obtained from all participants and approval from the Western Sydney Local Health District Human Research Ethics Committee. 5. Real-World Setting: o Conducted in a clinical setting, the study reflects real-world conditions, making the findings applicable to routine clinical practice. 6. Statistical Rigor: o Appropriate statistical tests (e.g., Mann-Whitney U, logistic regression) were used to analyze data, ensuring robust and valid results. Weaknesses of the Study: 1. Single-Site Recruitment: o Participants were recruited from a single hospital, which may limit generalizability to other populations or settings. 2. Missing Data: o HbA1c results were missing for 15% of control participants, which could have affected comparisons of glucose control between groups. 3. Socioeconomic Bias: o The study was conducted in an area with lower socioeconomic status (IRSD), which may have influenced cognition and QoL scores, potentially limiting generalizability. 4. Convenience Sampling: o Non-random sampling may introduce selection bias, as participants were recruited based on availability rather than random selection. 5. Cross-Sectional Design: o The study design does not allow for causal inferences or longitudinal tracking of cognitive function and QoL changes over time. 6. Limited Exploration of Mechanisms: o While the study identified associations between DFU, cognitive impairment, and QoL, it did not explore underlying mechanisms in depth (e.g., inflammation, cardiovascular disease). Validity of Results: The results are valid based on the following: • Internal Validity: o The use of validated tools, matched case-control design, and rigorous statistical analysis supports the reliability of the findings. o Significant associations between cognitive impairment, QoL, and DFU were demonstrated with strong effect sizes and statistical significance. • External Validity: o While the single-site recruitment and socioeconomic bias may limit generalizability, the findings are applicable to similar populations with diabetes and DFU. • Potential Bias: o Selection bias due to convenience sampling and missing data may slightly affect the robustness of the results, but the impact is likely minimal given the statistical rigor. Conclusion: The study's strengths outweigh its weaknesses, and the results are valid within the context of the study design. The findings provide valuable insights into the relationship between cognitive function, QoL, and DFU, emphasizing the need for integrated care approaches. Future research with larger, multi-site cohorts and longitudinal designs could further validate and expand upon these findings.
Do the conclusions follow logically from the design and results?	Yes, the conclusions follow logically from the design and results of the study. The study was designed as a cross-sectional case-control investigation to compare cognitive function and quality of life (QoL) in individuals with diabetes and a diabetes-related foot ulcer (DFU) to a control group with diabetes but no active foot ulceration. The methods used, including the Trail Making Test (TMT) for cognitive function and the EuroQol EQ-5D-5L for QoL, were appropriate and validated tools for assessing the study's objectives. The results demonstrated significant impairments in cognitive function (both rote memory and executive functioning) and lower QoL scores in individuals with DFU compared to controls. Statistical analyses showed strong associations between cognitive impairment and reduced QoL, as well as increased odds of DFU with longer TMT completion times. These findings align with the study's conclusions that cognitive function is significantly impaired in individuals with DFU and is associated with poorer QoL, emphasizing the need for integrating cognitive assessments into DFU management to improve adherence and patient outcomes. The study's design, statistical rigor, and interpretation of results support the logical progression to its conclusions.
How do the results relate to current practice and how might they influence future practice? (What does the answer mean anyway? So what? Who cares?)	The results of this study have significant implications for current and future practice in managing diabetes-related foot ulcers (DFU): Relation to Current Practice: 1. Cognitive Function and Adherence: The study highlights that individuals with DFU have impaired cognitive function, particularly in rote memory and executive functioning. These impairments can hinder adherence to complex treatment regimens, which is a known challenge in DFU management. Current practice often focuses on physical and medical aspects of DFU care, but cognitive function is not routinely assessed. 2. Quality of Life (QoL): The study confirms that individuals with DFU experience significantly poorer QoL. While QoL is sometimes considered in DFU management, it is not consistently integrated into care plans. Influence on Future Practice: 1. Integration of Cognitive Assessments: The findings suggest that cognitive assessments, such as the Trail Making Test (TMT), should be incorporated into routine DFU management. Identifying cognitive impairments early could help tailor educational materials and interventions to improve adherence and outcomes. 2. Holistic Care Approach: The study emphasizes the need for a more comprehensive approach to DFU care, addressing both physical and psychological factors. This could include targeted interventions to improve cognitive function and QoL, such as simplified treatment protocols, memory aids, or psychological support. 3. Patient Education: Educational materials and strategies should be adapted to accommodate cognitive impairments. For example, using visual aids, repetition, and simplified instructions could enhance understanding and adherence. 4. Preventative Strategies: The study suggests that addressing cognitive function and QoL early in diabetes care, even before DFU develops, could improve long-term outcomes. This might involve routine cognitive screening for individuals with diabetes and proactive measures to prevent DFU. 5. Research and Policy Development: Future research could explore the impact of cognitive and QoL interventions on DFU healing rates and recurrence. Policymakers might consider guidelines that mandate cognitive and QoL assessments as part of DFU care. In summary, the study's results advocate for a shift toward a more holistic, patient-centered approach in DFU management, integrating cognitive and QoL assessments to optimize adherence and improve outcomes.

