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Mafusi LG, Egenasi CK, Steinberg WJ, Benedict MO, Habib T, Harmse M, Van Rooyen C. Knowledge, attitudes and practices on diabetic foot care among nurses in Kimberley, South Africa. S Afr Fam Pract (2004) 2024; 66:e1-e10. [PMID: 38949451 PMCID: PMC11219695 DOI: 10.4102/safp.v66i1.5935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND Diabetic foot is a dangerous complication of diabetes and can lead to high morbidity and mortality. As essential team members of the healthcare system, nurses play an important role in diabetic foot management and are indispensable in patients' education to prevent diabetic foot. The study assessed nurses' knowledge, attitudes and practices regarding diabetic foot care in Sol Plaatje primary health care centres in the Northern Cape: Sol Plaatje's 14 district municipality clinics, Kimberley, Northern Cape. METHODS This was a descriptive cross-sectional analytical study. A questionnaire assessed nurses' knowledge, practices and attitudes towards diabetic foot care in the above setting. RESULTS A total of 128 professionals, enrolled and auxiliary nurses who are providing primary care to patients within the 14 clinics in the Sol-Plaatje sub-district were recruited for the study. Hundred and five participants completed the self-administered questionnaires. The majority (95%) were females and 58.1% knew that South African Diabetic Foot Guidelines existed, while 57.7% had read them. About 57% did not know about the 60-s diabetic foot screening tool, and 67% did not know the 10 g monofilament test. Approximately 29.8% had never attended a class on diabetic foot care and 85.6% required training on diabetic foot care. CONCLUSION This study revealed that the majority of nurses working in the Sol-Plaatje sub-district primary health care centres are knowledgeable of the diabetic foot guidelines for primary care. However, there is a need for ongoing education on diabetic foot care.Contribution: The study results will help improve nurses' awareness of the importance of diabetic foot care.
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Affiliation(s)
- Labala G Mafusi
- Department of Family Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa; and, Department of Family Medicine, Robert Mangaliso Sobukwe Hospital, Kimberley.
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Sibbald RG, Dalgarno N, Hastings-Truelove A, Soleas E, Jaimangal R, Elliott J, Coderre-Ball AM, Hill S, van Wylick R, Smith K. COVID-19 Pivoted Virtual Skills Teaching Model: Project ECHO Ontario Skin and Wound Care Boot Camp. Adv Skin Wound Care 2024; 37:76-84. [PMID: 38241450 DOI: 10.1097/asw.0000000000000095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To describe a virtual, competency-based skin and wound care (SWC) skills training model. The ECHO (Extension for Community Healthcare Outcomes) Ontario SWC pivoted from an in-person boot camp to a virtual format because of the COVID-19 pandemic. METHODS An outcome-based program evaluation was conducted. Participants first watched guided commentary and videos of experts performing in nine SWC multiskills videos, then practiced and video-recorded themselves performing those skills; these recordings were assessed by facilitators. Data were collected using pre-post surveys and rubric-based assessments. Descriptive statistics and thematic analysis were applied to data analysis. RESULTS Fifty-five healthcare professionals participated in the virtual boot camp, measured by the submission of at least one video. A total of 216 videos were submitted and 215 assessment rubrics were completed. Twenty-nine participants completed the pre-boot camp survey (53% response rate) and 26 responded to the post-boot camp survey (47% response rate). The strengths of the boot camp included the applicability of virtual learning to clinical settings, boot camp supplies, tool kits, and teaching strategies. The analysis of survey responses indicated that average proficiency scores were greater than 80% for three videos, 50% to 70% for three of the videos, and less than 50% for three of the videos. Participants received lower scores in local wound care and hand washing points of contact. The barriers of the boot camp included technical issues, time, level of knowledge required at times, and lack of equipment and access to interprofessional teams. CONCLUSIONS This virtual ECHO SWC model expanded access to practical skills acquisition. The professional development model presented here is generalizable to other healthcare domains.
