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Irwin R. Sparing the doctor's blushes: the use of sexually explicit films for the purpose of Sexual Attitude Reassessment (SAR) in the training of medical practitioners in Britain during the 1970s. MEDICAL HUMANITIES 2022:medhum-2021-012341. [PMID: 35319485 DOI: 10.1136/medhum-2021-012341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/16/2022] [Indexed: 06/14/2023]
Abstract
The general reluctance of medical practitioners in postwar Britain to 'speak of sex' during healthcare consultations increasingly became a matter of professional concern in the wake of legal reforms and social changes during the 1960s affecting sexual expression and reproductive health, and a growing optimism in the early 1970s concerning the treatment of sexual difficulties. In the mid-1970s, largely as a result of the work of Dr Elizabeth Stanley, Sexual Attitude Reassessment (SAR) seminars were introduced from the USA into some medical schools in Britain, usually as a part of courses that were intended to help students develop the attitudes, knowledge and skills needed to facilitate the discussion of patients' sexual concerns and to treat 'simple' sexual problems. SAR seminars entailed the showing of sexually explicit films as a stimulus for exploring, in small discussion groups, the sexual attitudes and beliefs of students, and the potential impact of these on future professional practice. Drawing on publications by Dr Elizabeth Stanley as well as archival materials, this article examines the aims of SAR seminars, the rationale provided for their inclusion in the undergraduate medical curriculum, and the 'permission-giving', educative approach to sexual counselling that SAR seminars supported. It also explores some of the barriers to the more widespread use of such seminars in medical education in Britain at this time. The behaviourally informed 'permission-giving' approach to sexual counselling promoted by Stanley and others is also considered alongside the more psychoanalytically informed 'interpretative' form of sexual counselling provided by some Family Planning Association doctors from the late 1950s onwards. This comparative analysis reveals contrasting perceptions concerning the role of medical practitioners' emotions in sexual counselling and elucidates some of the reasons for the fragmented and limited development of this aspect of medical practice in Britain.
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Shabhay A, Horumpende P, Shabhay Z, Mganga A, Van Baal J, Msuya D, Chilonga K, Chugulu S. Clinical profiles of diabetic foot ulcer patients undergoing major limb amputation at a tertiary care center in North-eastern Tanzania. BMC Surg 2021; 21:34. [PMID: 33435942 PMCID: PMC7802243 DOI: 10.1186/s12893-021-01051-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 01/05/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers complications are the major cause of non-traumatic major limb amputation. We aimed at assessing the clinical profiles of diabetic foot ulcer patients undergoing major limb amputation in the Surgical Department at Kilimanjaro Christian Medical Centre (KCMC), a tertiary care hospital in North-eastern Tanzania. METHODS A cross-sectional hospital-based study was conducted from September 2018 through March 2019. Demographic data were obtained from structured questionnaires. Diabetic foot ulcers were graded according to the Meggitt-Wagner classification system. Hemoglobin and random blood glucose levels data were retrieved from patients' files. RESULTS A total of 60 patients were recruited in the study. More than half (31/60; 51.67%) were amputated. Thirty-five (58.33%) were males. Fifty-nine (98.33%) had type II diabetes. Nearly two-thirds (34/60; 56.67%) had duration of diabetes for more than 5 years. The mean age was 60.06 ± 11.33 years (range 30-87). The mean haemoglobin level was 10.20 ± 2.73 g/dl and 9.84 ± 2.69 g/dl among amputees. Nearly two thirds (42/60; 70.00%) had a haemoglobin level below 12 g/dl, with more than a half (23/42; 54.76%) undergoing major limb amputation. Two thirds (23/31; 74.19%) of all patients who underwent major limb amputation had mean hemoglobin level below 12 g/dl. The mean Random Blood Glucose (MRBG) was 13.18 ± 6.17 mmol/L and 14.16 ± 6.10 mmol/L for amputees. Almost two thirds of the study population i.e., 42/60(70.00%) had poor glycemic control with random blood glucose level above 10.0 mmol/L. More than half 23/42 (54.76%) of the patients with poor glycemic control underwent some form of major limb amputation; which is nearly two thirds (23/31; 74.19%) of the total amputees. Twenty-eight (46.67%) had Meggitt-Wagner classification grade 3, of which nearly two thirds (17:60.71%) underwent major limb amputation. CONCLUSION In this study, the cohort of patients suffering from diabetic foot ulcers treated in a tertiary care center in north-eastern Tanzania, the likelihood of amputation significantly correlated with the initial grade of the Meggit-Wagner ulcer classification. High blood glucose levels and anaemia seem to be also important risk factors but correlation did not reveal statistical significance.