Journal Club - 6th December 2023

Fri, 08 Dec 2023 03:12:29 GMT

Article title	State of the art design protocol for custom made footwear for people with diabetes and peripheral neuropathy. (Bus, S. A., Zwaferink, J. B., Dahmen, R., & Busch-Westbroek, T.)
Journal	Diabetes/metabolism research and reviews
Issue/Page No:	36 Suppl 1(Suppl 1), e3237
Discussion date	Wednesday 6^th December 2023

Study objectives, hypothesis and question?	The study “aimed to develop a design protocol to support custom-made footwear prescription for people with diabetes and peripheral neuropathy.” Target population: “people with diabetes who are at moderate-to-high risk of developing a foot ulcer, for whom custom-made footwear (shoes and/or insoles) can be prescribed.” Discussion: Podiatrist and pedorthist colleague AJ shared that this protocol has been well received at the recent Pedorthic Association of Australia (PAA) Conference 2023 in Fremantle where the one of the authors (Sicco A. Bus) was the keynote speaker. This protocol is making an impact on the work of the profession. Prior to this, Rutger Dahmen’s work was the ‘gold standard’.
Rationale and relevance of the question? (why was the study done?)	Rationale for this protocol is to help guide the workforce. Protocol is required to assist with clear and clinical decision‐making in selecting the type of footwear. Currently there is minimal published protocol, shoe concept or algorithm. Prior to this paper, there have been only two consensus‐based algorithms for custom‐made footwear and a pressure‐ and foot shape‐guided design algorithm for custom‐made insoles identified in the scientific literature.
Relevance of this topic/question to Podiatrists?	All discussed that the protocol is relevant, essential, and useful to pedorthist, orthotist and podiatrist. For pedorthist, it will further guide practice, creation and manufacturing of footwear. There are no existing guidelines or standardised approach currently in place to make footwear and boots. Concerns about how to disseminate the study and guidelines were discussed. For podiatrist, this protocol will enhance knowledge to better provide patient centred care for patients. The protocol will assist podiatrist to educate patients on the footwear requirements as well as facilitating the referral of the patient to a pedorthist and working collaboratively with the pedorthist. Discussion: It is important for podiatrists to understand the design criteria of a footwear for a high risk patients and assist to support pedorthist to send the same message to the patient. For example, should a patient complain about the prescribed footwear being too chunky or too bulky, the podiatrist can assist to reiterate the reasons for the features of the footwear.
What methodological approach (design, analysis, etc). has been used? (RCT, Case control, case study series, meta-analysis etc).	A design protocol for custom‐made footwear for the moderate‐to‐high‐risk patient with diabetes and peripheral neuropathy was developed. 2 algorithms: 1) The pressure‐relief algorithm and 2) the footwear design and pressure‐relief algorithms. Method involved convening a group of experts including experts from rehabilitation medicine, orthopaedic shoe technology (pedorthics) and diabetic foot research. Meetings occurred over 2 hours for 12 sessions. Table 1 included 14 domains of foot pathology were defined. This included comprehensive details of the domain categorised into direct scientific evidence, in-direct scientific evidence and consensus working group. Table 2 demonstrates the pressure‐relief design algorithm, consisting of 10 required steps for design. Discussion: Table 1- Interesting to see that Charcot midfoot deformity was included as in practice, this deformity is commonly addressed with off the shelf devices. Table 2- Good to see the cost benefit for the patient was included as specialised footwear can be very costly to patients. F-scan and Pedar system are expensive. Sensors are approx. $150 short arm and $250 for long arm sensors. Sensors are reusable but unlikely that it as effective as new sensors. If cost benefit analysis is conducted is considered, the cost of expensive footwear that can cost up to $6000 is still effective compared to amputation costs. Pedorthist may find it difficult to adhere to the protocol due to the cost. Funding schemes may not fully covert the cost for patients and patients will unlikely be able to afford the footwear. Pedorthist may need to compromise certain features of a shoe in this scenario. E.g. Off the shelf footwear may be used instead costing $400-500. Cost is mainly from the labour. It is likely that 3D printing is used in this space however 3D printing can still be time consuming and may not bring down the cost at this present time. Pedorthist are choosing to outsource to other countries such as Bangladesh and Philippines.
What were the results of the study? (what did the investigators find?)	A design protocol for custom‐made footwear for the moderate‐to‐high‐risk patient with diabetes and peripheral neuropathy was developed.
Strengthens and weaknesses of this study? Are the results valid? Look at study design and the appropriateness of the method(s), population and sample size, appropriate study conduct, data gathering, subject follow-up, influences of bias, methods of analysis, discussion, current and comprehensive listed references).	Strengths: Robust study and expert panel came to a consensus. The pressure‐relief design algorithm consisted of 10 required steps for the design of custom‐made footwear. Weaknesses: Expert panel did not include experts such as rehabilitation physicians, orthopaedic surgeons, podiatrist
Do the conclusions follow logically from the design and results?	Yes
How do the results relate to current practice and how might they influence future practice? (what does the answer mean anyway? So what? Who cares?)	The protocol is a valuable resource for pedorthist as there are nil consensus prior to this. However, the concern is around the availability of skilled pedorthist who can implement this protocol and the cost to patients. Pedorthists may have limited clinical skills set and confidence to implement the protocol. In Australia, funding for patients for footwear needs to increase. Patient adherence was also a concern (“Will patient wear it?”). Suggestions that a protocol should be established for Australia to consider the many barriers to implementing the protocol e.g. the hot climate, cost, funding system. Conclusion that the protocol is useful however we may find that it may be difficult to translate the algorithms to practice in Australia.

