Improving foot care for people with diabetes mellitus--a randomized controlled trial of an integrated care approach

AIMS

To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review.

METHODS

A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1,939 people with diabetes (age > or =18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization.

RESULTS

Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29-5.07) between the groups. Patients' knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: -0.09 (95% CI -1.81-1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change -0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30-18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14).

CONCLUSIONS

Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services.

The Northwick Park Care Needs Assessment (NPCNA): a measure of community care needs: sensitivity to change during rehabilitation

OBJECTIVES

To determine whether the Northwick Park Care Needs Assessment (NPCNA) is sensitive to change occurring during rehabilitation and provides a reliable estimate of care needs in the community, and to compare the NPCNA with the Functional Independence Measure (FIM).

DESIGN

Prospective cohort study.

SETTING

Postacute neurorehabilitation unit for young patients with complex disabilities.

SUBJECTS

Thirty-nine consecutive patients with brain injury admitted over six months.

MEASUREMENTS AND METHODS

The NPCNA was assessed on admission and at discharge. Two subsets of patients were also assessed (a) at three-month follow-up in the community (n = 15), and (b) both in hospital and in the home environments at the discharge time point (n = 28). Data were compared with FIM scores on admission and discharge.

RESULTS

The median total weekly care hours fell from 52 hours (interquartile range (IQR) 25-66) on admission, to 17 hours (IQR 6-46) on discharge (p<0.001). There was a median reduction of approximate weekly cost of care from 600 pound sterling (IQR 224-824 pound sterling) to 168 pound sterling (IQR 56-280 pound sterling) (p<0.001). These benefits were sustained at follow-up, and the NPCNA measured in hospital at discharge gave a good estimation of the care hours and weekly cost of care in the community at three months after discharge. There was no significant correlation with FIM gain.

CONCLUSIONS

In this study the NPCNA, measured while the patient was still in hospital, gave a good estimation of care needs in the community and was sensitive to change occurring during rehabilitation in patients with severe complex disabilities.

Radionuclides in seals and porpoises in the coastal waters around the UK

It has been suggested that marine predators be assessed for biologically relevant contamination levels because of their trophic position. Accordingly, in studying radioactive contamination in the marine environment around the UK, tissues from seals and porpoises have been chosen. Liver and muscle tissue from dead seals and porpoises found stranded around the UK coast have been analysed for the following radionuclides: 134Cs, 137Cs, 238Pu, 239Pu + 240Pu. Multifactor analysis of variance indicated that, for radiocaesium, there was no significant difference for harbour seals, grey seals or porpoises in terms of species or gender; however, the tissue activity concentration increased with body weight and decreased with distance from Sellafield, the major nuclear reprocessing plant in the UK. The levels of radiocaesium in muscle were higher than those in liver, while there appeared to be a concentration factor of approximately 3-4 for muscle radiocaesium when compared to radiocaesium levels reported for fish, the main food source of the marine mammals under study. Approximate radiation dose calculations indicated that the average dose from radiocaesium was less than 10% of the dose from the naturally occurring radioisotope of potassium, 40K. The highest tissue activity concentration for plutonium of 0.037 Bq/kg (239Pu + 240Pu) was detected in a grey seal stranded at Rathlin Island in Northern Ireland. Calculation of approximate radiation doses from plutonium contamination showed that, as with radiocaesium, the average dose was small compared with that from 40K. In summary, the radiocaesium contamination in seals and porpoises decreased with distance from Sellafield indicating that the BNF plc processing plant was the major source of the contamination. The marine mammals concentrated radiocaesium from their environment by a factor of 300 relative to the concentration in seawater indicating the value of using marine mammal tissue to measure radiocaesium contamination in the marine environment. The maximum radiation dose to the marine mammals from radiocaesium was higher than doses previously assessed for critical groups of humans living near Sellafield, while the maximum dose from plutonium was comparable to the doses for humans.