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Affiliation(s)
- Ahmed Shabhay
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
- Institute of Infectious Diseases and Research, Lugalo Military College of Medical Sciences (MCMS) and General Military Hospital (GMH), Mwenge area, P.O. Box 60000, Dar es Salaam, Tanzania
| | - Pius Horumpende
- Institute of Infectious Diseases and Research, Lugalo Military College of Medical Sciences (MCMS) and General Military Hospital (GMH), Mwenge area, P.O. Box 60000, Dar es Salaam, Tanzania
- Kilimanjaro Clinical Research Institute (KCRI), P.O. Box 2236, Moshi, Tanzania
| | - Zarina Shabhay
- Department of Neuro-Surgery, Muhimbili Orthopedic Institute, P.O. Box 65474, Dar es Salaam, Tanzania
| | - Andrew Mganga
- Department of Public Health, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
| | - Jeff Van Baal
- ZGT Academy, Hospital Group Twente, Almelo, Hengelo, The Netherlands
- Cardiff University, Cardiff, Wales UK
| | - David Msuya
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Kondo Chilonga
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
| | - Samwel Chugulu
- Department of General Surgery, Kilimanjaro Christian Medical University College, P.O. Box 2240, Moshi, Tanzania
- Department of General Surgery, Kilimanjaro Christian Medical Centre, P.O. Box 3010, Moshi, Tanzania
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Yang HY, Fierro F, So M, Yoon DJ, Nguyen AV, Gallegos A, Bagood MD, Rojo-Castro T, Alex A, Stewart H, Chigbrow M, Dasu MR, Peavy TR, Soulika AM, Nolta JA, Isseroff RR. Combination product of dermal matrix, human mesenchymal stem cells, and timolol promotes diabetic wound healing in mice. Stem Cells Transl Med 2020; 9:1353-1364. [PMID: 32720751 DOI: 10.1002/sctm.19-0380] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/21/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022] Open
Abstract
Diabetic foot ulcers are a major health care concern with limited effective therapies. Mesenchymal stem cell (MSC)-based therapies are promising treatment options due to their beneficial effects of immunomodulation, angiogenesis, and other paracrine effects. We investigated whether a bioengineered scaffold device containing hypoxia-preconditioned, allogeneic human MSCs combined with the beta-adrenergic antagonist timolol could improve impaired wound healing in diabetic mice. Different iterations were tested to optimize the primary wound outcome, which was percent of wound epithelialization. MSC preconditioned in 1 μM timolol at 1% oxygen (hypoxia) seeded at a density of 2.5 × 105 cells/cm2 on Integra Matrix Wound Scaffold (MSC/T/H/S) applied to wounds and combined with daily topical timolol applications at 2.9 mM resulted in optimal wound epithelialization 65.6% (24.9% ± 13.0% with MSC/T/H/S vs 41.2% ± 20.1%, in control). Systemic absorption of timolol was below the HPLC limit of quantification, suggesting that with the 7-day treatment, accumulative steady-state timolol concentration is minimal. In the early inflammation stage of healing, the MSC/T/H/S treatment increased CCL2 expression, lowered the pro-inflammatory cytokines IL-1B and IL6 levels, decreased neutrophils by 44.8%, and shifted the macrophage ratio of M2/M1 to 1.9 in the wound, demonstrating an anti-inflammatory benefit. Importantly, expression of the endothelial marker CD31 was increased by 2.5-fold with this treatment. Overall, the combination device successfully improved wound healing and reduced the wound inflammatory response in the diabetic mouse model, suggesting that it could be translated to a therapy for patients with diabetic chronic wounds.
