Poster session 2: Epidemiology - International Symposium on the

Poster session 2: Epidemiology
Impact of secondary cardiovascular risk reduction persists at 10 years
Matthew Young, Royal Infirmary, Edinburgh, United Kingdom
Joanne McCardle, Royal Infirmary, Edinburgh, United Kingdom
Aims: The mortality from diabetic foot ulceration is very high. Cohort studies put the ten year
mortality at around 70% (Morbach). Two case controlled studies have demonstrated that
enhanced cardiovascular risk reduction methods can reduce the mortality over a period of up
to five years. To date no studies have looked beyond five years.
Methods: Two cohorts of diabetes patients attending a single specialist foot clinic were
followed for ten years after first foot ulcer. Cohort A: 202 (63% male) patients treated with
intensive cardiovascular risk reduction therapies (statins, anti-platelets and ACE inhibitors)
and Cohort B: 405 (62% male) historical control patients. Mortality was determined from
national diabetes database records.
Results: Cohort A had significantly lower mortality rates from year 1 (8% vs 16% p=0.005).
However after 10 years this advantage was no longer statistically significant (65% vs 69%
p=0.25). The annual mortality is detailed in Figure 1.
Conclusions: Whilst applying secondary cardiovascular prevention to diabetes foot ulcer
patients appears to delay mortality, the effect is reduced to non-significant levels as disease
progression after 10 years appears to have a greater effect.
Faglia et al. Diabetes Research Clinical Practice 2014;103, 292–297
Morbach et al. Diabetes Care.2012; 35: 2021–2027
Young et al. Diabetes Care 2008 31: 2143-2147.
Mortality over time for both cohorts
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Cardiovascular prevention in patients with diabetic foot
Lia Ferreira, Centro Hospitalar do Porto, Porto, Portugal
Marta Almeida, Centro Hospitalar do Porto, Porto, Portugal
Susana Garrido, Centro Hospitalar do Porto, Porto, Portugal
Maria Teresa Pereira, Centro Hospitalar do Porto, Porto, Portugal
Ana Rita Caldas, Centro Hospitalar do Porto, Porto, Portugal
Raquel Almeida, Centro Hospitalar do Porto, Porto, Portugal
Sara Pinto, Centro Hospitalar do Porto, Porto, Portugal
José Muras, Centro Hospitalar do Porto, Porto, Portugal
Isabel Gonçalves, Centro Hospitalar do Porto, Porto, Portugal
Joana Martins, Centro Hospitalar do Porto, Porto, Portugal
Helena Neto, Centro Hospitalar do Porto, Porto, Portugal
Claúdia Amaral, Centro Hospitalar do Porto, Porto, Portugal
André Carvalho, Centro Hospitalar do Porto, Porto, Portugal
Claúdia Freitas, Centro Hospitalar do Porto, Porto, Portugal
Rui Carvalho, Centro Hospitalar do Porto, Porto, Portugal
Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality
among diabetic patients. To reduce cardiovascular risk, the American Diabetes Association
recommend blood pressure control and treatment with statin and aspirin in those who have
overt CVD as well as in those who have at least one cardiovascular risk factor or target
organ damage.
Objective:The purpose of this study was to evaluate strategies to reduce cardiovascular risk
patients with diabetic foot.
Methods: A retrospective observational study was performed. Patients observed for the first
time in a multidisciplinary outpatient diabetic foot clinic between January and December
2012 were reviewed (n=613). Some data were collected: demographic data, type and
duration of diabetes, HbA1c, micro and macrovascular complications, additional
cardiovascular risk factors and treatment with statin, aspirin or antihypertensive medication.
Results :Patients were mainly men (59.7%), with a mean age of 67.2 years old., 89.7% had
type 2 diabetes, diagnosed 17±11 years before., The average of HbA1c was 8.0%. The
majority had microvascular disease (52.7% retinopathy, 32.9% nephropathy and 75.7%
peripheral neuropathy) or established macrovascular disease [22.9% coronary artery
disease (CAD), 23.4% cerebrovascular disease (CeVD) and 57.4% had peripheral arterial
disease (PAD)]. 83.5% had hypertension, 65.2% dyslipidemia and 12.1% were smokers.
