Dr Peta Tehan

Objective: Pedal acceleration time (PAT) is a novel method of using diagnostic ultrasound to evaluate the haemodynamic characteristics of pedal arteries and has potential as an adjunctive vascular testing method. The primary objective of this study was to assess the diagnostic accuracy of PAT in identifying peripheral artery disease (PAD) in a population with clinically suspected PAD. Methods: This was a multicentre cross sectional study to estimate the diagnostic test accuracy. Participants with clinically suspected PAD were recruited via consecutive sampling at four centres. Colour duplex ultrasound (reference standard) and toe brachial index (TBI) were measured by a vascular sonographer. A second vascular sonographer, blinded to all other measures, conducted the PAT measurements on the same limb. PAD was defined as a > 50% stenosis in any vessel from the distal aorta to the foot. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were estimated for all PAT values. Receiver operating characteristic curves were also generated. Results: One hundred and eighty-eight participants (227 limbs) were recruited, with a mean age of 71 years (standard deviation 10, range 43 ¿ 93) with 56 women (29.8%) including 133 (70.7) limbs having PAD (59%) and 61 (32.4%) claudicants. Area under the curve for PAT: lateral plantar artery 0.72 (0.65 ¿ 0.79), medial plantar artery 0.72 (0.65 ¿ 0.79), dorsal metatarsal artery 0.77 (0.70 ¿ 0.84), arcuate artery 0.71 (0.64 ¿ 0.78), and deep plantar artery 0.73 (0.67 ¿ 0.80). Utilising the worst case PAT measure for the limb for identifying PAD had an AUC of 0.79 (0.74 ¿ 0.85) and positive and negative predictive values of 0.81 (0.57 ¿ 0.89) and 0.66 (0.57 ¿ 0.75), respectively. Area under the curve for the toe brachial index was 0.78 (0.71 ¿ 0.85) and that of ankle brachial index was 0.70 (0.62 ¿ 0.77). Conclusion: PAT had an acceptable diagnostic test accuracy as an assessment tool to identify PAD in a population with clinically suspected PAD. All five measures yielded similar accuracy to toe pressure and TBI; however, using the worst case PAT value yielded the highest diagnostic test accuracy of all PAT measures. The PAT diagnostic threshold for the presence of PAD may be revised to > 85 ms to optimise the performance of the test for the identification of PAD.

Aim: Charcot neuro-osteoarthropathy (CNO) is a rare but serious inflammatory process in individuals with peripheral polyneuropathy leading to the development of fractures, dislocations and permanent foot deformity. Most commonly, CNO occurs in individuals with diabetes and the progression of significant foot deformity can predispose the individual to pressure-related ulcerations and increased risk of lower limb amputation. The lived experience of the individual with CNO is largely unknown. This study aims to explore the lived experience of individuals affected by active CNO and CNO in remission in Australia. Methods: This was a qualitative study using semi-structured interviews of a heterogeneous purposeful sample of individuals with CNO from a high-risk foot service in Australia. Interview questions were related to the physical, financial, social and emotional impacts of CNO and were developed based on the validated SF-36 outcome measure tool. A reflexive thematic analysis approach was used to analyse the dataset. Results: Fourteen participants were recruited including seven males, seven females with age ranging from 36 to 74¿years. Four themes were derived: (1) A burden to family and caregivers and feeling isolated and alone. (2) A lack of certainty relating to outcomes leading to increased anxiety. (3) Adaptive health behaviour changes made as a result of the CNO diagnosis. and (4) Limited access to healthcare information and healthcare support systems. Conclusions: The burden of CNO extends beyond the physical limitations of living with a significant foot deformity and the associated increased risk for further limb threatening complications. Individuals with CNO report feelings of increased anxiety, a loss of independence and feel they are a burden to their family impacting on their individual roles at home, including the ability to provide financially. This should be considered when managing individuals with CNO, with more holistic approaches to care required. This research highlights that increased engagement with mental health support services, social work and peer-group support along with greater access to evidence-based information on the management of CNO may better support the psycho-social needs of this population.