The Northwick Park Dependency Score (NPDS): a measure of nursing dependency in rehabilitation

BACKGROUND

Disability scores, such as the Functional Independence Measure (FIM) and Barthel Index, have been shown to correlate with care needs but cannot be used to assess them directly, as they do not indicate the number of people required to help with a task, nor the time taken. The Northwick Park Dependency Score (NPDS) is an ordinal scale that can be used to assess impact on nursing time. It takes 3-5 minutes to complete. Together with a short set of additional questions, it may be used directly to assess care needs in the community and to facilitate discharge planning.

AIMS

To develop and evaluate the NPDS for use in a rehabilitation setting.

METHODS

(1) DEVELOPMENT: Following a survey of existing instruments, tasks were selected on the basis of their impact on nursing time and divided into Basic Care Needs (BCN) and Special Nursing Needs (SNN). Cut-off points were devised to reflect the number of helpers needed and time taken. Following evaluation of the NPDS version 5, minor changes were made to produce version 6 which was re-evaluated on a smaller scale. (2) EVALUATION: Inter-rater and intra-rater reliability were tested in a cohort of 23 inpatients using five senior nurses. Analysis included assessment of degree of association, significant differences, absolute agreement, and agreement +1 level. Although there is no gold standard, the BCN section should correlate inversely with independently assessed Barthel scores. Re-evaluation of version 6 was undertaken using the same method of analysis in a cohort of 21 patients using three senior nurses.

RESULTS

On initial evaluation inter-rater reliability testing showed an excellent level of association in total composite score between each pair of nurses (rho = 0.73-0.92, p <0.01) and agreement +1 level for individual items ranged from 73 to 100%. Significant disagreements were in six items. On re-evaluation following minor modification, high levels of association were still seen for total BCN, SNN and composite scores both between and within raters, with very satisfactory levels of agreement for individual items. The BCN section of the NPDS showed good inverse correlation with Barthel scores (rho = 0.91, p <0.01).

CONCLUSION

The NPDS is simple and practical to use in a busy setting. It is shown to be reliable and valid in its assessment of nursing dependency on the ward. Its translation into a directly costable measure of continuing care needs in the community now requires evaluation.

Haemodynamic parameters predicting variceal haemorrhage and survival in alcoholic cirrhosis

The relationship between the various haemodynamic abnormalities observed in cirrhosis and their prognostic value remains unclear. We report haemodynamic measurements on 96 patients with alcoholic cirrhosis (mean Childs-Pugh Score, CPS, 9.0 +/- 0.2, mean age 55.6 +/- 1.0 years) and assess their value in predicting variceal bleeding and death during a mean follow-up of 19.3 +/- 1.5 months. Baseline CPS correlated with hepatic venous pressure gradient (HVPG) (p = 0.001), azygos blood flow (p < 0.05), cardiac index (p < 0.05), and inversely with mean arterial pressure (p < 0.01) and systemic vascular resistance index (p < 0.05). Renal blood flow was not related to any haemodynamic parameter or CPS. Thirty-eight patients died during follow-up, and 16 had a variceal bleed. Death (p = 0.001) and variceal bleeding (p < 0.05) were more likely in patients with HVPG > 16 mmHg than in those with HVPG < 16 mmHg, and variceal bleeding was more likely in patients with HVPG > 12 mmHg (vs. HVPG < 12 mmHg, p < 0.05). HVPG also predicted death and variceal haemorrhage on univariate and multivariate analyses. No other haemodynamic parameter predicted death or bleeding. In alcoholic cirrhosis, severity of liver disease is related to HVPG, collateral blood flow and degree of systemic circulatory abnormalities. HVPG is a useful predictor of survival and variceal bleeding in these patients.

Cognition and multiple sclerosis: a historical analysis of medical perceptions

The earliest descriptions of multiple sclerosis (MS) rarely distinguished cognitive impairment from the general category of "mental symptoms", which also encompassed a broad range of affective disorders. Case-study methods led to disputes about the extent and nature of these symptoms, exacerbated by different national medical traditions. Appropriate scientific methods were only used to investigate cognitive performance in a modest number of studies up to the 1960s, and it was being argued as late as the mid 1970s that affective processes rather than cognitive processes were the key to understanding the psychological aspects of MS. However, the early 1980s, saw major developments in test procedures for the detection of subtle and selective cognitive changes, in the use of brain imaging techniques, and in collaboration between neurologists and neuropsychologists. Pressure to use research findings to improve patients' daily lives suggests a need to reconsider the connection between affective and cognitive processes in MS.

