We offer many thanks to Williams, Price, and Harding for reading our article (1) with interest and for their comments regarding our study in this issue of Diabetes Care (2). In response to the specific points raised, we provide the following replies.
1) Patients with new-onset ulcers developing within the past 1 month were included in the study. Our records did not include whether these patients had previous ulcers that had healed completely. This may have been the case, but we feel only in a small minority of cases.
2) The study data were collected during initial assessment by a diabetologist/chiropodist in a diabetic foot clinic. The absence of two or more foot pulses on palpation is widely used as a diagnostic criterion for peripheral vascular disease and is used by many diabetologists (3). The use of ankle-brachial systolic pressure index is often misleading in diabetes. Color duplex scanning was done only in patients referred for vascular surgical assessment, and the data were not presented. As mentioned in the article, we presented data on simple clinical tests that can be performed in any hospital or community foot clinic and reflect common clinical practice.
3) Table 1 represents the total number of patients and absolute mortality statistics. Patients were recruited in the study over 5 years and thus had varying lengths of follow-up. To adjust for this, 5-year mortality rates were derived by Kaplan-Meier analysis and presented in Table 3 and Fig. 3. These would of course be different from the absolute mortality statistics and are not inconsistent.
The high mortality rates of patients with atherosclerotic vascular disease are well known. Atherosclerosis is more common with increasing age. This study points out that all diabetic patients with foot ulcers are at high risk, but those with vascular disease have a higher 5-year mortality, part of which could be due to the increased prevalence of atherosclerotic vascular disease with age. Similar comments have been made in other studies (4).
