Michael Edmonds is professor of Diabetic Foot Medicine, King’s College London, and consultant physician, King’s College Hospital, London, UK. A pioneer in many areas of the diabetic foot, Edmonds speaks about his interest in diabetes and its treatment, the success of the Diabetic Foot Service and Clinic at King’s College Hospital, and his most memorable career points.
Why did you decide you wanted a career in medicine, and why in particular did you choose to enter the diabetes field?
I loved both arts and science at school, especially history and biology, and could not decide at 16 years whether to go down the arts or science route. Medicine had a great attraction as it was both a science and an art. In my later years, I have been impressed by physicians who have emphasised the art of medicine especially Sir William Osler, one of whose aphorisms, admittedly at the beginning of the 20th century, was that “medicine is a science of uncertainty and an art of probability“.
As to diabetes, I was always excited in my general medical training when a diabetic coma patient came into Casualty. Over the next 12 hours, it was fascinating to quickly restore metabolic balance, usually with very good outcomes, and this attracted me to diabetes. To further my career in diabetes, I was fortunate to get a research fellowship at King’s College Hospital, London. Who have been your career mentors and what wisdom did they impart? My research fellowship was to study blood flow in the neuropathic foot under the supervision of Dr Peter Watkins who was an inspirational and charismatic expert on diabetic neuropathy. He declared that “the diabetic foot is uncharted territory” and encouraged me to concentrate my research into the diabetic foot, which I did under his expert guidance.
What has been the biggest development(s) in the treatment of diabetes during the course of your career?
Technology has had a major impact. Just before I started in diabetes, a patient had to go to a hospital lab for measurement of blood glucose. Patients can now access sophisticated home glucose monitoring systems that comprise simply a small sensor that measures continuous real-time blood glucose just under the skin every five minutes for up to seven days. A transmitter that is attached on top of the sensor sends data wirelessly to a suitable smart device. Information about the trends in blood glucose rather than a one-off reading can greatly help patients to improve their blood glucose control.
What are some of the proudest moments in your career?
One moment was the publication of our paper, reporting the development of one of the first multidisciplinary diabetic foot clinics: Edmonds ME, Blundell MP, Morris HE, Thomas EM, Cotton LT, Watkins PJ. Improved survival of the diabetic foot: the role of a specialised foot clinic (Quart J Med1986; 232:763–71). When I started my research, I looked for neuropathic feet, in which to measure blood flow, but most of these feet were ulcerated and often infected, which of itself would have affected blood flow. We had to get these feet healed and we thought it best that the various clinicians involved should see the patient together. This led to the development of a multidisciplinary diabetic foot clinic that opened in May 1981 and brought together a diabetic foot team comprising chiropodist (otherwise known as a podiatrist), nurse, orthotist, surgeon and diabetologist. It was able to achieve a high ulcer healing rate and a 50% reduction in major amputations from 1981 to 1984. This target was adopted by the World Health Organization in 1989, which set a five-year target of 50% reduction of major amputations in Europe in the so-called St Vincent Declaration. Overall, the foot clinic had three main aims: to provide the best possible care for patients with diabetic foot problems, to educate healthcare professionals to deliver such care, and to research into the causes of diabetic foot complications. In 2000, I co-authored a textbook, Managing the Diabetic Foot, which was later translated into Spanish and Japanese. It went into a second edition in 2005, which was also translated into Japanese and subsequently the third edition in 2014.
In 2011, I received The International Diabetic Foot Award, given every four years, at a meeting attended by over 75 countries, for outstanding contributions to diabetic foot care. The citation said “He had been a true pioneer in many areas of the diabetic foot… he devoted most of his professional work to people with diabetes and foot problems all over the world. Due to his relentless energy, he inspired many others to follow his path… he can be considered one of the founding fathers of the diabetic foot.”
What new vascular technology are you watching closely and why?
A specific vascular problem in the diabetic foot is severe occlusive disease below the ankle. This often results in the “desert foot” otherwise called “no-option ischaemia” where it is not possible to image any arteries in the foot. Attempts to tackle this situation have included venous arterialisation in which arterial blood is directed into the deep venous circulation. Recently, the LimFlow technique, which is a percutaneous deep vein arterialisation system, has been developed with initial promising clinical data in diabetic patients.
What is the most interesting paper on diabetic foot medicine that you have seen recently?
The paper is entitled Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South West of England (RB Paisey, A Abbott, R Levenson, A Harrington, D Browne, J Moore, M Bamford, M Roe, Diabetic Medicine 2018; 35:53–62). In 2012, the South West had one of the highest major amputation rates in England. A group of clinicians decided on the 10 most important service elements of a diabetic foot programme and worked with individual healthcare districts to encourage them to implement these elements. Services introduced included standardised general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist, administrative support and audit.
Introduction of more effective service provision resulted in significant reductions in major amputation incidence within two years.
Between 2013 and 2015, the amputation rates fell in those healthcare districts in which these service elements had been implemented but did not fall in areas where no improvements had been made.
With the number of people living with diabetes increasing year on year, how do you think it will be possible to tackle this epidemic and its vascular consequences?
Although type 1 diabetes is not affected by lifestyle, type 2 diabetes is often caused by a lifestyle of obesity and lack of exercise. It is preventable and there is now evidence that population prevention programmes can work.
