Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada

Abstract Background Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019. Methods Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher’s exact test or Chi-square test. Results Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved. Conclusion Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway

Measuring the microbiome of chronic wounds with use of a topical antimicrobial dressing – A feasibility study

<div><p>Background</p><p>Polymicrobial communities colonize all wounds, and biofilms are hypothesized to be a key link to the chronic state and stalled healing. Molecular methods offer greater insight when studying microbial ecology in chronic wounds, as only a small fraction of wound bacteria are cultured by currently available methods and studies have shown little agreement between culture and molecular based approaches. Some interventions, like dressings with oxidized silver, are reported to help the stalled wounds move to a normal healing trajectory but the underlying mechanisms are difficult to measure. One hypothesis is that the use of topical antimicrobial dressings targets the wound microbiome and reduces bioburden.</p><p>Objectives</p><p>Our objective was to determine if culture-independent molecular methods could be used to identify the microbial composition in chronic wounds, and measure the microbiome over time when a topical antimicrobial dressing is used to reduce bioburden.</p><p>Methods</p><p>Patients with chronic wounds defined as >6 weeks in duration and not taking systemic antibiotics were recruited to participate. A wound contact layer containing silver oxynitrate was applied immediately after routine sharp debridement material was collected and swabs of the wound bed taken. Next-generation sequencing of the bacterial 16S rRNA gene in each specimen was used to measure the microbiome.</p><p>Results</p><p>Distinct bacterial communities were observed between swab and debridement samples, highlighting spatial differences and the importance of sampling consistency. The microbial communities appeared to be similar between different diabetes statuses, but different among the three wound categories included.</p><p>Conclusions</p><p>Culture-independent methods can be applied to measure the microbiome of chronic wounds even when a topical antimicrobial dressing is applied to the wound.</p></div

Bacterial communities in swab and debridement samples.

<p>The 249 species level OTUs identified from the specimens are classified according to their corresponding phylum. The venn diagram shows 120 OTUs that are found in both debridement and swab specimens, while 59 OTUs are debridement-specific and 70 OTUs are swab-specific (as indicated by the square). OTUs with at least 2-fold numerical differences in relative abundance (>1% for at least one sample type) between the swab and debridement samples. <i>Allobaculum</i> sp. is more abundant in swab samples, while an undefined Burkholderiales sp. and <i>Roseateles depolymerans</i> are more abundant in debridement samples.</p

Comparison of alpha diversity in treated (V2-V6) samples.

<p>Comparison of alpha diversity in treated (V2-V6) samples.</p

Comparison of alpha diversity in pre-treatment (V1) samples.

<p>Comparison of alpha diversity in pre-treatment (V1) samples.</p

Overview of the bacterial communities between diabetes status and among wound types in pre-treated samples (V1 samples).

<p>(A) Plots for swab samples. The Y axis represents the percentage of the OTUs being observed among the total reads. (B) Plots for debridement samples. Y axis represents the percentage of the OTUs being observed among the total reads.</p

PCoA clustering, common/unique bacterial OTUs at species level, and differentially abundant bacterial OTUs between diabetes status and among wound types in post-treatment samples (V2-V6 samples).

<p>(A) Plots for swab samples. Venn diagrams suggest that diabetic status-associated and wound type-associated OTUs exist in swab samples. Differentially abundant OTUs are listed in the bar chart. (B) Plots for debridement samples. Venn diagrams suggest that diabetic status-associated and wound type-associated OTUs exist in debridement samples. Differentially abundant OTUs are listed in the bar chart.</p

Patient demographics and wound characteristics at baseline (T = 0) and the end of study (T = 4).

<p>Patient demographics and wound characteristics at baseline (T = 0) and the end of study (T = 4).</p

Comparison of median wound score (median BWAT ± IQR) between diabetes status and among wound types before and after treatment.

<p>Median wound score ratio = visit 6/visit 1 ± IQR, Median wound score change = visit 6—visit 1 ± IQR.</p

Bacterial relative abundance (>1% abundance in all samples) plots for three patient timelines.

<p>Plots are split by debridement samples (top panel) and swab samples (bottom panel). Wound locations are as follows: P10 (post-surgical abdomen, non-F/L wound), P8 (venous leg ulcer), P9 (diabetic foot ulcer). Debridement samples were not taken on visit 2.</p