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Affiliation(s)
- R Gary Sibbald
- R. Gary Sibbald, MD, MEd, FRCPC (Med, Derm), FAAD, MAPWCA, JM, is Professor of Public Health and Medicine, University of Toronto, Dalla Lana School of Public Health and Dept. of Medicine, Faculty of Medicine, University of Toronto, Canada. Nancy Dalgarno, HBOR, BEd, MEd, PhD, OCT, is Director of Education Scholarship, Office of Professional Development and Educational Scholarship, Faculty of Health Sciences, Queen's University, Kingston, Canada. Also at Queen's University, Amber Hastings-Truelove, MA, PhD, is Health Education Researcher and Consultant, Office of Professional Development and Educational Scholarship; and Eleftherios Soleas, MEd, PhD, OCT, is Director of Continuing Professional Development, Office of Professional Development and Educational Scholarship, Faculty of Health Sciences. Reneeka Jaimangal, MD, MScCH, is Project Manager, WoundPedia Project ECHO Ontario, Ontario Skin and Wound, Mississauga, Canada. James Elliott, MSc, is Director of Operations, Woundpedia, Mississauga. Also at Queen's University, Angela M. Coderre-Ball, MSc, PhD, is Research Associate, Department of Family Medicine; Shannon Hill, MEd, OCT, is PhD Candidate, School of Rehabilitation Therapy; Richard van Wylick, MD, FRCPC, is Associate Dean, Professional Development, Faculty of Health Sciences; and Karen Smith, MD, FRCPC, FAAPMR, FABEM, is Professor, Department of Physical Medicine and Rehabilitation
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Amini MR, Sanjari M, Mohajeri Tehrani MR, Nasli E, Yazdanpanah L, Mousavi Z, Forghan F, Valizadeh N, Gozashti MH, Afkhami-Ardekani M, Siavash M, Vahdat K, Shamsi A, Sadeghi D, Larijani B, Mehrdad N, Aalaa M. Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: a national multicenter study. BMC Endocr Disord 2023; 23:178. [PMID: 37605234 PMCID: PMC10440894 DOI: 10.1186/s12902-023-01401-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/03/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND AND PURPOSE The lack of timely foot care among individuals with diabetics often lead to ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening practices among patients with type 2 diabetes in various cities across Iran. METHODS The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, and diabetic foot self-care (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow's 60-Second Screen. RESULTS The study included 1094 diabetic patients with, with a majority being female (64.8%) and married (92.5%). The average age of the participants was 57.6 ± 10.21 (mean ± SD), and the mean duration of diabetes was 11.56 ± 7.41 years. Based on Inlow's 60-Second Screen criteria, 58% of the patients should undergo yearly foot ulcer screening, 47% exhibited peripheral neuropathy, and 37% were found to have inappropriate footwear. CONCLUSION The high prevalence of peripheral neuropathy observed in approximately half of the participants across different regions of Iran underscores the importance of continuous patient education regarding foot care and appropriate footwear. Furthermore, regular foot ulcer screenings, following the recommended intervals outlined in Inlow's screening protocol, should be implemented to effectively manage diabetic foot complications.
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Affiliation(s)
- Mohammad Reza Amini
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Sanjari
- Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Reza Mohajeri Tehrani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ensieh Nasli
- Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Leila Yazdanpanah
- Diabetes Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Zohreh Mousavi
- Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Neda Valizadeh
- Maternal and Childhood Obesity Research Center, Urmia University of Medical Sciences, Urmia, Iran
| | - Mohammad Hossein Gozashti
- Endocrine and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Mansour Siavash
- Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Katayoun Vahdat
- The Persian Gulf Tropical Medicine Research Center, The Persian Gulf Biomedical Sciences Research Institute, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Abbas Shamsi
- Department of Clinical Psychology, Khomein Branch, Islamic Azad University, Khomein, Iran
| | - Donya Sadeghi
- Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Neda Mehrdad
- Elderly Health Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.
| | - Maryam Aalaa
- Department of e-Learning in Medical Education, Center of Excellence for e-Learning in Medical Education, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
- Evidence Based Medicine Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of medical Sciences, Tehran, Iran.
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Amini MR, Sanjari M, Tehrani MRM, Nasli E, Yazdanpanah L, Mousavi Z, Forghan F, Valizadeh N, Gozashti MH, Afkhami-ardekani M, Siavash M, Vahdat K, Shamsi A, Sadeghi D, Larijani B, Mehrdad N, Aalaa M. Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: A national multicenter study.. [DOI: 10.21203/rs.3.rs-2880691/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2024]
Abstract
Abstract
Background and Purpose
Lack of timely foot care in diabetics result in ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening of patients suffering from diabetes around the country of Iran.
Methods
The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, diabetic foot self-care situation (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow’s 60-Second Screen.