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Affiliation(s)
- Hsin-Ya Yang
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Fernando Fierro
- Department of Cell Biology and Human Anatomy, University of California, Davis, Sacramento, California, USA.,Stem Cell Program, Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Michelle So
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Daniel J Yoon
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Alan Vu Nguyen
- Department of Dermatology, University of California, Davis, Sacramento, California, USA.,Institute for Pediatric Regenerative Medicine, Shriners Hospital for Children Northern California, Sacramento, California, USA
| | - Anthony Gallegos
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Michelle D Bagood
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Tomas Rojo-Castro
- Department of Biological Sciences, California State University, Sacramento, Sacramento, California, USA
| | - Alan Alex
- Department of Biological Sciences, California State University, Sacramento, Sacramento, California, USA
| | - Heather Stewart
- Stem Cell Program, Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - Marianne Chigbrow
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Mohan R Dasu
- Department of Dermatology, University of California, Davis, Sacramento, California, USA
| | - Thomas R Peavy
- Department of Biological Sciences, California State University, Sacramento, Sacramento, California, USA
| | - Athena M Soulika
- Department of Dermatology, University of California, Davis, Sacramento, California, USA.,Institute for Pediatric Regenerative Medicine, Shriners Hospital for Children Northern California, Sacramento, California, USA
| | - Jan A Nolta
- Stem Cell Program, Department of Internal Medicine, University of California, Davis, Davis, California, USA
| | - R Rivkah Isseroff
- Department of Dermatology, University of California, Davis, Sacramento, California, USA.,Dermatology Section, VA Northern California Health Care System, Mather, California, USA
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Déruaz‐Luyet A, Raabe C, Garry EM, Brodovicz KG, Lavery LA. Incidence of lower extremity amputations among patients with type 1 and type 2 diabetes in the United States from 2010 to 2014. Diabetes Obes Metab 2020; 22:1132-1140. [PMID: 32090430 PMCID: PMC7318669 DOI: 10.1111/dom.14012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 12/17/2022]
Abstract
AIM To compare the incidence of lower extremity amputation (LEA) among patients with type 1 diabetes (T1D) and patients with type 2 diabetes (T2D) with those without diabetes using US commercial claims and to assess the presence of key co-morbidities and precipitating factors at the time of the LEA. METHODS Cohorts were defined via IBM MarketScan research databases for beneficiaries with T1D and T2D during 2010-2014. For each T1D and T2D patient, one patient without a prior diabetic claim matched on calendar time, sex and age, was randomly selected. Multivariable Cox proportional hazards models were used to estimate adjusted hazard ratios (aHRs) and 95% confidence intervals. RESULTS Among the matched cohorts of 120 129 T1D patients and 1.7 million T2D patients, the incidence of LEA was higher among patients with T1D than patients with T2D, with the most frequent cases being minor LEAs (4.85 and 1.53 per 1000 patient years [PY], respectively), largely toe amputations (4.49 and 1.43 per 1000 PY, respectively). Compared with non-diabetic patients matched on age, sex and calendar time, T1D and T2D patients had more co-morbidities and a higher incidence of LEA (6.02 vs. 0.14 per 1000 PY; aHR, 22.47 [16.42-30.73] and 1.90 vs. 0.23 per 1000 PY; aHR, 4.64 [4.32-4.98]). CONCLUSIONS Our data showed a higher incidence of LEA, especially minor LEA, in patients with T1D and T2D compared with those without diabetes, with a greater risk among patients with T1D than patients with T2D. Accounting for known and measurable risk factors for LEA reduced the relative hazard by nearly 50%; the majority of LEA cases were minor LEAs and toe amputations.
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Affiliation(s)
| | | | | | | | - Lawrence A. Lavery
- Department of Plastic SurgeryUniversity of Texas Southwestern Medical CenterDallasTexas
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Guo Z, Yue C, Qian Q, He H, Mo Z. Factors associated with lower-extremity amputation in patients with diabetic foot ulcers in a Chinese tertiary care hospital. Int Wound J 2019; 16:1304-1313. [PMID: 31448507 DOI: 10.1111/iwj.13190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 07/28/2019] [Indexed: 12/30/2022] Open
Abstract
Providing a better understanding of the risk factors for amputation in this particular region, Hunan province, in China might help patients with diabetic foot ulcers receive timely and appropriate medical care and help prevent amputation. Diabetic foot ulcer patients referred to the Third Xiangya Hospital during the period between December 2014 and September 2018 were enrolled. Participants who underwent amputations and received conservative treatments were compared using univariate and multivariate analyses to identify the independent predictors of amputation. Those who required amputation presented significantly higher levels of white blood cell counts, platelet counts, erythrocyte sedimentation rate, C-reactive protein, and glycated haemoglobin (HbA1c) levels. However, levels of haemoglobin, postprandial plasma C-peptide, triglyceride, high-density lipoprotein cholesterol, albumin, and uric acid were decreased in patients with amputations. Patients with more advanced Wagner grades had much higher rates of amputation. Multivariable-adjusted odds ratios in stepwise logistic regression model was 1.317 for HbA1c (95% CI: 1.015-1.709), 0.255 for triglyceride (95% CI: 0.067-0.975), and 20.947 for Wagner grades (95% CI: 4.216-104.080). Independent risk factors for amputation in these Chinese diabetic foot ulcer patients included an elevated HbA1c level, lower triglyceride level, and higher Wagner grades.