Journal Club - 23rd February 2023

Thu, 02 Mar 2023 00:56:57 GMT

Article Title:

Reasons for (non-)adherence to self-care in people with a diabetic foot ulcer

Jaap J van Netten, Leonard Seng, Peter A Lazzarini, Jason Warnock, Bernd Ploderer

Journal:

Wound Repair & Regeneration: official publication of the Wound Healing Society and the European Tissue Repair Society 2019,

Issue/Page No:

27(5)

Discussion Date: 23 / 2 / 2023

Study objective, hypothesis and question?

Qualitative, hypothesis generating study exploring.

Interview style performed

Rationale and relevance of the question?

(Why was the study done?)

DFU self-care lack of evidence, explore intervention self-care activities to

Respect self-care and no foot ulcers. But in this space limited.

Relevant area of research, majority of care is seen outside of the clinical setting. Time factor, limiting impact. Most of the work is done outside of the clinical setting for the patient. What goals patients have and identifying barriers is essential

Self-care with risk of ulceration vs those with active ulcerations would be different.

Relevance of this topic/question to FH Podiatrists?

(Is it urgent or essential reading for a podiatrist working in an acute hospital?

Essential for any podiatrist to consider with patient presenting with HRF wound. Enlightening, exploring the issues with the patient around integrating offloading into their day. Valued part of the treatment. Limitations with available offloading (cumbersome, knee to ankle height offloading), environmental and life style barriers to wear devices. Short changing people with delivering in-effective education, aligning patient goals with therapeutic goals. Limitations with time in clinic, not necessarily seeing patient often enough to enforce the importance of therapeutic goals. What is their understanding of the therapeutic goals? Often patient confusion, not necessarily aware of the objectives of care.

Patient understanding of information supplied, what we communicate is essential, this may be interpreted differently. Motivation of the patient in this article was key to adherence

No indigenous or immigrant community included, barriers and issues maybe different or similar to general population?