Results
Participants were 1094 diabetic patients. Most of the participants were female (64.8%) and married (92.5%) with the average age of 57.6 ± 10.21 (mean ± SD). The mean duration of DM was 11.56 ± 7.41 years. According to the Inlow’s 60-Second Screen criteria, 58% of patients should have foot ulcer screened yearly and 47% of the patients had peripheral neuropathy, 37% of population had inappropriate foot wear.
Conclusion
Considering the prevalence of peripheral neuropathy among about than half of participants in this study across Iran, it is essential to have continuous patients’ education about foot care and foot wear. Additionally, foot ulcer screening would be performed in recommended interval of Inlow screen.
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Affiliation(s)
| | | | | | | | - Leila Yazdanpanah
- Health Research Institute, Ahvaz Jundishapur University of Medical Sciences
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Scientific and Clinical Abstracts From WOCNext® 2023: Las Vegas, Nevada ♦ June 4-7, 2023. J Wound Ostomy Continence Nurs 2023; 50:S1-S78. [PMID: 37632270 DOI: 10.1097/won.0000000000000980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Nanofibrous Vildagliptin/PLGA Membranes Accelerate Diabetic Wound Healing by Angiogenesis. Pharmaceuticals (Basel) 2022; 15:ph15111358. [PMID: 36355530 PMCID: PMC9696371 DOI: 10.3390/ph15111358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/27/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
The inhibition of dipeptidyl peptidase-4 (DPP4) significantly enhances the wound closure rate in diabetic patients with chronic foot ulcers. DPP4 inhibitors are only prescribed for enteral, but topical administration, if feasible, to a wound would have more encouraging outcomes. Nanofibrous drug-eluting poly-D-L-lactide-glycolide (PLGA) membranes that sustainably release a high concentration of vildagliptin were prepared to accelerate wound healing in diabetes. Solutions of vildagliptin and PLGA in hexafluoroisopropanol were electrospun into nanofibrous biodegradable membranes. The concentration of the drug released in vitro from the vildagliptin-eluting PLGA membranes was evaluated, and it was found that effective bioactivity of vildagliptin can be discharged from the nanofibrous vildagliptin-eluting membranes for 30 days. Additionally, the electrospun nanofibrous PLGA membranes modified by blending with vildagliptin had smaller fiber diameters (336.0 ± 69.1 nm vs. 743.6 ± 334.3 nm, p < 0.001) and pore areas (3405 ± 1437 nm2 vs. 8826 ± 4906 nm2, p < 0.001), as well as a higher hydrophilicity value (95.2 ± 2.2° vs. 113.9 ± 4.9°, p = 0.004), and showed a better water-retention ability within 24 h compared with PLGA membranes. The vildagliptin-eluting PLGA membrane also enhanced the diabetic wound closure rate for two weeks (11.4 ± 3.0 vs. 18.7 ± 2.6 %, p < 0.001) and the level of the angiogenesis using CD31 expression (1.73 ± 0.39 vs. 0.45 ± 0.17 p = 0.006 for Western blot; 2.2 ± 0.5 vs. 0.7 ± 0.1, p < 0.001 for immunofluorescence). These results demonstrate that nanofibrous drug-eluting PLGA membranes loaded with vildagliptin are an effective agent for sustained drug release and, therefore, for accelerating cutaneous wound healing in the management of diabetic wounds.
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Silveira IA, Oliveira BGRBD, Souza PAD, Oliveira BC, Sergio FR, Carvalho MRD. CONSTRUCT VALIDITY AND RELIABILITY OF THE LEG ULCER MEASUREMENT TOOL SCALE ADAPTED FOR BRAZIL. TEXTO & CONTEXTO ENFERMAGEM 2022. [DOI: 10.1590/1980-265x-tce-2021-0212en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to validate the Portuguese version of the Leg Ulcer Measurement Tool regarding construct and reliability. Method: this is a methodological research study. Data collection was conducted between January and July 2019. A total of 105 participants were included for construct validation and internal consistency and, of these, 50 were selected for intra-observer stability. For the analysis of construct validity, factor analysis was performed; for internal consistency, Cronbach's alpha coefficient was calculated, and for stability, the intraclass correlation coefficient. Results: A total of 12items were confirmed for the Brazilian reality, meeting all the theoretical requirements of the factor analysis model. As for the internal consistency (reliability) analysis, the Cronbach's alpha coefficient values (α=0.711) showed that the set of items that make up the scale measures the same characteristics and presents internal consistency. In the global stability analysis (ICC=0.823), the Leg Ulcer Measurement Tool test and retest scores presented good agreement, showing that the adapted scale is stable. Conclusion: the Leg Ulcer Measurement Tool scale adapted to the Portuguese language contains 12 items, with scores varying from 0 to 4 and, thus, produces a score from 0 to 48 points. It presents construct validity analyzed by means of factor analysis and reliability in terms of internal consistency and stability.