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Affiliation(s)
- Zi Guo
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Chun Yue
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Qiang Qian
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Honghui He
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Zhaohui Mo
- Department of Endocrinology, The Third Xiangya Hospital, Central South University, Changsha, China
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Nanwani B, Shankar P, Kumar R, Shaukat F. Risk Factors of Diabetic Foot Amputation in Pakistani Type II Diabetes Individuals. Cureus 2019; 11:e4795. [PMID: 31396465 PMCID: PMC6679704 DOI: 10.7759/cureus.4795] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Introduction The major grave outcome of diabetic complications is the amputation of lower limb extremities. Recurrent foot infections, trauma, ischemia, and peripheral neuropathy play a crucial role in predicting foot amputation. The aim of this study is to identify the risk factors of diabetic foot amputations in Pakistani patients. Methods Patients admitted with diabetic foot-related complications were followed throughout their hospital stay. Their sociodemographic and disease-related characteristics were recorded. Patients who were advised foot amputation were taken as group A, and patients who were managed conservatively were termed as group B. Their characteristics were then compared. Results Out of 226 study participants, there were 51 (22.5%) patients in group A who were advised foot amputation. There were more men in group A as compared to group B (72.5% vs. 30.8%; p<0.00001). Group A also had a longer duration of diabetes (15.23 ± 8.52 years vs. 11.98 ± 9.69; p=0.03). Group B included more patients taking insulin therapy (44.5% vs. 37.3%; p=0.002). All three risk factors of atherosclerosis - smoking, hyperlipidemia, and hypertension - were significantly associated with group A (p≤0.05). This coexistence of diabetic nephropathy and retinopathy were more common in group A (p≤0.05). Conclusion The incidence of foot amputation in diabetic patients is high. Crucial risk factors include male gender, smoking, hyperlipidemia, hypertension, cardiac history, and the coexistence of diabetic nephropathy and retinopathy.
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Affiliation(s)
- Bhawna Nanwani
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Prem Shankar
- Internal Medicine, Dow Medical College, Karachi, PAK
| | - Ravi Kumar
- Internal Medicine, Chandka Medical College, Larkana, PAK
| | - Faizan Shaukat
- Internal Medicine, Jinnah Postgraduate Medical Center, Karachi, PAK
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Vadiveloo T, Jeffcoate W, Donnan PT, Colhoun HC, McGurnaghan S, Wild S, McCrimmon R, Leese GP. Amputation-free survival in 17,353 people at high risk for foot ulceration in diabetes: a national observational study. Diabetologia 2018; 61:2590-2597. [PMID: 30171278 PMCID: PMC6223842 DOI: 10.1007/s00125-018-4723-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 07/30/2018] [Indexed: 12/25/2022]
Abstract
AIMS/HYPOTHESIS Our aim was to investigate amputation-free survival in people at high risk for foot ulceration in diabetes ('high-risk foot'), and to compare different subcategories of high-risk foot. METHODS Overall, 17,353 people with diabetes and high-risk foot from January 2008 to December 2011 were identified from the Scotland-wide diabetes register (Scottish Care Information-Diabetes: N = 247,278). Participants were followed-up for up to 2 years from baseline and were categorised into three groups: (1) those with no previous ulcer, (2) those with an active ulcer or (3) those with a healed previous ulcer. Participants with prior minor or major amputation were excluded. Accelerated failure time models were used to compare amputation-free survival up to 2 years between the three exposure groups. RESULTS The 2 year amputation-free survival rate in all people with diabetes with high-risk foot was 84.5%. In this study group, 270 people (10.0%) had an amputation and 2424 (90.0%) died during the 2 year follow-up period. People who had active and healed previous ulcers at baseline had significantly lower 2 year amputation-free survival compared with those who had no previous ulcer (both p < 0.0001). The percentage of people who died within 2 years for those with healed ulcer, active ulcer or no baseline ulcer was 22.8%, 16% and 12.1%, respectively. CONCLUSIONS/INTERPRETATION In people judged to be at high risk of foot ulceration, the risk of death was up to nine times the risk of amputation. Death rates were higher for people with diabetes who had healed ulcers than for those with active ulcers. However, people with active ulcers had the highest risk of amputation.
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Affiliation(s)
- Thenmalar Vadiveloo
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | | | - Peter T Donnan
- Division of Population Health Sciences, Medical Research Institute, University of Dundee, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK
| | - Helen C Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Sarah Wild
- Usher Institute for Public Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Rory McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Graham P Leese
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
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Alarcão V, Machado FL, Giami A. [The construction of sexology as a profession in Portugal: composition professional group and types of sexologists]. CIENCIA & SAUDE COLETIVA 2016; 21:629-40. [PMID: 26910170 DOI: 10.1590/1413-81232015212.11112015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 07/05/2015] [Indexed: 11/22/2022] Open
Abstract
This study sets out to discuss the emergence of the profession of sexologist in Portugal, comparing its development with international trends. This research also seeks to understand the self-identification of sexologists and the significances they attribute to it. The empirical information presented derives from a survey conducted with 91 Portuguese sexologists identified through the leading professional associations and from 44 in-depth interviews with experts selected by intentional sampling to ensure the diversity of Portuguese sexologists. The results of the survey indicate that the Portuguese sexologist is on average 43 years old, mainly female, non-physician, and has training in sexology. Considering the qualifications of the interviewees, their professional trajectories and the activities they develop in the field, and the discourses related to their ideals of the profession, a typology was found with five types: sexologists by vocation, sexologist by clinical practice, sexologists by certification, social scientist-sexologists and sexologists by media coverage. The survey identified an interesting diversity of practices and professional conceptions in the field of sexology in Portugal. Being a sexologist appears to be more associated with the ideals of the profession than the time devoted to same.