Regarding cardiovascular prevention 73.5%, 52% and 47% were treated with
antihypertensive, statin and aspirin, respectively. These medications were significantly more
frequent in patients with hypertension and dyslipidemia(p <0.05). The percentage of patients
on aspirin was significantly higher in the presence of CAD and CeVD., The percentage of
patients on statin was significantly higher among those with CAD(p <0.05). No differences
were found regarding cardiovascular prevention strategies among patients with PAD.
Conclusions: The level of intervention for reducing cardiovascular risk in this group of
diabetic patients was insufficient. This may reflect an undervaluation of PAD in assessing
cardiovascular risk. It is important to reinforce the need to adopt prevention strategies in
these patients, which can reduce their morbidity and mortality.
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The prevalence of diabetic foot disease
Claire O'Shea, Waikato District Health Board, Hamilton, New Zealand
Aim: The aim of this research project is to establish the prevalence of high risk diabetic foot
Objectives: To determine the prevalence of early diabetic foot disease. To review the use of
a foot screening tool by a non-podiatrist health professional. To obtain data that could help in
planning for podiatry and foot care services in both primary and secondary care by reviewing
the number of people identified with foot disease.
Method: This project will involve those who consent to a foot screen being performed at the
same appointment as their retinal eye screening appointment. This will capture data from,
people with diabetes within a 6 month period from May to November 2014., People referred
to the Diabetes Service mobile retinal photo screening service comprise of all known people
with diabetes in the region other than those with established retinopathy who attend a
specialist eye clinic.,
The health professional performing the foot screening will be trained by the primary
researcher. A random sample of 5% will be independently reviewed by the primary
researcher, to assess the consistency of the screening by the non-podiatrist. Demographic
and descriptive data will be collected using excel and digital photography was used to take
pictures of the feet.,
The Scottish Intercollegiate Guidelines Network diabetic foot risk and stratification and triage
tool will be utilised to categorise the foot status by the lead researcher. The GP will be
notified of the results of the foot screen so any necessary treatment plan can be actioned by
the GP.,
Results: The preliminary results: total population was 3860 people, this project represents
approximately 77% of people with diabetes within the region. 2192 consented to a foot
screen., The risk categories results are low 69.4%, moderate 17.8%, high 12.6%, active
Conclusion: This project will help in providing the needed data on diabetes foot disease for
this population, align with what is occurring internationally and what has shown to be
necessary by national documents produced over the past decade., This foot screening
programme will work in partnership with primary and secondary care and will provide an
objective and sound assessment, to allow comprehensive foot care for people with diabetes.
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The dialysis foot: Is there a difference in foot complications in African Hispanic and
European Americans?
Lawrence Lavery, UT Southwestern, Dallas, United States
Javier LaFontaine, UT Southwestern, Dallas, United States
David Lavery, Statistical Consultant, Denver, United States
Suzanne van Asten, UT Southwestern, Dallas, United States
Aim: In the US there is a large difference in the incidence of diabetes related amputations in
African and Hispanic Americans compared to people of European descent. The aim of this
study is to compare the prevalence of foot complications in a cohort of 327 dialysis patients
with diabetes that were stratified according to race.
Methods: We prospectively evaluated a cohort of dialysis patients with diabetes at 12
centers in Texas for peripheral neuropathy (PN), peripheral arterial disease (PAD), history of
ulcers or amputations and active ulcers. PAD was defined as an ankle-brachial index <0.7,
PN was defined as a vibration perception threshold >25 volts. Comparison of groups of data
was performed using the chi square test.
Results: There was no significant difference in the mentioned foot complications based on
race or gender. 96.3% of subjects had at least one foot complication. 80% of patients with an
amputation history had a leg or thigh level amputation. 26% reported symptoms of
intermittent claudication.
Conclusion: There is no difference in prevalence of diabetic foot complications in dialysis
patients between races. Dialysis patients seem to have more diabetic foot complications
than previously reported numbers in patients without kidney disease.