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Sumpio BE, McConnie S, Maharaj D. Heterogeneity in the guidelines for the management of diabetic foot disease in the Caribbean. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000446. [PMID: 36962244 PMCID: PMC10021831 DOI: 10.1371/journal.pgph.0000446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 04/13/2022] [Indexed: 11/19/2022]
Abstract
The prevalence of diabetes mellitus, diabetic foot (DF) disease and, as a result, lower extremity amputation rates remain high in the Caribbean. This study was undertaken to determine whether Caribbean countries have designated individuals that monitor DF disease and whether there are DF protocols consistent with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. Relevant DF health care personnel(s) from the CARICOM and Dutch Caribbean countries were called or sent questionnaires regarding the presence of structured programs to monitor and manage DF problems in the population. All 25 countries (100%) responded. 81% of respondents could not identify any Ministry, Hospital or individual initiatives that monitored the DF. Only 9 (36%) countries had any guidelines in place. Only 3 countries with guidelines in place utilized IWGDF guidelines. Only 6 (24%) countries had podiatrists and 10 (40%) had vascular surgery availability. 7 (28%) countries had the components for a multidisciplinary team. The presence or the appointment of a designated individual and/or a multidisciplinary approach within the countries for DF disease was absent in the majority of respondent countries. Only a minority of countries implemented DF guidelines or had expertise available to organize a DF multidisciplinary team. Vascular surgery and podiatric care were noticeably deficient. These may be critical factors in the variability and reduced success in implementation of strategies for managing DF problems and subsequent amputations amongst these Caribbean countries.
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Affiliation(s)
- Bauer E Sumpio
- Department of Vascular Surgery, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | | | - Dale Maharaj
- Caribbean Vascular & Vein Clinic, Port of Spain, Trinidad and Tobago
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Lee EJ, Jeong IS, Kim IJ, Cho YH, Kim YJ. Risk assessment and classification for foot ulceration among patients with type 2 diabetes in South Korea. Int J Nurs Pract 2021; 28:e13012. [PMID: 34545667 DOI: 10.1111/ijn.13012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 07/01/2021] [Accepted: 08/14/2021] [Indexed: 11/30/2022]
Abstract
AIM This study aimed to investigate the distribution of foot conditions, the risk of foot ulceration and its associated factors in patients with diabetes. Few studies have focused on the risk of foot ulceration in patients with diabetes. METHODS A total of 267 patients with diabetes who attended outpatient clinics in two tertiary referral hospitals were recruited from June to September 2016. The risk of foot ulceration was classified using the American Diabetes Association (ADA), International Working Group on the Diabetic Foot (IWGDF) and Scottish Intercollegiate Guidelines Network (SIGN) classification systems. The risk categories of each system were reclassified into high- (categories of 2 and 3 for the ADA and IWGDF systems and high for the SIGN system) and low-risk. RESULTS Foot deformity was the most prevalent condition (38.2%). Among 261 patients without active ulcers, between 17.6% to 35.2% were classified in the high-risk group and overall agreement among systems ranged from .42 to .56 of the kappa statistic. Insulin treatment was consistently associated with a high-risk of foot ulceration. CONCLUSIONS As the risk varies between systems, nurses should select a suitable classification system through validation studies and assess the risk in patients with diabetes, particularly, those receiving insulin treatment.