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Affiliation(s)
- Violeta Alarcão
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Estremadura, Portugal,
| | - Fernando Luís Machado
- Centro de Investigação e Estudos de Sociologia, Instituto Universitário de Lisboa, Lisboa, Portugal
| | - Alain Giami
- Institut de la Santé et de la Recherche Médicale, Paris, França
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Verrone Quilici MT, Del Fiol FDS, Franzin Vieira AE, Toledo MI. Risk Factors for Foot Amputation in Patients Hospitalized for Diabetic Foot Infection. J Diabetes Res 2016; 2016:8931508. [PMID: 26998493 PMCID: PMC4779829 DOI: 10.1155/2016/8931508] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 01/04/2016] [Accepted: 01/27/2016] [Indexed: 01/04/2023] Open
Abstract
The aim of this study was to identify and quantify risk factors for amputation in diabetic patients hospitalized for foot infections. This cross-sectional study comprised 100 patients with diabetic infectious complications in the lower limbs. The variables investigated were related to diabetes, infection, and treatment compliance. Multiple Cox regression analysis was performed to identify the variables independently associated with the outcome of amputation. The most prevalent chronic complications were neuropathy and hypertension. Most patients presented with a neuroischemic foot (86%). The Morisky test showed that 72% were not compliant with diabetes treatment. Regarding patient outcome, 61% progressed to amputation, 14% to debridement, and 9% to revascularization. The results showed a 42% higher risk for progression to amputation in patients with previous use of antimicrobials. Also, the amputation risk was 26% higher for those less compliant with diabetes treatment. An increase of one point in the Wagner ulcer classification criteria corresponded to a 65% increase in the risk of amputation. Undergoing conservative, nonsurgical procedures prior to admission provided a 63% reduction in the risk of amputation. Knowledge of these factors is critical to enable multidisciplinary teams to develop treatment plans for these patients so as to prevent the need for amputation.
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Affiliation(s)
| | - Fernando de Sá Del Fiol
- University of Sorocaba, Rodovia Raposo Tavares, Km 92,5, 18023-000 Sorocaba, SP, Brazil
- *Fernando de Sá Del Fiol:
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Namgoong S, Jung S, Han SK, Jeong SH, Dhong ES, Kim WK. Risk factors for major amputation in hospitalised diabetic foot patients. Int Wound J 2015; 13 Suppl 1:13-9. [PMID: 26478562 DOI: 10.1111/iwj.12526] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/15/2015] [Accepted: 09/20/2015] [Indexed: 12/30/2022] Open
Abstract
Diabetic foot ulcers are the main cause of non-traumatic lower extremity amputation. The objective of this study was to evaluate the risk factors for major amputation in diabetic foot patients. Eight hundred and sixty diabetic patients were admitted to the diabetic wound centre of the Korea University Guro Hospital for foot ulcers between January 2010 and December 2013. Among them, 837 patients were successfully monitored until complete healing. Ulcers in 809 patients (96·7%) healed without major amputation and those in 28 patients (3·3%) healed with major amputation. Data of 88 potential risk factors including demographics, ulcer condition, vascularity, bioburden, neurology and serology were collected from patients in the two groups and compared. Among the 88 potential risk factors, statistically significant differences between the two groups were observed in 26 risk factors. In the univariate analysis, which was carried out for these 26 risk factors, statistically significant differences were observed in 22 risk factors. In a stepwise multiple logistic analysis, six of the 22 risk factors remained statistically significant. Multivariate-adjusted odds ratios were 11·673 for ulcers penetrating into the bone, 8·683 for dialysis, 6·740 for gastrointestinal (GI) disorders, 6·158 for hind foot ulcers, 0·641 for haemoglobin levels and 1·007 for fasting blood sugar levels. The risk factors for major amputation in diabetic foot patients were bony invasions, dialysis, GI disorders, hind foot locations, low levels of haemoglobin and elevated fasting blood sugar levels.