Aim To achieve consensus on priorities for chronic wound research in Australia. Methods A three-round modified online Delphi survey using RAND/UCLA methods was undertaken to seek consensus from a random sample of Australian multidisciplinary expert chronic wound practitioners and researchers. Participants rated their agreement/disagreement on a nine-point Likert scale for each potential research topic. Customised software calculated median scale scores and 30¿70% inter-percentile range for each item. Results A sample of 20 practitioners and researchers were invited and 12 agreed to participate. After three rounds, 102 topics achieved consensus as national priorities, including 26 items on diabetes-related foot ulcers, 25 on pressure injuries, 17 on mixed chronic wounds, and 16 on venous leg ulcers. The highest rated topics included pain management, compression therapy to prevent venous leg ulcers, pressure injury management for heels and wheelchair users, and compression therapy adherence. Conclusion This study found that while diabetes-related foot ulcers and pressure injury topics had the greatest number of consensus national priority topics for chronic wound research in Australia, pain management, compression therapy for venous leg ulcers and pressure injury management were the highest rated priorities. These findings could be used to target funding for national grant schemes.

Importance: The economic value of cleaning and disinfection of shared medical equipment is currently unknown. Objective: To evaluate whether or not better environmental cleaning and disinfection of shared medical equipment would be cost-effective compared with usual care. Design, Setting, and Participants: This economic evaluation study was a within-trial cost-effectiveness analysis of a stepped-wedge cluster randomized clinical trial: the Cleaning and Enhanced Disinfection (CLEEN) study. The trial included 5002 inpatients and was conducted in 10 adult acute-care wards at a tertiary hospital in Australia between March 20, 2023, and November 24, 2023. The evaluation takes a hospital costing perspective. A decision-tree model was developed to evaluate the intervention; costs are presented in Australian dollars. Statistical analysis was performed from May to October 2024. Interventions: A multimodal cleaning intervention was introduced during the intervention, focusing on additional cleaning hours, education, audit, and feedback. The control group received usual care, including routine cleaning by clinical staff. Main Outcomes and Measures: Incremental cost-effectiveness ratio, where the mean change to costs associated with the intervention is divided by the mean change in outcomes. Results: This study assessed 5002 patients (2478 [49.5%] male, 2524 [50.5%] female [50.5%]; mean [SD] age, 71.6 [16.1] years). For a cohort of 1000 patients at risk of health care-associated infection (HAI), the estimated total costs associated with the intervention were $1513300, compared with $2155310 for usual care. The estimated number of HAIs was 100 in the intervention group, compared with 130 for the usual care group. Compared with usual care, the intervention was associated with reduced HAIs and costs, with a 90.5% chance that intervention adoption was cost-saving. This probability increased to 99.9% if a decision-maker was willing to pay $20000 to avoid an infection. Conclusions and Relevance: In this economic evaluation study of enhanced cleaning and disinfection of shared medical equipment, the intervention resulted in reduced HAIs and a $642010 reduction in costs per 1000 patients, compared with the control group. These results suggest that the CLEEN intervention is a cost-saving initiative.

Background: Diabetes related foot ulcer (DFU) is a leading cause of impaired quality of life, disability, hospitalisation, amputation and mortality in people with diabetes. It is therefore critical that podiatrists across all settings, including community settings, are confident and capable of providing care for diabetes-related foot complications. This study aims to describe current practice, confidence and anxiety levels of community podiatrists in the management of patients with foot ulceration. Furthermore, current barriers to service provision and interest in future educational opportunities will also be explored. Methods: An online cross-sectional survey was distributed to Australian community podiatrists. Descriptive variables including gender, age, professional experience, practice location and practise setting were elicited. A modified competitive State Anxiety Inventory-2 (CSAI-2) was utilised to measure anxiety related to managing a foot ulcer. Other questions included a combination of multiple choice and open-ended free-text responses relating to assessment, confidence and referral pathways. Results: One hundred and twenty-two Australian community-based podiatrists responded to the survey. A variety of ulcer sizes and complexity were reported to be managed in community settings. Confidence in DFU management was high in most manual skill domains including: stabilisation of the foot (85.7%, standard deviation [SD] 17.42), scalpel control (83.0%, SD 20.02), debridement with a scalpel (82.7%, SD 18.19) and aseptic technique (81.0%, SD 18.62, maintaining integrity of healthy tissue (77.3%, SD 21.11), removal of appropriate tissue (75.6%, SD 22.53), depth of ulceration (73.7%, SD 23.99) and ability to manage messy wounds (69.1%, SD 26.04). Curette debridement had substantially lower levels of reported confidence (41.0%, SD 34.24). Performance anxiety was low with somatic and cognitive anxiety of 6/24 and 3/8 on the CSAI-2, respectively. Conclusion: Community podiatrists are managing foot ulcers of varying size and complexity. Confidence and anxiety do not pose a barrier to care. Adherence to wound assessment clinical guidelines is low and confidence with the use of curette was sub-optimal. Further educational programs may overcome these barriers and support shared models of care between community and acute podiatry services.

