Graham P. Leese

There is accumulating evidence that the natural history of diabetic eye disease is sufficiently slow that 2-yearly retinal screening, or even longer, may be safe for some patients with diabetes. The information technology underpinning call-recall systems within screening programmes permits a more sophisticated approach to organizing retinal screening, as directed by the clinical evidence. This commentary explores the evidence for moving towards a biennial retinal screening programme for patients with Type 2 diabetes and diabetes duration of less than 10 years. Such an approach may allow capacity to introduce 6-monthly screening for high-risk patients, a targeted approach to recurrent defaulters and possible introduction of new aspects of screening such as optical coherence tomography, in addition to accommodating for the expanding number of patients with diabetes. A UK-four nations group is now critically looking at the evidence for any such changes.

The Scottish Diabetes Foot Action Group (SDG) has developed and introduced a national strategy plan for diabetic foot care across Scotland. This has involved the implementation of an evidence-based national foot screening and risk stratification programme that has already covered 61% of the population in just the first two years. Nationally agreed patient information foot leaflets and professional education material have been introduced, and a consensus for antibiotic use in the diabetic foot has been published. Information on multidisciplinary specialist foot services has been collected, indicating that 58% of Health Board areas have consultants with dedicated sessions in their job plan to a foot clinic, and 42% had integrated orthotic involvement. The SDG aims to increase these figures. Work has been undertaken to support local podiatry networks and improve communication between the specialist centre and the community. At a national level the SDG is working with Foot in Diabetes UK (FDUK) to recognize key podiatry skills by developing core competencies and a competency framework for the diabetes podiatrist and diabetes orthotist. The annual Scottish Diabetes Survey indicates some improvement in amputation rates with prevalence decreasing from 0.8% to 0.5%, and improved recording of foot ulceration at a national level. This national strategy has helped highlight the importance and difficulties facing diabetes foot care and should help to continue to improve the quality of care of people with diabetes who have foot-related problems.

We aimed to identify which individual risk factors best predict foot ulceration in routine clinical practice and whether an integrated clinical tool is a better screening tool for future foot ulceration. Routinely collected clinical information on foot and general diabetes indicators were recorded on the regional diabetes electronic register. Follow-up data on foot ulceration were collected from the same electronic record, the local multidisciplinary foot clinic and community and hospital podiatry paper records. Data were electronically linked to see which criteria best predicted future foot ulceration. Foot risk scores were recorded on 3719 patients (44% female, mean age 59±15years) across community and hospital clinics. Overall, 851 (22.9%) had insensitivity to monofilaments, in 629 (17.2%) both pulses were absent and 184 (4.9%) had a prior ulcer. In multivariate analysis, the strongest predictors of foot ulceration were prior ulcer, insulin treatment, absent monofilaments, structural abnormality and proteinuria and retinopathy. The sensitivity of predicting foot ulceration was 52% for prior ulcer, 61% for absent monofilaments, 75% for 'high risk' on an integrated risk score and 91% for high and moderate risk combined. The corresponding specificities were 99, 81, 89 and 61%. Positive likelihood ratio was 52 for prior ulcer and 6.8 for foot risk, with negative likelihood ratios of 0.48 and 0.15, respectively. Integrated foot risk scores are more sensitive than individual clinical criteria in predicting future foot ulceration and are likely to be better screening tools, where excluding false negative results is of paramount importance.

A diabetes foot action plan was introduced to Scotland in 2006. This has included developing a foot-screening programme with foot risk stratification. Currently 140,000 people (61% of all patients with diabetes) have undergone foot risk stratification, with 69% categorised as low risk, 20% as moderate risk and 11% as being at high risk of foot ulceration. This has helped support the introduction of needs-related care pathways. Schemes to support community-based podiatrists and strengthen links and referral pathways to specialist foot services have been introduced. Identifying key competencies for podiatrists and orthotists working for patients with diabetes has underpinned the development of a competency framework for each profession. Nationally agreed and utilised patient education leaflets and staff education programmes, including online training programmes have been introduced. Surveys of multidisciplinary foot services, have shown amongst other things, a low level of consultant involvement in such clinics (58% of Health Boards). Overall, national data indicated that across Scotland in 2009 the prevalence of foot ulceration was 2.5% in December 2010 and amputation was 0.5% in 2009, the latter having declined from 0.8% in 2003.

J Clin Endocrinol Metab, published October 6, 2010, 10.1210/jc.2010-0854

Fifteen per cent of patients with diabetes will develop a foot ulcer at some point in their life. Ill-fitting footwear frequently contributes to foot ulceration. A good fitting shoe is an essential component in the management of the diabetic foot. The objective of this study was to assess the feet and footwear of patients with diabetes to determine whether they are wearing the correct-sized shoes. One-hundred patients with diabetes who were attending the general diabetic clinic had their foot length measured using a 'Clarks' shoe shop device and foot width using a pair of callipers. Measurements were taken whilst seated and standing. Shoe dimensions were also assessed by recording the manufactured shoe length and using callipers to assess shoe width. A calibrated measuring stick standardised shoe lengths. Neurovascular status and the presence of deformities in the foot were also recorded. One-third of diabetic patients were wearing the correct shoes on either foot whilst seated or whilst standing. However, only 24% of patients were wearing shoes that were of the correct length and width for both feet whilst seated and 20% upon standing. Seventeen per cent of patients appeared in both groups. No significance was found between any other variables, such as sensory neuropathy. Many patients with diabetes wear shoes that do not fit, particularly, shoes that are too narrow for their foot width. Assessing the appropriateness of footwear maybe an important part of foot examination.

Summary: Objective  We aimed to describe the changing incidence of thyroid disease in a population‐based study in Tayside, Scotland (population 390 000) between 1994 and 2001.Design  A retrospective, data‐linkage, population‐based study measuring the incidence and prevalence of thyroid disease.Patients  All patients with newly diagnosed, treated and stable thyroid disease in Tayside were identified by electronic linkage of six datasets, including all regional biochemistry data, hospital admissions, deaths and a thyroid follow‐up register.Results  The overall prevalence of thyroid dysfunction has increased from 2·3% to 3·8% (1994–2001). The prevalence of ever having had hyperthyroidism increased from 0·86% to 1·26% in females and 0·17% to 0·24% in males (P < 0·0001 for both). The standardized incidence of hyperthyroidism increased from 0·68 to 0·87 per 1000 females/year, representing a 6·3% annual increase (P < 0·0001). The prevalence of primary hypothyroidism increased from 3·12% to 5·14% in females and 0·51% to 0·88% in males (P < 0·0001 for both). The standardized incidence of primary hypothyroidism did not change and varied between 3·90 and 4·89 per 1000 females/year over the 8 years. Incidence of hypothyroidism in males increased from 0·65 to 1·01 per 1000 males/year (P = 0·0017). Mean age at diagnosis of primary hypothyroidism declined in females from 1994 to 2001.Conclusions  The prevalence of primary hypothyroidism and previous hyperthyroidism has increased in Tayside, Scotland. This is partly due to an increasing incidence of disease, increased ascertainment and earlier diagnosis of disease. This will result in an increased workload for endocrinologists and general practitioners.