Ecological correlates of motor neuron disease mortality: a hypothesis concerning an epidemiological association with radon gas and gamma exposure

This study investigates variations in motor neuron disease (MND) mortality rates between the counties of England and Wales from 1981 to 1989, and their relationship with gamma-ray dose rates, indoor radon gas concentrations and enhanced general life expectancy. A strong correlation was confirmed between age-adjusted rates of MND mortality and life expectancy. Weaker, but statistically significant, associations were observed between indoor radon gas concentrations, terrestrial gamma radiation and marginal variations in MND mortality. Life expectancy and radon gas concentrations were positively associated with MND mortality rates whilst gamma radiation was negatively associated. The negative correlation of gamma radiation with MND mortality may be understood with reference to its negative effects on overall population life expectancy. Radon gas concentrations seemingly account for a small elevation in MND mortality, amounting to at most 4% of total deaths. Further research is required to investigate this association.

Effect of dietary protein content on behavior in dogs

OBJECTIVE

To determine the effect that feeding diets containing a low (17%), medium (25%), or high (32%) protein content would have on behavior in dogs.

DESIGN

Prospective, controlled study.

ANIMALS

12 dogs with dominance aggression, 12 dogs with hyperactivity, 12 dogs with territorial aggression, and 14 control dogs without behavioral problems.

PROCEDURE

Dogs were fed each of the diets for a 2-week period, and owners were instructed to score their dogs' behavior on a daily basis.

RESULTS

Behavior of the dogs with dominance aggression, dogs with hyperactivity, and control dogs was unchanged by the dietary manipulations. Territorial aggression was significantly reduced when dogs were fed the low- or medium-protein diet, compared with territorial aggression when fed the high-protein diet. Post hoc analysis indicated that this effect was attributable to a marked reduction in aggression in a subset of the group (n = 7) in which territorial aggression was a result of fear.

CLINICAL IMPLICATIONS

Results of this study suggest that a reduction in dietary protein content is not generally useful in the treatment of behavior problems in dogs, but may be appropriate in dogs with territorial aggression that is a result of fear.

Decline and rise of mortality from motor neuron disease in Spain, 1960-1989: demographic, environmental and competitive influences

Mortality rates from motor neuron disease (MND) in Spain were analysed for the years 1960-1989, a period in which 3,530 deaths were recorded from the disease and during which the crude annual mortality rate ranged between 0.35 and 0.95 deaths per 100,000 persons. Whilst the crude mortality rate fell by 54% during the decade 1960-1969, there was a net increase of 26% over the entire period. The influence of three sets of variables-the increasing mean age of the population, changing environmental factors, and changing competition between diseases-upon mortality rates were investigated through Gompertzian analysis of crude and age-adjusted mortality rates. The increased mean age of the population contributed significantly to the overall rise in mortality from MND over the whole period, a feature that has previously been demonstrated to occur in the majority of industrialised countries. The unusual pattern of a decline and subsequent rise in mortality appears to be due to the influence of changing environmental factors on a sub-population susceptible to the disease.

Mortality from motor neuron disease in Japan, 1950-1990: association with radioactive fallout from atmospheric weapons testing

Motor neuron disease (MND) is a progressive and invariably fatal disease affecting the nuclei of the pyramidal tract and anterior horn cells. Despite intensive research into environmental agents associated with the onset or course of the disease, there is no single factor that can be confidently linked over time with regional, national or international variations in mortality rates. However, unusual variations in MND mortality rate in Japan from 1950-1990 were found to correlate highly significantly with variations in radioactive fallout released by atmospheric weapons testing in the Pacific. This association could be explained by the ingestion of alpha-emitting radionuclides acting upon a pre-existing susceptible subpopulation, a hypothesis which is consistent with recent research on the epidemiology and pathology of MND. However, it is likely that radiation is only one of many factors that act singly or in combination to accelerate the condition in subpopulations susceptible to MND.