Outcomes of diabetic foot complications across different races
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Anatomical classification of foot ulcers in "Entities of the DFS"
Dirk Hochlenert, Centrum für Diabetologie, Endoskopie und Wundheilung, Köln, Germany
Gerald Engels, Chirurgische Praxis am Bayenthalgürtel, Köln, Germany
Stephan Morbach, Marienkrankenhaus Soest, Soest, Germany
Aim: We developed a classification of diabetic foot ulcers based on the link between the
localization and the causes. The term „entity“ describes a relatively homogenous clinical
picture with defined localization and biomechanical disorder, probability of PAD and other
causes as well as appropriate measures of offloading and prognostic information.
Methods: Data and photos of 10.037 treatments with extra funding by special contracts with
insurance companies were analyzed. Each photo was related to one of 50 defined areas of
the foot. Risks and treatment results of were analyzed.
Results: The 50 analyzed regions were summarized into 22 entities with comparable
pathobiomechanical situations, offloading concepts and prognosis. Using interdisciplinary
discussion appropriate methods of internal and external offloading could be allocated to
distinct entities.
Conclusions: Defining "entities" uses the association between localization and causes of
the DFS to develop a systematization scheme. This enables the standardization of pressure
redistribution. To shift load from risky areas to parts of the foot which are suitable for weight
bearing is the best method of offloading, as it keeps the patient walking and respects the
overall goal of maintaining mobility. This classification helps to spread the knowledge about
how to obtain this weight redistribution by surgical procedures, devices or accomodative
dressings. It enables a more accurate interdisciplinary discussion between surgeons,
diabetologists and shoemakers about the preferable available techniques or the need of
developing new approaches. The system also enables to estimate the prognosis more
As a result, the “entities of the DFS” shall facilitate the further spreading, scientific discussion
on offloading procedures and their further development.
Hochlenert D, Engels G, Morbach S (2014) Das Diabetische Fußsyndrom - Über die Entität
zur Therapie. Springer Verlag Berlin Heidelberg
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Risk factors for first ever recorded foot ulcer among patients with type 1 and type 2
Sine Hangaard, Steno Diabetes Center, Gentofte, Denmark
Anne Rasmussen, Steno Diabetes Center, Gentofte, Denmark
Thomas Almdal, Department of Medicine F, Gentofte University Hospital, Hellerup, Denmark
Kirsten Engelhard Nielsen, Steno Diabetes Center, Gentofte, Denmark
Annemette Anker Nielsen, Steno Diabetes Center, Gentofte, Denmark
Volkert Siersma, The Research Unit for General Practice, Department of Public Health,
University of Copenhagen, Copenhagen, Denmark
Per Holstein, Department of Dermatology and Copenhagen Wound Healing Center,
Copenhagen, Denmark
Aim: Diabetic foot ulcer (DFU) is a major complication of diabetes with an increasing burden
for health care systems and impaired quality of life for patients. Knowledge of factors
involved in the development of DFU may help in screening strategies to identify patients at
high risk of DFU. The purpose of the present investigation was to identify risk factors for first
recorded DFU over a period of 11 years.
Methods: This cohort study included 4809 patients with type 1 diabetes (T1D) and 5959
patients with type 2 diabetes (T2D) treated at a large diabetes center in Denmark in the
period 2001 to 2011. Patients with a prior or present DFU diagnosis were excluded from the
study. Data on baseline characteristics and comorbidities were collected from electronic
patient records. Influences of various risk factors of incident DFU were assessed as hazard
ratios (HR) from Cox proportional hazard regression models on time from enrolment to DFU
diagnosis or end-of-study (censoring).
Results: The risk of developing DFU over a period of 11 years in patients with T2D was
about 20%, twice that of patients with T1D. Among patients with T1D independent risk
factors for the DFU incidence were high age (HR=1.4-2.5), micro albuminuria (HR=1.9),
reduced vibration sense (HR=1.9-4.0), advanced retinopathy (HR=3.2–3.5), no palpable foot
pulse (HR=2.3) and poor metabolic control (HR=2.2). 69.3% of all identified DFU’s were
found in T1D patients with poor metabolic control at baseline. Among patients with T2D risk
factors were male gender (HR=2.0), reduced vibration sense (HR=3.1-6.0) and advanced
retinopathy (HR=2.7–4.4). 89.6% of all identified DFU’s were found in T2D patients with
reduced vibration sense at baseline.