Determine how healthcare professionals perceive their role in nutrition assessment and management, and explore barriers and enablers to assessment and management of nutrition in individuals with DFU. Mixed methods including a cross-sectional online survey derived from current international guidelines and theoretical domains framework, and semi-structured interviews with conventional content analysis was performed. One hundred and ninety-one participants completed the survey, with 19 participating in interviews. Many health professionals are not confident in their ability in this area of practice, are uncertain their nutrition advice or management will be effective in assisting wound healing outcomes and are uncertain their intervention would result in adequate behaviour change by the individual with DFU. Major barriers to implementation of nutrition assessment and management were: inadequate time, lack of knowledge and lack of clinical guidance and enablers were as follows: professional development, a standardised clinical pathway and screening tool and a resource addressing wound healing and diabetes management. Nutrition assessment and management in individuals with DFU is not consistently applied. Whilst health professionals believed nutrition was important for wound healing, they lacked confidence in implementing into their practice. Further dissemination of existing guidance and implementation of education programs and resources would help overcome cited barriers.

Background: Diabetes-related foot disease (DFD) is a leading cause of the Australian and global disease burdens and requires proportionate volumes of research to address. Bibliometric analyses are rigorous methods for exploring total research publications in a field to help identify volume trends, gaps and emerging areas of need. This bibliometric review aimed to explore the volume, authors, institutions, journals, collaborating countries, research types and funding sources of Australian publications investigating DFD over 50¿years. Methods: A systematic search of the Scopus® database was conducted by two independent authors to identify all Australian DFD literature published between 1970 and 2023. Bibliometric meta-data were extracted from Scopus®, analyzed in Biblioshiny, an R Statistical Software interface, and publication volumes, authors, institutions, journals and collaborative countries were described. Publications were also categorised for research type and funding source. Results: Overall, 332 eligible publications were included. Publication volume increased steadily over time, with largest volumes (78%) and a 7-fold increase over the last decade. Mean co-authors per publication was 5.6, mean journal impact factor was 2.9 and median citation was 9 (IQR2-24). Most frequent authors were Peter Lazzarini (14%), Vivienne Chuter (8%) and Jonathon Golledge (7%). Most frequent institutions affiliated were Queensland University Technology (33%), University Sydney (30%) and James Cook University (25%). Most frequent journals published in were Journal Foot and Ankle Research (17%), Diabetic Medicine (7%), Journal Diabetes and its Complications (4%) and International Wound Journal (4%). Most frequent collaborating countries were the United Kingdom (9%), the Netherlands (6%) and the United States (5%). Leading research types were etiology (38%), treatment evaluation (25%) and health services research (13%). Leading funding sources were no funding (60%), internal institution (16%) and industry/philanthropic/international (10%). Conclusions: Australian DFD research increased steadily until more dramatic increases were seen over the past decade. Most research received no funding and mainly investigated etiology, existing treatments or health services. Australian DFD researchers appear to be very productive, particularly in recent times, despite minimal funding indicating their resilience. However, if the field is to continue to rapidly grow and address the very large national DFD burden, much more research funding is needed in Australia, especially targeting prevention and clinical trials of new treatments in DFD.

Background: Hospital-acquired pneumonia (HAP) also known as non-ventilator associated pneumonia, is one of the most common infections acquired in hospitalised patients. Improving oral hygiene appears to reduce the incidence of HAP. This study aimed to describe current practices, barriers and facilitators, knowledge and educational preferences of registered nurses performing oral health care in the Australian hospital setting, with a focus on the prevention of HAP. We present this as a short research report. Methods: We undertook a cross sectional online anonymous survey of Australian registered nurses. Participants were recruited via electronic distribution through existing professional networks and social media. The survey used was modified from an existing survey on oral care practice. Results: The survey was completed by 179 participants. Hand hygiene was considered a very important strategy to prevent pneumonia (n = 90, 58%), while 45% (n = 71) felt that oral care was very important. The most highly reported barriers for providing oral care included: an uncooperative patient; inadequate staffing; and a lack of oral hygiene requisite. Patients' reminders, prompts and the provision of toothbrushes were common ways believed to help facilitate improvements in oral care. Conclusion: Findings from this survey will be used in conjunction with consumer feedback, to help inform a planned multi-centre randomised trial, the Hospital Acquired Pneumonia PrEveNtion (HAPPEN) study, aimed at reducing the incidence of HAP. Findings may also be useful for informing studies and quality improvement initiatives aimed at improving oral care to reduce the incidence of HAP.

