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 & 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:

•         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.

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 & 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

• -        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.