Leucocyte interleukin-1-like activity in the common seal (Phoca vitulina) and grey seal (Halichoerus grypus)

Interleukin-1 (IL-1) is an important cytokine with predominantly proinflammatory activities, which have been characterized in many mammals. This study showed the production of IL-1-like bioactivity by cultured seal leucocytes. Increasing concentrations of lipopolysaccharide (LPS) (0-1 micrograms/ml) stimulated an increase in measurable IL-1-like activity in cell culture supernates. This activity increased for the first 24 h after LPS stimulation and the substance responsible had an apparent molecular weight of 17 kDa on gel filtration, similar to that described for other species. Specificity of the bioassay used was confirmed by blocking the bioactivity with an IL-1 receptor antagonist (IL-1 ra).

Growth responses to patterned GH delivery

We have investigated the effects of different patterns of administration of recombinant human growth hormone (rhGH) on weight gain, organ growth, serum GH binding protein (GHBP) and insulin-like growth factor-l (IGF-1) levels in a series of studies using hypophysectomized (Hx) or GH-deficient dwarf (dw/dw) rats. Animals were given rhGH either by subcutaneous (s.c.) injections (1 or 2 per day) or s.c. infusions and rhlGF-1 (2 mg/kg/day) by s.c. infusion. In Hx rats, all rhGH regimes increased body weight, tibial epiphyseal plate width, and organ weights in a dose-related manner. Dwarf rats showed a smaller growth response to rhGH than Hx rats, whereas rhGH induced greater elevations in serum GHBP in drarf rats. Growth responses depended on the pattern of rhGH administration (twice daily injections > continuous infusions > daily injections). The shape of the body growth curves also differed; rhGH injections increased weight gain linearly, whereas infusions gave an initial rapid weight gain which slowed with time (a curvilinear response). For both regimens, tibial epiphyseal plate width increased linearly with rhGH dose but infusions were 5-fold more potent than daily injections. Spleen and thymus weights were markedly increased by rhGH and were also affected by the pattern of GH exposure. At 5 mg rhGH/kg/day, thymus weights were 390±35 mg for injectionsvs. 613 ± 34 mg for infusions (P<0.001) compared with 248 ± 16 mg in vehicle-treated Hx controls. Infusions of rhlGF-1 also stimulated specific organ growth but caused less weight gain. RhlGF-1 additively increased the weight gain caused by rhGH injections but not by rhGH infusions. Circulating IGF-1 and GHBP levels were increased in a dose-dependent manner by rhGH infusion, whereas daily injections were ineffective. Thus, differential organ growth could be related to the higher serum IGF-1 concentrations induced by continuous rhGH administration. These studies show that whole body growth is best maintained by intermittent rhGH exposure, whereas, paradoxically, differential organ growth is most pronounced with continuous rhGH administration.

Rising mortality from motor neurone disease in Sweden 1961-1990: the relative role of increased population life expectancy and environmental factors

Recent studies of mortality from motor neurone disease (MND) in Sweden have demonstrated rising levels of mortality from the disease, especially amongst older age groups. Case-control investigations have suggested that certain environmental factors are significantly related to variations in mortality from the disease, and are associated with a probable individual susceptibility to MND. This study applies an innovative epidemiological technique to longitudinal and cohort analysis of Swedish mortality from MND during the period 1961 to 1990. Survival modelling shows that a subpopulation susceptible to MND exists in Sweden, as has been demonstrated in other countries. The increased life expectancy of the Swedish population since 1961 has resulted in more of that susceptible population living to the ages at which MND is expressed, explaining the majority of the increase in mortality from the disease. However, environmental factors may play a role in accelerating the course of MND and may affect the timing of death within the susceptible sub-population.

New approach to superior vena caval obstruction

Images