Conclusions: The present study concludes that T2D patients are more likely to develop
DFU than T1D patients. The identified risk factors for the development of DFU can be used
to identify at-risk patients and when planning primary prevention programs to reduce the rate
of foot ulceration and suggests that different approaches should be used in the two diabetes
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Differences in commonly measurable clinical and biomechanical parameters between
ulcerated and non-ulcerated diabetic neuropathic patients
Roozbeh Naemi, Staffordshire University, Stoke on Trent, United Kingdom
Aoife Healy, Staffordshire University, Stoke on Trent, United Kingdom
T Revathi, India Diabetes Research Foundation, Chennai, India
Lakshmi Sundar, India Diabetes Research Foundation, Chennai, India
Nachi Chockalingam, Staffordshire University, Stoke on Trent, United Kingdom
Anju Pillai, India Diabetes Research Foundation, Chennai, India
Ambady Ramachandran, India Diabetes Research Foundation, Chennai, India
Aim: A variety of risk factors have been identified that contribute to ulceration in previous
investigations (O’Brien, et al. 2014, Monteiro-Soares, et al. 2011). Some studies identified
biomechanical parameters (i.e. limited joint mobility), and neuropathy score measures i.e.
high vibration perception thresholds (VPTs) to be a risk factor for ulceration (Crawford et al,
2007), whilst other studies reported blood biochemical measures like increased Glycated
haemoglobin (HbA1c) to increase ulceration risk (Boyko et al, 2006)., Therefore the aim of
this study was to identify the parameters which can potentially identify patient, at risk of foot
Methods: 70 diabetic patients with neuropathy were recruited from and tested at a diabetes
hospital in South India. Blood biochemical parameters, neuropathy scores, and
biomechanical parameters including ankle and intersegmental foot range of motion and
isometric strength, Romberg balance parameters and Foot Posture Index (FPI) were
measured at the beginning of the study then patients were followed up for 18 months. At the
end of follow-up, 4 patients had ulcerated. Independent t-test was utilised to identify
significant differences (p<0.05) between ulcerated and ulcer free patients.
Results and conclusion: The ulcerated group showed significantly higher: regional and
average VPT scores for both the left (η2= 0.414) and the right foot (η2= 0.394), FPI for right
(η2= 0.107) and left foot (η2= 0.123), load on the right forefoot during standing shod (η2= 0.
304 ) and right mid-foot range of motion (η2= 0. 080).
The significantly lower Anterio-posterior centre of pressure excursion in shod closed eyes
(η2= 0.183) and centre of pressure excursion area during shod open eyes (η2= 0.324) were
observed in ulcerated patients.
Patients with a higher neuropathy score, less centre of pressure variation during standing
and more pronated feet seem to be more vulnerable to ulceration.
Monteiro-Soares, M., et al. (2011). Diabetologia 54.5: 1190-1199.
O’Brien, et al. (2014). Clinical Research on Foot and Ankle, 2(155), 2.
Crawford, F., et al. (2007). Qjm 100.2: 65-86.
Boyko, E.J., et al. (2006). Diabetes care 29.6: 1202-1207.
DiabSmart, FP7-PEOPLE-2011-IAPP, EC Grant Agreement No 285985;
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Comparison of clinical characteristics and medical costs of patients with diabetic foot
ulcer between 2004 and 2012 in China
Yijuan Ban, Diabetes Center, 306th Hospital of PLA, Beijing, China,
Xingwu Ran, West China Hospital Sichuan University, Chengdu, China
Chuan Yang, Sun Yat-sen Memorial Hospital Sun Yat-sen University, Guangzhou, China,
Penghua Wang, Tianjin Medical University Metabolic Diseases Hospital, Tianjin, China,
Zhangrong Xu, Diabetes Center, 306th Hospital of PLA, Beijing, China
Aim: To compare and analyze clinical characteristics, prognosis and medical cost in the
patients with diabetic foot in 2004 and 2012 in China.
Methods: Diabetic foot disease data from 14 teaching hospitals in 2004 and 15 teaching
hospitals in 2012 in China were collected and analyzed.