Relevance is identified, duration of working in HRF and noting that education is important and how it is interpreted by the patients.

What methodological approach (design, analysis, etc.) has been used?

(RCT, Case control, case study series, meta analysis etc.)

A qualitative study using face-to-face semi-structured interviews, using the framework approach.

A 40-item, semi-structured interview guide was developed. The systematic nature of the framework approach allowed for the interview guide to be structured to align with the various aspects and factors of diabetic foot ulcer self-care.

Interview guide was piloted with two persons not included in the study, to ensure validity and feasibility.

5 key threads to that approach – interview

Familiarisation, Thematic framework identification, indexing, charting, mapping and interpreting data.

WHO adherence dimensions (social and economic factors; therapy-related factors; patient-related factors; health-system related factors; condition-related factors

Bias with study design,

-interview was completed after the appointment.

-not clear if patients were questioned by same person.

Missing methods information

Themes and interpretations were discussed

Smart phone use - may exclude some relevant participants.

What were the results of the study? (What did the investigators find?)

Multi-dimensional factors that contribute to non-adherence.

Nothing new, that self-care is not well done. Didn’t look at the communication or education provided by the practitioner.

Patient explored the adherence at home only. Many factors, in education.

Research location (South East Queensland) may not have full relevance to the general population.

Further research proposing possible solutions to these issues with self-care rather than providing a reflective element to the study conclusion.

Strengths & weaknesses of this study? Are the results valid? Look at study design, appropriateness of the method(s), population and sample size, appropriate study conduct, data gathering, subject follow‐up, influences of bias, methods of analysis, discussion, currentness and comprehensiveness of the listed references

Limitations:

Small sample size
More type 1 participants
No indigenous or immigrant participants
Testing hypothesis rather than finding new research
Did not encapsulate the whole population or cohort of DFU
Applicable to those with neuropathy only
Small sample
Possible bias – patient going from HRF appt to interview straight away. Re-discussion of results in the interview -.
Interview environment could have influence
Smart phone use, population younger, possibly wealthier, intellectually more advanced, cognition, higher socioeconomic group?? Tech savvy.
No formal assessment of health literacy – known for patients with DFU early dementia.
Dialysis patients have poor retention of information post dialysis with education – multiple research sources
Not generalisable limitations with population sample -potential for future research.
Not fresh minds participants from another study, possible bias with potential convenience.
Those that participate in research tend to be more engaged, likely to be more likely to follow education. Possible bias, higher health literacy.
Gaps in methods not discussed but clarification with Jaap the investigators were different to the clinicians.
Chronicity of the wounds would be interesting to explore, may influenced patient perception.
Those wearing TCC vs removable devices answers would be different from interview.

Strengths

WHO framework identified – part of the theme of the paper and 5 point framework. Qualitative commentary is still valid. Points to think in own practice.
Learning points: new app for qualitative data app (www.saturateapp.com)

Do the conclusions follow logically from the design and results?

Yes, null hypothesis that difficulty in self care was going to be an issue. It reaffirms what we know, how do we address this in practice.

Apply this study to a wider cohort – difficulty in the qualitative design

Not assuming patients have any knowledge – care needs to be explicitly explained, clinical environment and time can influence effectiveness.

How do the results relate to current practice and how might they influence future practice? (What does the answer mean anyway? So what? Who cares?)

What we confirm and all believe and know, there are barriers and themes that need to be addressed with education and self-care.

Teaching and communication – we don’t recognise or research well, how well do we communicate to our patients?

Clinicians often assume that they communicate consistently with a valid and reliable outcome.

NESB/. Indigenous population and other populations can be impacted when the message does not get across. Repetition isn’t always effective communication. Patient can reach a point of saturation.

Outcomes from communication – need to be explored and the styles of communication/education used clinically.

Jaap comments

Qualitative study and question around possible bias environment and when clients were interviewed?

-Researchers were interviewers, early research career person and a non podiatric / no DFU experience colleague.

Japp not one of the interviewers

Qualitative research you will always have an element of bias with questioning. Early career researcher, structure was useful and controlling research design. Actively caring for the patient may influence patient.