Introduction: Current guidelines for noninvasive lower limb vascular testing specify a preference for toe brachial pressure measurement to aid in the diagnosis of peripheral arterial disease populations with high suspicion of peripheral vessel calcification, such as those with kidney failure with replacement therapy. Objectives: The aim was to identify the current literature on toe systolic blood pressure and toe brachial pressure index for individuals with kidney failure who are receiving replacement therapy. Design: A scoping review. Methods: MEDLINE, CINAHL, AMED and SPORTDiscus were systematically searched between July 15 and July 30, 2023. The scoping review followed the Arksey and O'Malley framework, with data reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for scoping reviews. Results: Sixteen studies were included in the review. There was limited data examining the significance of toe systolic blood pressure and toe brachial pressure index during a dialysis session. There were differences in the normative values for toe brachial pressure index values used in the studies and limited reporting on the measurement protocols used to determine toe systolic blood pressure and toe brachial pressure index. Conclusion: The review found limited data examining the clinical utility of toe systolic blood pressure and toe brachial pressure index in populations receiving dialysis. The use of toe systolic blood pressure and toe-brachial index to identify peripheral artery disease in this population is important. However, there is limited evidence and conflicting information on measurement protocols, reliability, diagnostic accuracy, and prognostic capacity.

Background: Despite the important role that cleaning plays in reducing the risk of healthcare-associated infections, no research has been undertaken to quantify the time required for effective cleaning and disinfection of different pieces of shared medical equipment commonly used in hospitals. This short report presents the results from a study that aimed to quantify the time required to clean common pieces of shared medical equipment effectively. Methods: An observational time and motion study was conducted in a nursing simulation laboratory to determine the time required for effective cleaning and disinfection of 12 pieces of shared medical equipment commonly used in hospital. After training, the participants cleaned and disinfected equipment, with the time taken to clean recorded. Cleaning was deemed to be effective if =80% of ultraviolet fluorescent dots were removed during the cleaning process. Main results: The time to clean equipment effectively ranged from 50 s [blood glucose testing kit; 95% confidence interval (CI) 0:40¿1:00 (min:s)] to 3 min 53 s [medication trolley; 95% CI 3:36¿4:11 (min:s)]. The intravenous stand was cleaned most effectively, with 100% of dots removed (N = 100 dots). In contrast, the bladder scanner was the most difficult to clean, with 12 attempts required to meet the 80% threshold for effective cleaning. Conclusion: This study will inform staffing and training requirements to plan the cleaning and disinfection of shared medical equipment effectively. The findings can also be used for business cases, and in future cost-effectiveness evaluations of cleaning interventions that include shared medical equipment.

Introduction: Sesamoiditis is a common, and often painful, musculoskeletal pathology frequently encountered by podiatrists. However, there are currently no recommendations to guide podiatrists in the assessment and management of people with sesamoiditis. The aim of this study was to develop consensus-driven clinical recommendations on the assessment and management of people with sesamoiditis. Methods: A four-round online Delphi survey was conducted with a panel of New Zealand and Australian podiatrists. In the first round, panellists answered open-ended questions that were used to create statements. In round two, the panellists scored the statements from 1 to 9 (1¿=¿not at all important, 9¿=¿absolutely essential). Consensus was defined using the RAND/University of California Los Angles Disagreement Index. Panellists were asked to reconsider statements that did not achieve consensus in round three. In the final round, content validity and acceptability of the statements for inclusion in clinical recommendations were determined using content validity ratios and the Content Validity Index (CVI). Results: Eighteen panellists completed round one with 16 (89%) completing all four rounds. A total of 118 statements were generated following round one. Following rounds two and three, 78 statements were accepted by panellists as being important, with 62 statements achieving sufficient content validity for inclusion in clinical recommendations. The CVI for these 62 statements was 0.58. These recommendations provide guidance on subjective assessment (pain characteristics/symptomology, activity/sports/training history and medical history) objective assessment (establishing a diagnosis, identifying contributing biomechanical factors, footwear/orthoses, ruling out differential diagnoses) and management (temporary padding/strapping, education, footwear, foot orthoses and when to consider referral). Conclusion: This consensus exercise has provided a set of consensus-based recommendations for the assessment and management of people with sesamoiditis. In the current absence of research-based evidence in this area, these recommendations are intended to support clinicians. The recommendations may also serve as a basis for future clinical trials evaluating the efficacy of conservative interventions for people with sesamoiditis.