Results: 386 cases in 2004 and 682 cases in 2012 were recruited. No significant differences
in age, educational level, duration of diabetes, glycosylated hemoglobin A1c, triglyceride,
high density lipoprotein cholesterol, uric acid, prevalence of dyslipidemia, cerebrovascular
and peripheral artery disease, peripheral neuropathy, the percentage of neuropathic or
ischemic foot ulcer, and medical cost between the 2 groups. Duration of diabetic foot was
shorter, more patients with smoking and/or drinking, lower fasting and post-meal glucose,
total cholesteroland and low density lipoprotein cholesterol in 2012 than in 2004. The higher
prevalence of hypertension, coronary heart disease, diabetic kidney disease, diabetic
retinopathy, and more patients with infectious foot ulcer, more patients with severe foot
disease whose foot ulcer classified as Wagner 3 and above or Texas D (76.6% vs 68.7%,
52.4% vs 29.5%,46.7% vs 34.3%;all P<0.05) in 2012. There were significantly lower
major amputation rate, higher ulcer healing rate, shorter hospital stay(2.3% vs 5.9%,52.3%
vs 18.2%,18(12-32) vs 21(15-32) d,all P<0.05 ), but higher total amputation rate (17.2%
vs 10.2%,P<0.05) in 2012. Medical cost for these patients in 2012 and 2004 was
17183(9535~30599) vs 12364(7985~18725) Yuan, no significant difference after consumer
price index corrected.
Conclusions: The patients with diabetic foot disease in 2004 and 2012 were older, with
more men, low educational level, long duration of diabetes, poor control of hyperglycemia,
high medical cost and with more cardiovascular risk factors and diabetic complications.
Compared with the patients in 2004, patients with diabetic foot in 2012 had more
concomitant diseases and complications, with more severe foot ulcers and infections, higher
total amputation rate, but lower major amputation rate, higher ulcer healing rate, and shorter
hospital stay.Fund:The military clinical major projects of advanced technology (2010gxjs054)
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Long-term prognosis of diabetic patients with a first foot ulcer
Susana Garrido, Centro Hospitalar do Porto, Porto, Portugal
Jorge Dores, Centro Hospitalar do Porto, Porto, Portugal
Cláudia Amaral, Centro Hospitalar do Porto, Porto, Portugal
Cláudia Freitas, Centro Hospitalar do Porto, Porto, Portugal
Helena Neto, Centro Hospitalar do Porto, Porto, Portugal
Rosa Guimarães, Centro Hospitalar do Porto, Porto, Portugal
Sara Pinto, Centro Hospitalar do Porto, Porto, Portugal
Joana Martins, Centro Hospitalar do Porto, Porto, Portugal
Isabel Gonçalves, Centro Hospitalar do Porto, Porto, Portugal
José Muras, Centro Hospitalar do Porto, Porto, Portugal
André Carvalho, Centro Hospitalar do Porto, Porto, Portugal
Rui Carvalho, Centro Hospitalar do Porto, Porto, Portugal
Background: Diabetic foot ulcer (DFU) is a major cause of morbidity and mortality in
patients with diabetes. There is insufficient data on long-term outcomes in patients with a
first DFU.
Aims: To evaluate the 5-year outcomes of diabetic patients with a first DFU, concerning
amputations and all-cause mortality, and to analyze the clinical and demographic variables
related with mortality.,
Methods: Retrospective analysis of clinical data of patients with a DFU attending for the first
time our Diabetic Foot Clinic during 2008. Patients with history of previous DFU were
excluded, as were those with missing relevant data. Statistical analysis was performed using
descriptive and inferential statistics as appropriate.
Results: Of the 248 patients included in the study, 54 0% were male and 94 3% had type 2
diabetes. The median age at presentation was 70 years (IQR=16) and the median diabetes
duration was 15 years (IQR=14). Ulcers were neuropathic in 37 0% of the patients and
neuroischemic/ischemic in 63 0%. During the 5-year period, a total of 31 9% of the patients
had at least one minor amputation and 23 7% a major amputation. The 5-year mortality rate
was 45 3% for the entire group. Patients with neuroischemic/ischemic foot had a higher
mortality rate (54 2% vs 28 9%, p<0 001). Patients who died were older at presentation
(median age 75 years, IQR 12 vs 64 years, IQR=16; p<0 001) and had longer diabetes
duration (median duration 15 years, IQR 20 vs 14 years, IQR=14; p=0 03). Other factors
associated with a higher mortality were: ischemic heart disease (p=0 005), cerebrovascular
disease (p<0 001), peripheral arterial disease (p<0 001) and hypertension (p=0 001). None
of the other clinical and demographic variables tested were related with this outcome.