Stranger may open up more.

Possible bias controlled and other variable with relatively structured approach to interview questions, researcher early in research career.

-Interview was completed in clinic room? Would it have made a difference, time, space between appointment?

Environment was considered with study design – patient home vs clinical space. Awareness of influence on question outcomes.

Awareness that participants were happy to identify barriers to self-care. Jaap didn’t feel this influenced the conclusions from the study. Current study is not generalisable, but still adds to the research pool.

Future research opportunity different population sample, further focus on themes already identified from WHO framework and current study conclusions. Negative patient may seek opportunity to complain to an outside researcher, could influence conclusions in qualitative research

Interview vs focus group – structured interview slightly better, where focus groups the researcher has to manage patient interaction and note where conversation may go. Interaction was missed with patients which is prevalent in focus group. Questions were used during current study with ‘other patients have experienced X…..” await outcome from participant.

Where do we go from here?

Does this open up for further research to be conducted here?

Clinical day and time can influence outcomes and education delivered.

The invisible balls that patients are constantly juggling with their health care. How do we incorporate education and self-care focus into our practice. Not more checklists, already heavy administrative burden with a questionnaire or check list, more of an awareness and working more collaboratively. Difficult.

Interactions with people assumptions that you carry – insightful and people’s motivation. Aligning patient goals with therapeutic goals vs therapeutic goals aligning with patient goals. Holistic care. Staged approach to include more therapeutic care goals at each appointment.

Sample size small

Not generalisable
Use of mobile technology, higher intellect
Restricted sample size to control variables for early career researcher.
With a general population – different themes, already 5 barriers noted with WHO. Would not have made a huge difference on the conclusions reached with the current study

Journal Club - 20th July 2022

Thu, 21 Jul 2022 04:01:21 GMT

Article Title: Duration of total contact casting for resolution of acute Charcot foot: a retrospective cohort study

Journal: Journal of Foot and Ankle Research

Issue/Page No: 14:44 1-12

Discussion Date: 20/7/2022

Study objective, hypothesis and question?

The median TCC duration for the resolution of an acute Charcot foot in Australia. Exploring clinical factors.

Rationale and relevance of the question?

(Why was the study done?)

There was varying TCC treatment lengths in different countries and limited Australian data in regards to the duration of TCC treatment.

Study was done to present more Australian data and identify any clinical factors affecting its duration.

Relevance of this topic/question to FH Podiatrists?

(Is it urgent or essential reading for a podiatrist working in an acute hospital?

Podiatrists are not able to provide guidance on time-frames in TCC treatment length. This study is relevant to set patient expectations and providing informed consent for treatment. It also assists patients with organising social supports, finances and work.
There is varying data in duration around the world.
It is important to gather Australian data for Australian podiatrists and patients.
Highly relevant to HRF podiatrists in acute and community
The study also highlights the high number of misdiagnosed patients when signs and symptoms first appeared.

What methodological approach (design, analysis, etc.) has been used?

(RCT, Case control, case study series, meta analysis etc.)

Retrospective cohort study over a 3 years period. The cohort was from a large metropolitan hospital.

The study group was small consisting of 27 participants.

The study’s eligibility criteria were strict where current ulcers were excluded from the study.

What were the results of the study? (What did the investigators find?)

The study showed a median of 4.3 months of treatment time in TCC.

Patients diagnosed with osteoarthritis before they had an active Charcot’s foot showed a TCC treatment time-frame of more than 4 months - had more incidents of osteoarthritis (in any joint) post treatment.

Identified a high misdiagnosis of Charcot’s foot before attending the high risk foot service.

The greatest reduction in temperature was at the affected Charcot site.

Strengths:

Robust screening and strict criteria, study is easily repeated.
Strengths in identifying risks in TCC treatment were only minor skin rubbing and irritation.
Findings were generalisable to those with diabetes and peripheral neuropathy, therefore applicable to similar patients.
Realistic representation of the population – patients were not using assistive ambulating devices (crutches, walkers, knee scooters) and continuing daily activities of living whilst receiving treatment.