Rest pain, ulceration and gangrene are hallmark features of chronic limb-threatening ischaemia (CLTI). Wound healing can be challenging, and this is compounded by an inability to measure lower limb perfusion via non-invasive tools such as toe pressure (TP). Novel perfusion tests, such as pedal acceleration time (PAT), may overcome some limitations. This study aimed to quantify the proportion of patients with CLTI that were unable to undergo TP measurement. Over a three-year duration, 344 consecutive patients with CLTI underwent PAT assessment (403 limbs). Overall, 32% of limbs were unable to undergo first toe TP, and 12.9% were unable to undergo first and second toe TP due to forefoot/digit amputation or tissue loss. Inability to measure first toe TP disproportionately impacted CLTI patients with diabetes compared to patients without diabetes (39.6% limbs (106/268); vs. 17% limbs (23/135); p < 0.001). Novel modalities may provide a useful tool for assessing perfusion in CLTI.

Background: Healthcare-associated infections (HAIs) are a common, costly, yet largely preventable complication impacting patients in healthcare settings globally. Improving routine cleaning and disinfection of the hospital environment has been shown to reduce the risk of HAI. Contaminated shared medical equipment presents a primary transmission route for infectious pathogens, yet is rarely studied. The CLEEN study will assess how enhanced cleaning and disinfection of shared medical equipment affects the rate of HAIs in a tertiary hospital setting. The initiative is an evidence-based approach combining staff training, auditing and feedback to environmental services staff to enhance cleaning and disinfection practices. Methods: The CLEEN study will use a stepped wedge randomised controlled design in 10 wards of one large Australian hospital over 36¿weeks. The intervention will consist of 3 additional hours per weekday for the dedicated cleaning and disinfection of shared medical equipment on each ward. The primary outcome is to demonstrate the effectiveness of improving the quality and frequency of cleaning shared medical equipment in reducing HAIs, as measured by a HAI point prevalence study (PPS). The secondary outcomes include the thoroughness of equipment cleaning assessed using fluorescent marker technology and the cost-effectiveness of the intervention. Discussion: Evidence from the CLEEN study will contribute to future policy and practice guidelines about the cleaning and disinfection of shared medical equipment. It will be used by healthcare leaders and clinicians to inform decision-making and implementation of best-practice infection prevention strategies to reduce HAIs in healthcare facilities. Trial registration: Australia New Zealand Clinical Trial Registry ACTRN12622001143718.

Background: Diabetes, end stage renal disease (ESRD), and peripheral arterial disease (PAD) are associated with a higher risk of diabetes-related lower limb amputation. Timely identification of PAD with toe systolic blood pressure (TSBP) and toe-brachial pressure index (TBPI) is critical in order to implement foot protection strategies to prevent foot complications in people with ESRD. There is limited evidence describing the effect of haemodialysis on TSBP and TBPI. This study aimed to determine the variability of TSBP and TBPI during haemodialysis in people with ESRD, and to determine whether any observed variability differed between people with and without diabetes. Methods: TSBP and TBPI were taken before dialysis (T1), one hour into dialysis (T2) and in the last 15¿min of dialysis (T3) during a single dialysis session. Linear mixed effects models were undertaken to determine the variability in TSBP and TBPI across the three time points and to determine whether this variability differed between people with and without diabetes. Results: Thirty participants were recruited, including 17 (57%) with diabetes and 13 (43%) with no diabetes. A significant overall reduction in TSBP was observed across all participants (P < 0.001). There was a significant reduction in TSBP between T1 and T2 (P < 0.001) and between T1 and T3 (P < 0.001). There was no significant overall change in TBPI over time (P = 0.62). There was no significant overall difference in TSBP between people with diabetes and people with no diabetes (mean difference [95% CI]: -9.28 [-40.20, 21.64], P = 0.54). There was no significant overall difference in TBPI between people with diabetes and people with no diabetes (mean difference [95% CI]: -0.01 [-0.17, 03.16], P = 0.91). Conclusion: TSBP and TBPI are an essential part of vascular assessment of the lower limb. TBPI remained stable and TSBP significantly reduced during dialysis. Given the frequency and duration of dialysis, clinicians taking toe pressures to screen for PAD should be aware of this reduction and consider how this may have an impact on wound healing capacity and the development of foot related complications.