Conclusion: DFU is associated with high amputation and mortality rates, especially among
older patients with longer diabetes duration, history of macrovascular disease and
hypertension. These patients must be carefully followed and managed by multidisciplinary
Acknowledgements: The authors thank A.Cruz, A.Serra, A.Silva, J.Correa, J.Vale,
J.Cardoso, M.Laranjo, M.Gonçalves, M.Barreira, M.Fernandes, R.Rodrigues, R.Pereira,
V.Tavares, medical students of ICBAS-UP, who contributed to the data collecting process
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Diabetes versus the rest: who has the greatest foot disease burden in our inpatient
Peter Lazzarini, Queensland University of Technology, Brisbane, Australia
Vanessa Ng, Queensland Health, Brisbane, Australia
Suzanne Kuys, Griffith University, Gold Coast, Australia
Maarten Kamp, Queensland University of Technology, Brisbane, Australia
Michael d'Emden, Queensland Health, Brisbane, Australia
Courtney Thomas, Queensland Health, Mount Isa, Australia
Jude Wills, Queensland Health, Rockhampton, Australia
Ewan Kinnear, Queensland Health, Brisbane, Australia
Scott Jen, Queensland Health, Ipswich, Australia
Sheree Hurn, Queensland University of Technology, Brisbane, Australia
Lloyd Reed, Queensland University of Technology, Brisbane, Australia
Aim: Foot disease causes large numbers of hospitalisations, yet the exact prevalence is
unclear., The aims of this paper were to investigate the point-prevalence of different foot
complications in general inpatient populations, and, analyse differences in diabetes and nondiabetes sub-groups.
Methods:, Eligible participants were all adults admitted overnight for any reason into five
diverse hospitals on one day; excluding maternity, mental health and cognitively impaired.
Participants underwent a physical foot examination by trained podiatrists to clinically
diagnose foot complications using validated measures, including: wounds, infections,
deformity, peripheral arterial disease (PAD) and peripheral neuropathy (PN)., Demographic,
social determinant, medical history, foot disease history, self-care, footwear and reason for
admission variables were also collected.
Results: Overall, 733 (83%) of 883 eligible participants consented; mean±SD age 62±19
years, 480 (55.8%) male, 172 (23.5% (95% CI) (20.5-26.7)) had diabetes., Foot
complications were a reason for admission in 11.2% (9.1-13.7) of participants., Diabetes
inpatients had significantly higher prevalence of foot complications as a reason for admission
than non-diabetes (19.8% vs 8.6%; p < 0.001)., Foot complication prevalence included:
wounds 9.0% (5.1-8.7), infections 3.3% (2.2-4.9), deformity 22.4% (19.5-26.7), PAD 21.0%
(18.2-24.1) and PN 22.0% (19.1-25.1)., Diabetes inpatients had significantly higher foot
complication prevalence than non-diabetes (p < 0.01); wounds (15.7% vs 7.0%), infections
(7.1% vs 2.2%), deformity (30.5% vs 19.9%), PAD (35.1% vs 16.7%) and PN (43.3% vs
15.4%)., In backwards stepwise multivariate analyses diabetes inpatients were
independently associated (OR (95% CI) with PN (4.2 (2.8-6.3), PAD (2.1 (1.4-3.2)) and
wounds (2.3 (1.3-3.9)).,
Conclusion: Findings indicate one in every ten inpatients, and one in five with diabetes, had
been hospitalised with a foot complication as a reason., Diabetes was independently
associated with inpatient foot complications and had significantly higher prevalence of all
foot complications than non-diabetes inpatients., Further research is required to tackle this
large inpatient foot complication burden, particular in diabetes inpatients.
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