diabetes study day talk 4th july 17.pdfhad dm.1 international diabetes federation diabetes atlas,...
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The Rotherham NHS
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Diabetes Study Day 4th July 2017
Diabetes Podiatry Service
Sarah Jane Hayhurst
Diabetes Lead Podiatrist
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The Rotherham NHS
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The Diabetes Education & Resource Centre
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Diabetes: Worldwide
• Diabetes is a global epidemic.
– In 2015 415 million people
had DM.1
International Diabetes Federation Diabetes Atlas, 7th Ed, 2015
• UK DM Prevalence 2016 =
5.6%.2
– 3.6 million diagnosed with
DM.2
– A further 1 million
undiagnosed T2.2
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The Rotherham NHS
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Diabetes
• The prevalence of DM is
nearly 3 x higher than
the prevalence of all
cancers combined.2
Diabetes UK, State of the Nation, 2016
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• NHS Rotherham CCG – Resident population 260,100,
– 48,900 are over 65-years of age,
• 8.9% of the population have DM,
• Compared with 6.4% in England.3,12
• Diabetic Foot Ulcers – 15 - 25% lifetime incidence.4
– Annual incidence 1.9 - 4.1%.5-7
– This equates to approximately 380 – 779 active ulcers per year in the Rotherham area
Current active diabetic foot
disease caseload – 201.
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0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
Site Ischaemia Neuropathy BacterialInfection
Area Depth
National Diabetes Foot Care Audit 2014 – 20168 We have larger, deeper ulcers with more infection
The Rotherham NHS Foundation Trust
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The Rotherham NHS
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Major amputations per 1,000
people aged 17+ with diabetes
Minor amputations per 1,000 people aged 17+ with diabetes
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Gold Standard Care -
Guidelines Active Diabetic Foot Disease
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The Rotherham NHS
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All Guidelines • Optimal glycaemic control
• Optimal wound care
• Optimal offloading
• Aggressive management
of infection
• Access to vascular
• Access to imaging
• Education
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So whats the problem?
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Loss of protective
Sensation
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=0CAcQjRw&url=http://imgkid.com/tick-and-cross.shtml&ei=yoJ1VM_TJc6IuATW34CwCg&psig=AFQjCNHxT5FVRO3CyFEWED-QTFkbK6F16Q&ust=1417073190399052http://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://imgkid.com/tick-and-cross.shtml&ei=v4J1VK_7N4uRuQSBqYGQCw&psig=AFQjCNHxT5FVRO3CyFEWED-QTFkbK6F16Q&ust=1417073190399052
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Signs and symptoms of peripheral
neuropathy [13]
•“Feet feel asleep” / numbness / “dead feeling”
•Tingling / pins and needles / “ant bites”
•Burning pain
•Shooting pains / “like electric shock”
•Lancinating pains / “knife like”
•Contact pain, often with day-time clothes and bedclothes on (allodynia)
•Pain on walking described as “walking barefoot on marbles” or walking barefoot on hot sand or broken
glass.
•Sensations of heat or cold in the feet, persistent achy feeling in the feet, cramp-like sensations in the legs
•Foot ulceration
•Ataxia (a lack of muscle control during voluntary movements)
•Weakness
•Falls
•Orthostatic hypotension
•Nocturnal exacerbations
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Inspect for foot deformity
High
plantar
pressure
sites
Charcot / rocker bottom
deformity
Toe deformities:
Hammer / Mallets / Clawing
intrinsic minus foot
hallux abducto valgus
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Signs and symptoms of PVD [14]
• Skin colour may be pale / white
• Skin appearance thin / fragile “Parchment-like”
• Hair less
• Muscle atrophy
• Weak pulses / pulse less
• Cool to cold temperature
• Atrophic nails
• Capillary refilling time >3 seconds
• Intermittent Claudication
• Rest pain
• Cyanosis
• Tissue loss/ ulceration
• Gangrene
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Ankle Brachial Pressure Index Toe pressures/ Toe Brachial Index [15]
Grade ABPI
Normal 0.91 - 1.30
Mild 0.60 – 0.90
Moderate 0.40 – 0.60
Severe < 0.40
Poorly Compressible >1.30
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Toe pressures/Toe Brachial Index
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MOTOR
Muscle wasting & atrophy (weakness)
Deformity
Abnormal pressure
High plantar pressure
Callus formation
SENSORY
Loss of protective sensation
Loss of biological incentive to seek
help
AUTONOMIC
Anhidrosis & dry skin
↓Sympathetic tone (altered blood flow
regulation)
CHARCOT
MICRO
STRUCTURAL Capillary BM
thickening
FUNCTIONAL AV Shunting
MACRO
STRUCTURAL Atherosclerosis
Occlusive narrowing
(stenosis)
Critical limb ischemia
↓ Nutrient Capillary Blood Flow
ISCHEMIA
Diabetic Foot Ulcer (Anemia, nutritional deficit)
Amputation
Structural Deformity
& Cheiroarthropathy
ESRF & Dialysis
Impaired response
to infection
Trauma (Footwear & Barefoot Walking)
DPN (micro) Vascular
Pathway to Ulceration in Patient with DM [modified from 20 & 21]
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Things we need to look for
-Fungus
-Nail care: thickened, damaged, fungal infection
-In growing toe nails +/- infection
-Corns -Callus
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Podiatry Treatment
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If you can’t see it, how can you assess it?