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Affiliation(s)
- Sik Namgoong
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Suyoung Jung
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Seung-Kyu Han
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Seong-Ho Jeong
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Eun-Sang Dhong
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, South Korea
| | - Woo-Kyung Kim
- Department of Plastic Surgery, Korea University College of Medicine, Seoul, South Korea
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Arbanas G, Reisman Y, Andrews S. The sociocultural aspects, professional characteristics, and motivational factors of the first fellows of the European committee of sexual medicine. J Sex Med 2015; 12:1368-74. [PMID: 25919908 DOI: 10.1111/jsm.12900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION After a century of development in the field of sexology and decades of attempts to establish the field of sexual medicine, the first examination that led to the qualification as Fellows of the European Committee of Sexual Medicine (FECSM) was held in December 2012. AIM This study aims to describe the first European specialists in sexual medicine, their clinical practice, motivation, and professional self-identification. METHODS A web-based survey of the first FECSM on demographic data, data on the practices of their work (gender of clients, setting, and time frame), and reasons for entering the sexual medicine (five-point Likert rating of motives and open question on other reasons) was conducted. MAIN OUTCOME MEASURE Gender, religion, specialty, region, and their association with professional practices of the first FECSM. RESULTS The first FECSM have a wide range of experience in the field of sexual medicine (0-30 years) and were mainly men (79%) and urologists (56%). Only 15.5% had other qualifications related to sexual medicine and 60% self-identified as sexual medicine specialists. Only a small proportion of the professional time was dedicated to the practice of sexual medicine. The primary speciality influenced the gender of their patients seen, setting of work (couple vs. individuals), and time spent with patients. Only a minority managed sexual problems in women; hypoactive sexual desire is treated by 41% of FECSM and dyspareunia by 17%. The participants were motivated by the pleasure of knowing new things and desire to understand and to help patients, whereas prestige, finances, and own sex lives are less important. CONCLUSIONS The first FECSM are very diverse in terms of age, culture, religion, and primary specialty. Their practice is strongly influenced by their primary specialty, and this needs to be taken into account in future development of the speciality.
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Affiliation(s)
- Goran Arbanas
- Department for Sexual Medicine, General Hospital Karlovac, Karlovac, Croatia
| | - Yacov Reisman
- Urology, Amstelland Hospital, Amstelveen, The Netherlands
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Lavery LA, Fulmer J, Shebetka KA, Regulski M, Vayser D, Fried D, Kashefsky H, Owings TM, Nadarajah J. The efficacy and safety of Grafix(®) for the treatment of chronic diabetic foot ulcers: results of a multi-centre, controlled, randomised, blinded, clinical trial. Int Wound J 2014; 11:554-60. [PMID: 25048468 PMCID: PMC7951030 DOI: 10.1111/iwj.12329] [Citation(s) in RCA: 163] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Revised: 05/30/2014] [Accepted: 06/05/2014] [Indexed: 01/02/2023] Open
Abstract
In a randomised, controlled study, we compared the efficacy of Grafix®, a human viable wound matrix (hVWM) (N = 50), to standard wound care (n = 47) to heal diabetic foot ulcers (DFUs). The primary endpoint was the proportion of patients with complete wound closure by 12 weeks. Secondary endpoints included the time to wound closure, adverse events and wound closure in the crossover phase. The proportion of patients who achieved complete wound closure was significantly higher in patients who received Grafix (62%) compared with controls (21%, P = 0·0001). The median time to healing was 42 days in Grafix patients compared with 69·5 days in controls (P = 0·019). There were fewer Grafix patients with adverse events (44% versus 66%, P = 0·031) and fewer Grafix patients with wound‐related infections (18% versus 36·2%, P = 0·044). Among the study subjects that healed, ulcers remained closed in 82·1% of patients (23 of 28 patients) in the Grafix group versus 70% (7 of 10 patients) in the control group (P = 0·419). Treatment with Grafix significantly improved DFU healing compared with standard wound therapy. Importantly, Grafix also reduced DFU‐related complications. The results of this well‐controlled study showed that Grafix is a safe and more effective therapy for treating DFUs than standard wound therapy.