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Affiliation(s)
- Eun Joo Lee
- Department of Nursing, Dong-Eui University, Busan, Republic of Korea
| | - Ihn Sook Jeong
- College of Nursing, Pusan National University, Yangsan, Republic of Korea
| | - In Ju Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Young Hye Cho
- Department of Family Medicine, Pusan National University Yangsan Hospital & Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Yun Jin Kim
- Department of Family Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Department of Family Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
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Construction and Validation of an Instrument for Assessing the Feet of Persons with Diabetes. Adv Skin Wound Care 2020; 33:267-271. [PMID: 32304450 DOI: 10.1097/01.asw.0000658588.28614.96] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To construct and validate an assessment instrument to evaluate the feet of people with diabetes mellitus in Brazil. METHODS Methodological research developed in three stages: construction of the Assessment Instrument for the Feet of People with Diabetes Mellitus, validation of face and content validity, and field research with 131 participating patients. The Pearson (r) and Spearman correlation coefficients (ρ) were used for criterion validity. To test reliability, the internal consistency of the Cronbach α domains was evaluated and simple κ, weighted κ, and intraclass correlation coefficients for interobserver evaluation were determined. RESULTS The instrument demonstrated validity and reliability. The content validity index represented a high internal consistency (α > .70). The interclass correlation coefficient was high (>0.98). The Pearson (r) and Spearman (ρ) correlation tests confirmed a correlation between the two variables. CONCLUSIONS The instrument was valid and reliable for assessing the feet of people with diabetes mellitus in Brazil. Future studies should identify the cut off point for the diagnosis of neuropathic and vascular impairment of the feet of diabetic persons through appropriate statistical methods.
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Validated 60-Second General Foot Screen: A Pilot Trial and Guide to Diagnoses and Treatment. Adv Skin Wound Care 2020; 32:490-501. [PMID: 31625965 DOI: 10.1097/01.asw.0000582624.75772.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
GENERAL PURPOSE To provide information on a 60-second General Foot Screen to assist in the prevention and/or identification and management of common foot problems. TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After participating in this educational activity, the participant should be better able to:1. Use the 60-second General Foot Screen to assist healthcare professionals in the recognition of common foot problems.2. Identify risk factors, causes, and treatment of selected foot problems. ABSTRACT Foot health is important to overall patient health. Early diagnosis and treatment of diabetes, neuropathy, fungal foot infections, foot deformity, and vascular disease/lower leg edema can improve patient quality of life. One way to achieve this is effective screening. To this end, researchers piloted a validated 10-item screening tool to assess foot health on 120 patients; 74.17% had at least one positive abnormality, demonstrating the critical importance of these early findings. Only 25.83% of individuals had completely low-risk feet. This easy-to-use tool can assist healthcare professionals in the recognition and treatment of common foot problems. The article also outlines the early signs of disease by screening item and provides a guide to treatment to enable effective prevention and quality care.
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Lanting SM, Spink MJ, Tehan PE, Vickers S, Casey SL, Chuter VH. Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability. J Foot Ankle Res 2020; 13:3. [PMID: 31988664 PMCID: PMC6966840 DOI: 10.1186/s13047-020-0371-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/13/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Testing of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes. METHODS Three podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year's clinical experience. The intra- (Cohen's К) and inter-rater (Cohen's or Fleiss' К) reliability of each test was determined. RESULTS Fifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38-0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41-0.95, p < 0.01). The 10-site monofilament (К: 0.44-0.77) outperformed the 4-site test (К: 0.34-0.67) and the dampened tuning fork method (К: 0.41-0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52-0.57) and graduated methods (К: 0.50-0.57). CONCLUSION We support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.
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Affiliation(s)
| | | | - Peta Ellen Tehan
- School of Health Sciences, University of Newcastle, Newcastle, Australia
- Priority Research Centre for Gender, Health and Ageing, University of Newcastle, Newcastle, Australia
| | - Stephanie Vickers
- School of Health Sciences, University of Newcastle, Newcastle, Australia
| | - Sarah Louise Casey
- School of Health Sciences, University of Newcastle, Newcastle, Australia
| | - Vivienne Helaine Chuter
- School of Health Sciences, University of Newcastle, Newcastle, Australia
- Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Newcastle, Australia