Weakness:

Time that patients were out of the TCC treatment was still included in the treatment time. However, this was justified by the patient only spending 1 week out of a TCC for flying and were in appropriate offloading such as a removable walker.
Osteoarthritis prevalence could be in any joint.
The osteoarthritis was not measurable via imaging before or after, it was dependent on medical history
Study did report that the increase in osteoarthritis was difficult to be explained, but maybe from biomechanical factors
Small sample size
Retrospective study – medical documentation flaws
External factors that can influence TCC duration length
Medical specialty led clinics
Experienced/trained clinician in identifying Charcot foot status

Do the conclusions follow logically from the design and results?

Yes, duration of TCC treatment is shorter or comparable to data reported in the UK, US, Europe and Asia Pacific countries.

How do the results relate to current practice and how might they influence future practice? (What does the answer mean anyway? So what? Who cares?)

The study supports change in podiatry practice by giving podiatrists the ability to provide better informed consent and education for TCC treatment.

Ability to estimate time-frames and setting expectations.

Advising patients of risk factors.

Journal Club - 3rd March 2022

Wed, 27 Apr 2022 23:18:51 GMT

Article Title: Evaluating Cognitive Impairment in People with Diabetes-Related Foot Ulceration

Journal: Journal of Clinical Medicine

Issue/Page No: 2021, 10 (13)

Discussion Date: 03/03/2022

Study objective, hypothesis and question?

Study Objective: To determine whether there is an excess of cognitive impairment in patients with T2DM and foot ulceration.

Hypothesis Question: Whether DFUs in people with T2DM is associated with greater cognitive impairment, compared with T2DM without DFU.

Rationale and relevance of the question?

(Why was the study done?)

Patients with a Diabetic Foot Ulcer often do not complete what is required to manage their DFU. Is there some Cognitive Impairment in patients with a Diabetic Foot Ulcer that impedes ability to carry out what’s required to manage DFU?

Should tools be used to assess/explore cognitive impairment to improve patient education and patient outcomes?

Relevance of this topic/question to FH Podiatrists?

(Is it urgent or essential reading for a podiatrist working in an acute hospital?

Highly relevant across all HRFS.
Patients provided with instructions and information, yet are unable to complete instructions.
Essential reading for podiatrists working in HRFS/with patients presenting with DFUs.

What methodological approach (design, analysis, etc.) has been used?

(RCT, Case control, case study series, meta analysis etc.)

Methodological approach used: observational cross-sectional study which was the most pragmatic design based on the resources available.

What were the results of the study? (What did the investigators find?)

No difference found between the two groups assessed regarding cognitive scores. The study did not show an excess of cognitive impairment in patients with T2DM and DFU compared with patients with T2DM and no DFU.

50% of participants across both groups had mild cognitive impairment.

Prior studies conducted and compared results between population with T2DM and DFUs vs no diabetes – Found disparity between co-morbidities, potentially influencing causation and pathway for cognitive impairment.

Strengths

- The amount of data collected was substantial.

Weakness

- Cross-sectional design means it is not possible to draw conclusions regarding causality.
- Logistical constrains meant that 111 participants were recruited instead of 200 participants (100 per group) as initially planned which may have contributed to a type 2 error.
- Recruitment from a hospital outpatient clinic may limit the generalisability of findings.
- Assessment of foot self-care relied on self-reporting allowing room for the possibility of recall and social desirability bias.
- Patients better matched with comorbidities in this study, and have common pathways regarding diabetes.
- No longitudinal data was assessed. The prognostic impact of any impact of any differences between cohorts could not be investigated.

Do the conclusions follow logically from the design and results?

Yes

How do the results relate to current practice and how might they influence future practice? (What does the answer mean anyway? So what? Who cares?)

Future research is needed to establish whether cognitive impairment impacts DFU healing/LEA outcomes.

Detailed assessment of self-care behaviour currently under review, not yet published.

Non-adherence and adverse DFU outcomes may potentially be driven by other factors such as behavioural aspects, personality constructs, social disadvantage, education aspects, work commitments, family commitments, health literacy impacting self-care behaviour.

Clinicians need to adjust how patient education is delivered to this vulnerable cohort of patients who have challenges regarding memory and retention – Change delivery of education to be succinct and clear, being mindful of prevalence in patient cohort.

Improved access to Health Psychology within a High-Risk Foot Service is required to improve outcomes for patients.