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Affiliation(s)
- Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern, Dallas, TX, USA
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Buckley CM, Ali F, Roberts G, Kearney PM, Perry IJ, Bradley CP. Timing of access to secondary healthcare services for diabetes management and lower extremity amputation in people with diabetes: a protocol of a case-control study. BMJ Open 2013; 3:e003871. [PMID: 24171939 PMCID: PMC3816241 DOI: 10.1136/bmjopen-2013-003871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Lower extremity amputation (LEA) is a complication of diabetes and a marker of the quality of diabetes care. Clinical and sociodemographic determinants of LEA in people with diabetes are well known. However, the role of service-related factors has been less well explored. Early referral to secondary healthcare is assumed to prevent the occurrence of LEA. The objective of this study is to investigate a possible association between the timing of patient access to secondary healthcare services for diabetes management, as a key marker of service-related factors, and LEA in patients with diabetes. METHODS/DESIGN This is a case-control study. The source population is people with diabetes. Cases will be people with diabetes who have undergone a first major LEA, identified from the hospital discharge data at each of three regional centres for diabetes care. Controls will be patients with diabetes without LEA admitted to the same centre either electively or as an emergency. Frequency-matching will be applied for gender, type of diabetes, year and centre of LEA. Three controls per case will be selected from the same population as the cases. With a power of 90% to detect OR of 0.4 for an association between 'good quality care' and LEA in people with diabetes, 107 cases and 321 controls are required. Services involved in diabetes management are endocrinology, ophthalmology, renal, cardiology, vascular surgery and podiatry; timing of first contact with any of these services is the main exploratory variable. Using unconditional logistic regression, an association between this exposure and the outcome of major LEA in people with diabetes will be explored, while adjusting for confounders. ETHICS AND DISSEMINATION Ethical approval was granted by the Clinical Research Ethics Committee of the Cork Teaching Hospitals, Ireland. Results will be presented at conferences and published in peer-reviewed journals.
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Affiliation(s)
- Claire M Buckley
- Department of General Practice, University College Cork, Cork, Ireland
- Department of Epidemiology & Public Health, University College Cork, Cork, Ireland
| | - Fauzi Ali
- Department of Medicine and Metabolism, Waterford Institute of Technology, Waterford, Ireland
| | - Graham Roberts
- Department of Medicine and Metabolism, Waterford Institute of Technology, Waterford, Ireland
| | - Patricia M Kearney
- Department of Epidemiology & Public Health, University College Cork, Cork, Ireland
| | - Ivan J Perry
- Department of Epidemiology & Public Health, University College Cork, Cork, Ireland
| | - Colin P Bradley
- Department of General Practice, University College Cork, Cork, Ireland
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Lowe JR, Raugi G, Reiber G, Whitney JD. Does incorporation of a clinical support template in the electronic medical record improve capture of wound care data in a cohort of veterans with diabetic foot ulcers? J Wound Ostomy Continence Nurs 2013; 40:157-62. [PMID: 23466720 PMCID: PMC3591837 DOI: 10.1097/won.0b013e318283bcd8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE The purpose of this cohort study was to evaluate the effect of a 1-year intervention of an electronic medical record wound care template on the completeness of wound care documentation and medical coding compared to a similar time interval for the fiscal year preceding the intervention. METHODS From October 1, 2006, to September 30, 2007, a "good wound care" intervention was implemented at a rural Veterans Affairs facility to prevent amputations in veterans with diabetes and foot ulcers. The study protocol included a template with foot ulcer variables embedded in the electronic medical record to facilitate data collection, support clinical decision making, and improve ordering and medical coding. RESULTS The intervention group showed significant differences in complete documentation of good wound care compared to the historic control group (χ = 15.99, P < .001), complete documentation of coding for diagnoses and procedures (χ = 30.23, P < .001), and complete documentation of both good wound care and coding for diagnoses and procedures (χ = 14.96, P < .001). CONCLUSIONS An electronic wound care template improved documentation of evidence-based interventions and facilitated coding for wound complexity and procedures.
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Affiliation(s)
- Jeanne R. Lowe
- Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Box 359731, Seattle, WA 98104, (206) 356-6045, (206) 744-9957 (fax)
| | - Greg Raugi
- VA Northwest HSR&D Center of Excellence, 1100 Olive Way, Suite 1400, Seattle, WA 98101, (206) 764-4370
| | - Gayle Reiber
- VA Northwest HSR&D Center of Excellence, 1100 Olive Way, Suite 1400, Seattle, WA 98101, (206) 764-2089
| | - JoAnne D. Whitney
- Biobehavioral Nursing and Health Systems, University of Washington School of Nursing, Box 357266, Seattle, WA 98195, (206) 277-3129, (206) 685-2264, (206) 543-4771 (fax)
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Lipsky BA, Weigelt JA, Sun X, Johannes RS, Derby KG, Tabak YP. Developing and validating a risk score for lower-extremity amputation in patients hospitalized for a diabetic foot infection. Diabetes Care 2011; 34:1695-700. [PMID: 21680728 PMCID: PMC3142050 DOI: 10.2337/dc11-0331] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetic foot infection is the predominant predisposing factor to nontraumatic lower-extremity amputation (LEA), but few studies have investigated which specific risk factors are most associated with LEA. We sought to develop and validate a risk score to aid in the early identification of patients hospitalized for diabetic foot infection who are at highest risk of LEA. RESEARCH DESIGN AND METHODS Using a large, clinical research database (CareFusion), we identified patients hospitalized at 97 hospitals in the U.S. between 2003 and 2007 for culture-documented diabetic foot infection. Candidate risk factors for LEA included demographic data, clinical presentation, chronic diseases, and recent previous hospitalization. We fit a logistic regression model using 75% of the population and converted the model coefficients to a numeric risk score. We then validated the score using the remaining 25% of patients. RESULTS Among 3,018 eligible patients, 21.4% underwent an LEA. The risk factors most highly associated with LEA (P < 0.0001) were surgical site infection, vasculopathy, previous LEA, and a white blood cell count >11,000 per mm(3). The model showed good discrimination (c-statistic 0.76) and excellent calibration (Hosmer-Lemeshow, P = 0.63). The risk score stratified patients into five groups, demonstrating a graded relation to LEA risk (P < 0.0001). The LEA rates (derivation and validation cohorts) were 0% for patients with a score of 0 and ~50% for those with a score of ≥21. CONCLUSIONS Using a large, hospitalized population, we developed and validated a risk score that seems to accurately stratify the risk of LEA among patients hospitalized for a diabetic foot infection. This score may help to identify high-risk patients upon admission.