Wound bed preparation & debridement - if required and safe - based on aetiology!
Pre-debridement WA Post-debridement WA
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Remove devitalised tissue and reduce bacterial burden!
Wound bed description and severity in notes is dependent on debridement!
No debridement = eschar (necrosis?) With debridement = granulating
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• Always clean the wound with sterile solution
(saline/water)
• Cover with a sterile dressing
• Monitor the wound, if the
wound deteriorates inform ward doctors
• Refer to Dr Franke Endocrine Consultant
• Refer Podiatry
• Refer Tissue Viability Nurses
Cover & clean all wounds
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Typical
features of
Diabetic Foot
Ulcers
according to
aetiology17
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Images from: International Best Practise Guidelines
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WA Check List
Chronic neuropathic ulcer, 1.5 yrs, A1 TWC
1st PMA – transfer lesion, no pain
100% unhealthy granulation
Size 1.6cm x 1.3cm, 0.3cm, no probing
Macerated fibrotic edges
Periwound macerated callus
Heavy serous exudate, no odour
No overt signs of infection
Wound history/causal factors
Aetiology
Type of wound
Location
Wound bed
Size (PROBING / STATIC = WHY)
Underlying tissues
Wound edges (UNDERMINING?)
Periwound
Exudate type & consistency
Odour
Pain (IN NEUROPATHIC PATIENT?)
INFECTION
Suspicion of malignancy
Classification
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116
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INFECTION: Never underestimate it! Classical Signs? [16]
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PROBING - Hidden Depths
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Stage 1
Haemostasis
- Initial bleeding
- Vasoconstriction of vessels to minimise blood
loss
- Platelet aggregation
- Temporary clot formation
Stage 2
Inflammatory Response
- Release of inflammatory mediators
- Vasodilatation
- Phagocytosis commences
Increased permeability of vessels
Localised swelling, redness & tenderness
- Macrophages release growth factors
- Regulation of healing process
Stage 3
Proliferation
- Macrophages stimulate angiogenesis
- Promotion of new tissue
- Proliferation of connective tissue
- Wound decreases in size by granulation, contraction
and epitheliaslisation
Stage 4
Maturation
- This phase can last for many months# Initially the
scar is red and raised
- In time the blood supply to the area reduces and
the scar will become pale and flatten
Four Stages of wound healing19
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Inform patient of
diabetic foot
emergency advise/
what to look for &
where to get help
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Clinic
Commu
nity
Clinic
LOW No risk factors
Callus alone is considered low risk
Annual screening by trained Healthcare Professional
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The Diabetes Education & Resource Centre
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nity
Clinic
MODERATE
Deformity * or
Neuropathy (loss of sensation) or
Lower limb peripheral arterial disease
Refer to specialist podiatrist
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The Rotherham NHS
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The Diabetes Education & Resource Centre
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Commu
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Commu
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Commu
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Clinic
Commu
nity
Clinic
HIGH
Previous ulceration or
Previous amputation or
On renal replacement therapy (dialysis or transplant) or
Neuropathy (loss of sensation) and lower limb peripheral arterial disease together
or
Neuropathy (loss of sensation) in combination with callus and/or
deformity* or
Lower limb peripheral arterial disease in combination with callus and/or
deformity*
Refer to specialist podiatrist
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The Diabetes Education & Resource Centre
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Commu
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ACTIVE Ulceration or
Spreading infection or
Critical limb ischemia (severe peripheral arterial disease)
Gangrene
Suspicion of acute Charcot foot or an
unexplained hot, red, swollen foot with or without pain
Rapid referral (within one working
day) MDT, for triage within one further working day
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Red, hot, swollen!
https://goutandyou.com/gout-in-pictures/
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Types of off-loading devices KEY: FW = forefoot wounds, MW = midfoot wounds, HW = heel wounds
Non-pneumatic
removable cast
walker (RCW)
(FW, MW)
Heel wedge
half-shoe (HW)
Total contact
insole
(prevention &
post-healing)
Peg-assist
insert, used in
combination
with RCW or
post-op shoe
(FW, MW, HW)
Pneumatic
RCW (FW,
MW)
Total contact
cast (FW, MW)
Forefoot
wedge half-
shoe (FW)
Wound care
rocker shoe
(FW, MW)
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https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116
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Diabetic foot ulcers precede up to 83% of major amputation [22]
Take home message
and 93% of minor amputations [22] 85%are preventab e[23]
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NOW...