Background: Adequate nutrition is essential in individuals with diabetic foot ulceration (DFU); therefore, an assessment of dietary intake is critical. A lack of nutrients including protein, zinc and vitamins C and D have all been associated with poor wound healing. However, the comprehensive dietary intake of Australian adults with DFU is poorly understood. The aim of this cross-sectional study was to describe the dietary intake of adults with DFU in an Australian setting. Methods: Participants (n = 115) with diabetes (type 1 and 2), a mean body mass index of 36 and current foot ulceration were recruited from across New South Wales, Australia. Dietary intake was assessed using the Australian Eating Survey, a self-reported validated food frequency questionnaire. Results: The mean (SD) reported energy intake was 9.57 (±SD 4.43) MJ¿day¿1. A mean protein intake of 104 (±SD 49) g¿day¿1 is below recommended intake for wound healing; however, the mean protein intake contribution to energy (19%E) was within recommendations for normal populations. The mean carbohydrate intake (43%E) was within recommended ranges for healthy populations; however, the mean total fat intake (36%E) was above recommendations. Micronutrient intake was adequate, apart from folate, which was below the recommended intake, and sodium, vitamin C, vitamin A and selenium, which were above the recommended intake. Conclusions: A lack of adequate folate may have a negative impact on healing, with folate proposed to play a role in tissue repair. Wound management of individuals with DFU should include a regular assessment of dietary intake to recognise deficiencies in macro- and micronutrients, and subsequently address these inadequacies to optimise healing.

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation.

The postexercise ankle¿brachial index (ABI) is recommended in patients with normal resting ABI when peripheral artery disease (PAD) is suspected. The aims of this study were to determine the comparative diagnostic accuracy of the resting and postexercise ABI for detecting PAD, and, the effect of the presence of diabetes on these. Three methods of interpretation currently in use were also investigated: a reduction in postexercise ABI by >20% compared to resting ABI, an ABI value of =0.90 postexercise, or a reduction in systolic ankle pressure of >30 mmHg postexercise. This retrospective study used colour duplex ultrasound (CDU) as the reference standard. In 278 limbs (whole group), the resting ABI had an overall area under the curve (AUC) of 0.71, with the postexercise ABI yielding a similar diagnostic accuracy of AUC 0.72. In the non-diabetes group (n=171), the resting ABI had an overall AUC of 0.74 and the postexercise ABI had a similar AUC of 0.76. In the diabetes group (n=107), overall accuracy was reduced compared to the non-diabetes group, with the resting ABI having an overall AUC of 0.65 and the postexercise ABI yielding a similar accuracy with an AUC of 0.64. The overall diagnostic accuracy of the postexercise ABI for diagnosing PAD was not greatly improved compared to resting ABI. Given the lower overall diagnostic accuracy in the diabetes group, both the resting and the postexercise ABI results in diabetes populations should be interpreted with caution. There is a risk of undiagnosed disease if relying on these results alone to determine lower limb vascular status.

The toe-brachial index (TBI) is used as an adjunct to the ankle-brachial index (ABI) for non-invasive lower limb vascular screening. With increasing evidence suggesting limitations of the ABI for diagnosis of vascular complications, particularly in specific populations including diabetes cohorts, the TBI is being used more widely. The aim of this review was to determine the sensitivity and specificity of the TBI for detecting peripheral artery disease (PAD) in populations at risk of this disease. A database search was conducted to identify current work relating to the sensitivity and specificity of toe-brachial indices up to July 2015. Only studies using valid diagnostic imaging as a reference standard were included. The QUADAS-2 tool was used to critically appraise included articles. Seven studies met the inclusion criteria. Sensitivity of the TBI for PAD was reported in all seven studies and ranged from 45% to 100%; specificity was reported by five studies only and ranged from 16% to 100%. In conclusion, this review suggests that the TBI has variable diagnostic accuracy for the presence of PAD in specific populations at risk of developing the disease. There was a notable lack of large-scale diagnostic accuracy studies determining the diagnostic accuracy of the TBI in detecting PAD in different at-risk cohorts. However, standardised normal values need to be established for the TBI to conclusively determine the diagnostic accuracy of this test.