2. A GLOBAL PERSPECTIVE ON DIABETIC FOOT PROBLEMS Professor Andrew JM Boulton Professor of Medicine Universities of Manchester, UK and Miami, Fl, USA. Director, Extra-European Educational Activities, EASD.

3. Who is at Risk of Foot Ulceration? Neuropathy Peripheral Vascular Disease Past history of foot ulceration Microvascular Complications Elderly, living alone Foot deformity Unilateral amputees

4. Diabetic Neuropathy ‘PAIN – God’s greatest gift to mankind’ Paul Brand

5. ‘Coming Events cast their shadows before.’ Thomas Campbell

7. Do you know which of these people will develop a diabetic foot ulcer? Do you know which of these people will develop a diabetic foot ulcer?people

9. The ‘at-risk’ patient may be completely asymptomatic: risk cannot be assessed without a clinical exam of the foot

10. How can we reduce foot ulcers and amputation in diabetes?

11. Remove the patients’ shoes and socks and examine the feet every time you see someone with diabetes Paul Brand MD, 1980

13. Causal Pathways for Foot Ulceration Neuropathy most important component cause (78%) Critical triad: neuropathy, deformity, and trauma present in 63% Ischemia component cause in 35% >80% of ulcers potentially preventable Reiber, Vileikyte et al, 1999.

14. The Most Common Causal Pathway to Incident Diabetic Foot Ulcers

18. “If I were to choose between pain and nothing ….. I would choose pain” William Faulkner

20. “For one mistake made for not knowing, ten mistakes are made for not looking.” J A Lindsay