Hands on !!
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116
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References 1. International Diabetes Federation. IDF Diabetes Atlas, 7th edn. Brussels, Belgium: International
Diabetes Federation; 2015. 2. Diabetes UK. State of the nation 2016: Time to take control of diabetes. 2016. 3. Public Health England. Cardiovascular disease profile – Diabetes April 2016: NHS Rotherham
CCG. Available at: http://webarchive.nationalarchives.gov.uk/20170302112650/http://www.yhpho.org.uk/ncvincvd/pdf/Diabetes/03L_Diabetes.pdf
4. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2): 217–28.
5. Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med. 2002;19(5):377–84.
6. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Predictive value of foot pressure assessment as part of a population-based diabetes disease management program. Diabetes Care. 2003;26(4):1069–73.
7. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care. 1999;22(3):382–7.
8. Health and Social Care Information Centre. National Foot Care Audit Local Report: Providers. 2014-2016. Available at: content.digital.nhs.uk/footcare
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116
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References 9. Health and Social Care Information Centre. National Diabetes Inpatient Audit 2016. Hospital Level
Analysis – England. Available at: content.digital.nhs.uk/footcare
10. The Yorkshire and Humber Clinical Networks. Yorkshire and the Humber VISUAL Diabetes Footcare
Activity Profile – August 2016. Available at: www.yhscn.nhs.uk
11. Armstrong DG, Lavery LA & Harkless LB. (1998) Validation of a diabetic wound classification
system: The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care,
21(5) pp: 855-859.
12. Cardiovascular disease data and analysis: a guide for health professionals. Diabetes Prevalence
estimates for local population. 2015. Available at: https://www.gov.uk/guidance/cardiovascular-
disease-data-and-analysis-a-guide-for-health-professionals.
13. The Journal of Foot & Ankle Surgery. Diabetic Foot Disorders A Clinical Practise Guideline. Practise
Guideline (2006 revision). 2006. p.S-6.[accessed 07 Oct 2016]. Available from:
http://www.jfas.org/article/S1067-2516(07)60001-5/pdf
14. 14. Diabetes UK. Putting Feet First. Annual foot review for everyone with Diabetes over 12 years
old. 2015. Available from: https://www.diabetes.org.uk/Professionals/Resources/shared-
practice/Footcare/
15. American Diabetes Association. Peripheral Arterial Disease in people with Diabetes. Diabetes Care.
2003; 26(12): 3333-3341. [accessed 14 Oct 2016). Available form:
http://care.diabetesjournals.org/content/26/12/3333.
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116https://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttps://www.gov.uk/guidance/cardiovascular-disease-data-and-analysis-a-guide-for-health-professionalshttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttp://www.jfas.org/article/S1067-2516(07)60001-5/pdfhttps://www.diabetes.org.uk/Professionals/Resources/shared-practice/Footcare/https://www.diabetes.org.uk/Professionals/Resources/shared-practice/Footcare/https://www.diabetes.org.uk/Professionals/Resources/shared-practice/Footcare/http://care.diabetesjournals.org/content/26/12/3333
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References 16. Armstrong DG, Lavery LA and Harkless LB. Validation of a diabetic wound classification system. The
contribution of depth, infection and ischemia to risk of amputation. Diabetes Care. 1998; 21(5): 855-859
17. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds
International, 2013. Available from: www.woundsinternational.com
18. Swanson T, Grothier L, Schultz G. Wound Infection Made Easy,. 2014. Available at
www.woundsinternational.com .
19. Ousey K, McIntosh C. Lower Extremity Wounds. A problems-based learning approach. John Wiley &
Sons, Lts; England. 2008.
20. Boulton AJM. The pathway to foot ulceration in diabetes. Med Clin N Am. 2013; 97(5): 775-
790.
21. Frykberg RG, et al. Diabetic foot disorders: A clinical practice guideline. The Journal of Foot &
Ankle Surgery. 2006; 45(5): S1-S64.
22: Veves A (ed.), Giurinin JM (ed.) and LoGerto FW (ed.). The Diabetic Foot Medical and
Surgical Management. 2010. p. 37. [accessed 07 Oct 2016]. Available from:
file:///C:/Users/Sarah/Desktop/The%20Diabetic%20Foot%203rd%20ed%202012.pdf.
23: International Working Group on the Diabetic Foot. Time to Act. Netherlands; Los Druk &
Design BV Naaran. 2011.
https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=0ahUKEwiwp4rcxc7TAhVkLcAKHaeiAF4QjRwIBw&url=https://commons.wikimedia.org/wiki/File:NHS-Logo.svg&psig=AFQjCNHTax3pC259ICKDEh9xKgCiz3SmDg&ust=1493722941488116http://www.woundsinternational.com/http://www.woundsinternational.com/file:///C:/Users/Sarah/Desktop/The Diabetic Foot 3rd ed 2012.pdf