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Shojaiefard A, Khorgami Z, Larijani B. Independent risk factors for amputation in diabetic foot. Int J Diabetes Dev Ctries 2011; 28:32-7. [PMID: 19902045 PMCID: PMC2772008 DOI: 10.4103/0973-3930.43096] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND: Diabetic foot (DF) is the main cause of nontraumatic lower extremity amputation. Early recognition and management of risk factors for foot complications may prevent amputations and other adverse outcomes. MATERIALS AND METHODS: At our hospital we have a protocol for the management of patients hospitalized because of DF. We collected clinical and laboratory data, details of diabetes complications, and history of comorbidities in 146 patients who were admitted for management of DF to determine the risk factors of amputation (major or minor) in these patients. We divided these patients into two groups, those whose treatment included amputation and those who were treated conservatively and carried out a comparative analysis of the variables in the two groups. RESULTS: Major amputation was performed in 5.5% of the patients and minor amputation in 22.6%. Those who required amputation presented a significantly higher (P < 0.05) incidence of nephropathy, history of previous amputation, ischemic diabetic foot and first fasting blood glucose (FBG) > 200 mg/dl after admission. Multivariable-adjusted odds ratios in stepwise logistic regression model was 2.64 for nephropathy (95%CI: 1.06 to 6.60; P = 0.03); 3.03 for ischemic diabetic foot (95%CI: 1.28 to 7.18; P = 0.01); and 3.01 for first FBG > 200 after admission (95%CI: 1.32 to 6.83; P= 0.01). CONCLUSION: Nephropathy, ischemic diabetic foot, and first FBG > 200 mg/dl are independent predictors of limb amputation in patients hospitalized for DF lesions. In addition to early detection and treatment of foot lesions, early management of risk factors is also important.
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Affiliation(s)
- Abolfazl Shojaiefard
- Department of Surgery and Endocrinology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Whitehead SJ, Forest-Bendien VL, Richard JL, Halimi S, Van GH, Trueman P. Economic evaluation of Vacuum Assisted Closure® Therapy for the treatment of diabetic foot ulcers in France. Int Wound J 2010; 8:22-32. [PMID: 20875048 DOI: 10.1111/j.1742-481x.2010.00739.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The objective of the study was to assess the cost-effectiveness of Vacuum Assisted Closure® (V.A.C.®) Therapy compared with advanced wound care (AWC) for the treatment of diabetic foot ulcers (DFUs) in France. A cost-effectiveness model intended to reflect the management of DFUs was updated for the French setting. The Markov model follows the progression of 1000 hypothetical patients over a 1-year period. The model was populated with French-specific data, obtained from published sources and clinical experts. The analysis evaluated costs and health outcomes, in terms of quality-adjusted life-years (QALYs), wounds healed and amputations, from the perspective of the payer. The patients treated with V.A.C.® Therapy experienced more QALYs (0.787 versus 0.784) and improved healing rates (50.2% versus 48.5%) at a lower total cost of care (€24,881 versus €28,855 per patient per year) when compared with AWC. Sensitivity analyses conducted around key model parameters indicated that the results were affected by hospital resource use and costs. DFU treatment using V.A.C.® Therapy in France was associated with lower costs, additional QALYs, more healed ulcers and fewer amputations than treatment with AWC. V.A.C.® Therapy was therefore found to be the dominant treatment option.
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Affiliation(s)
- Sarah J Whitehead
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, UK.
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Goldstein I. EDITORIAL: Keeping The Journal of Sexual Medicine Unique. J Sex Med 2005. [DOI: 10.1111/j.1743-6109.2005.00143.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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