Interventions to support populations to keep to a beneficial diet and maintain a healthy weight have been successful in the prevention of type 2 diabetes. For those patients who already have diabetes, very good control of the blood glucose, as well as the blood pressure, will prevent microvascular complications. The situation regarding the prevention of macrovascular complications is not so clear. Although blood glucose control is necessary, together with cessation of smoking, prevention of hypertension and hypercholesterolemia is more effective than glucose lowering therapy.
You have seen a reduction in amputations with the Diabetic Foot Service and Clinic at King’s College Hospital. How has this been achieved?
It is important to appreciate that three great pathologies come together in the diabetic foot: neuropathy, ischaemia and infection. Neuropathy often delays the patients’ presentation with ischaemia because they do not have pain and may not take their condition seriously. This is a mistake that can also be made by the medical attendants, who have been educated in a diagnostic process that assumes pain is a reliable indicator of the seriousness of the presentation.
This is not true in the diabetic foot. In this background of neuropathy, infection and ischaemia are the two drivers that are responsible for the progression to tissue necrosis, which is the fundamental hallmark of the natural history of the diabetic foot. Progression of infection from initial break in the skin to the classical “wet” diabetic gangrene can take as little as 48 hours.
Staphylococci and streptococci as well as other bacteria can easily invade open wounds and cause thrombosis in the small arteries leading to a rapid reduction in blood supply to the foot. To treat such a problem, it is important to provide a special form of care for the diabetic foot patient, including open access to the clinic and a fast track one stop vascular service.
Offering a rapid and open access service allows the patient to be seen at the earliest possible moment and encourages early presentation. This facilitates early diagnosis and treatment for diabetic patients with new foot problems, especially infection. Rapid admission to hospital can also be arranged through this open access service. The patient with suspected ischaemia is seen in the fast-track, one-stop vascular service in which investigations are carried out, results reviewed and treatment implemented—all in the same day. It is attended by a vascular surgeon, podiatrist, nurse and diabetologist.
After initial examination to assess tissue loss and possible infection, duplex angiography is carried out in the vascular laboratory, and then a decision on revascularisation is made. This may be initially angioplasty and can be carried out as a day case where appropriate.
Alternatively, arterial bypass, often a distal bypass or a hybrid procedure, may be indicated. The combination of the low-tech support of effective organisational strategies such as open access to foot clinics, combined with the high tech of interventional revascularisation strategies, has proved very effective in the care of the ischaemic diabetic foot patient.
In your opinion, what is the importance of initiatives such as ilegx to tackle the global problem of major amputations?
The aim of the ilegx philosophy was to achieve the early diagnosis of the causes of leg/foot tissue loss and to promote early intervention with interdisciplinary collaboration in the management of these conditions. It was an important initiative started in 2008 and it will be celebrating its 10th anniversary at the Charing Cross meeting in 2018.
The development of this philosophy led to an ilegx algorithm that reviews both diagnosis and definitive management of leg/foot tissue loss, dividing the aetiologies into vascular and non-vascular causes. The category of vascular ulcers (70%) comprises ischaemic arterial, renal arterial, diabetic arterial, inflammatory, venous and lymphatic ulcers caused by derangement of macro- as well as microvascular pathophysiology; non-vascular ulcers (30%) are defined as caused by non-arterial diabetic pathological changes, pressure and a variety of other causes.
The ilegx algorithm, in the shape of a turning wheel, highlights the diagnostic approach and reminds the specialist of key management steps and which disciplines he should include given a particular diagnosis. It is a powerful tool which simplifies this highly complex disease area. The majority of major amputations are preventable both in the diabetic and non-diabetic foot and early referral and interdisciplinary work are the key to save legs and fulfil the ilegx vision to reduce significantly the global number of lower limb amputations.
Could you tell us about one of your most memorable cases?
A diabetic patient developed a large blister on the right foot and attended the Foot Clinic. There was no obvious spreading infection but he had local cellulitis and a body temperature of 37.7°C and it was decided to admit him. He insisted on going home first because he wished to take his car home as it was parked in the hospital car park. He said that he would leave his car at home and ask his brother to bring him to the hospital. He was brought back by his brother later that afternoon. In two hours, he had become extremely ill with a temperature of 40.2°C. He was drowsy and shivering and had a spreading cellulitis. Blood pressure was 90/60mmHg. Blood cultures grew Staphylococcus aureus and group G Streptococcus.
He was resuscitated, given intravenous antibiotics and recovered. The blister developed into an area of necrosis but this gradually improved. He was discharged after 10 days.
I learnt that diabetic foot infections can proceed rapidly. Initially, the diabetic patient can seem well with minimal local and systemic signs of infection. It is important to pay attention even to a slight rise in of body temperature in a diabetic patient. A diabetic foot patient can be sat up reading the newspaper and then within an hour or two can “crash”.
What are some of your hobbies and interests outside of medicine?
I have always had an interest in sport and played cricket and football for my medical school in King’s College, London. Since the age of eight, I have been a fan of the Manchester United football team and also the England cricket team who at the time of this interview is trailing 2–0 to Australia in a five-match series in Australia! Whilst studying medicine, I completed a diploma in theology (Associateship of King’s College, AKC). This triggered a lifelong interest in theology and its expression in the world’s religions and in particular its representation in Christianity. I am also Chair of the Elders of the local Christian United Church.