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Woldemariam GT, Atnafu NT, Radie YT, Wolde GT, Gebreagziabher TT, Gebrehiwot TG, Teka YH, Hagos MG, Hagezom HM, Yigzaw HB, Gebremedhin HT, Mezgebo HM, Gebremariam A. Determinants of Diabetic Foot Ulcer Among Adult Patients with Diabetes Attending the Diabetic Clinic in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: Unmatched Case-Control Study. Diabetes Metab Syndr Obes 2020; 13:3739-3747. [PMID: 33116723 PMCID: PMC7571574 DOI: 10.2147/dmso.s265988] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/19/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic foot ulcer is among the commonest complications of diabetic mellitus attributed to a number of morbidity and mortality cases in diabetic patients. Nowadays, the incidence of diabetic foot ulcer is increasing due to the increased prevalence of diabetes. However, the risk factors of the problem are less studied in Ethiopia. Hence, this study was conducted to assess the determinants of diabetic foot ulcer among adult patients with diabetes attending a diabetic clinic in Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia in 2019. PATIENTS AND METHODS An institution-based unmatched case-control study was conducted on 161 patients with diabetes (53 patients with diabetes with foot ulcer and 108 patients with diabetes without foot ulcer). Cases were selected from patients with diabetes with foot ulcer by consecutive sampling technique and controls from patients with diabetes without diabetic foot ulcer by systematic random sampling technique. A binary logistic regression model was used to assess the association between the dependent and independent variables. All variables with a P-value<0.25 were included in the multivariable analysis. Statistical significance was declared at P-value<0.05 with 95% confidence interval. RESULTS In this study, 28 (52.8%) cases and 55 (50.9%) controls were male. Taking insulin alone (AOR=2.75, 95% CI=1.04-7.23), having peripheral neuropathy (AOR=7.56, 95% CI=2.82-20.24), not inspecting feet daily (AOR=5.61, 95% CI=2.24-14.05), and using moisturizing cream between toes (AOR=3.35, 95% CI=1.35-8.32) were positively associated with diabetic foot ulcer, whereas employed (AOR=0.35, 95% CI=0.14-0.87) and combined treatment (insulin and oral hypoglycemic agents) (AOR=0.11, 95% CI=0.02-0.57) were negatively associated with diabetic foot ulcer. CONCLUSION Diabetic foot ulcer was significantly associated with occupation, kind of treatment of diabetes mellitus taking, peripheral neuropathy, inspecting feet daily, and putting moisturizing cream between toes. It will be helpful if diabetic patients inspect their feet on a daily basis and do not put moisturizing cream between their toes.
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Affiliation(s)
- Guesh Teklu Woldemariam
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
- Correspondence: Guesh Teklu WoldemariamDepartment of Nursing, College of Medicine and Health Sciences, Adigrat University, Postal Address: 50, Tigrai, EthiopiaTel +251940304140 Email
| | - Niguse Tadele Atnafu
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yosief Tsige Radie
- School of Nursing and Midwifery, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | | | - Yared Haileselassie Teka
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Milete Gebrehiwot Hagos
- Department of Nursing, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Haftamu Mamo Hagezom
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Hailu Belay Yigzaw
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Haftom Tesfay Gebremedhin
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Hagos Mehari Mezgebo
- Department of Psychiatry, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
| | - Alem Gebremariam
- Department of Public Health, College of Medicine and Health Sciences, Adigrat University, Tigrai, Ethiopia
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Papanas N, Pafili K, Demetriou M, Papachristou S, Kyroglou S, Papazoglou D, Maltezos E. The Diagnostic Utility of VibraTip for Distal Symmetrical Polyneuropathy in Type 2 Diabetes Mellitus. Diabetes Ther 2020; 11:341-346. [PMID: 31782049 PMCID: PMC6965598 DOI: 10.1007/s13300-019-00738-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION The aim of this study was to assess the performance of VibraTip, a device used to test a person's vibration perception during routine checks for peripheral neuropathy, against two thresholds of the Neuropathy Disability Score (NDS) for diagnosing distal symmetrical polyneuropathy (DSPN) in patients with type 2 diabetes mellitus (T2DM). METHODS One hundred consecutive subjects with T2DM were enrolled in the study, of whom 54 were men. The mean age was 62.3 years, and the mean T2DM duration was 12.6 years. VibraTip was used at one foot site (on the pulp of the hallux; protocol A) and at three foot sites (pulp of the hallux and first and third metatarsal head; protocol B). NDS thresholds of ≥ 3 and ≥ 6 were used to establish the diagnosis of DSPN. RESULTS Against the NDS ≥ 3 threshold, VibraTip showed a very high sensitivity (91.3%) and negative predictive value (NPV) (92%) and a high specificity (85.2%) with protocol A, and a very high sensitivity (95.6%) and NPV (96.1%) and a very high specificity (90.7%) with protocol B. Against the NDS ≥ 6 threshold, VibraTip showed a very high sensitivity (100%) and NPV (100%) and a very high specificity (95.2%) with protocol A, and very high sensitivity (100%) and NPV (100%) and very high specificity (96.8%) with protocol B. CONCLUSIONS The diagnostic performance of VibraTip is very high in patients with T2DM, rendering it a very useful device as a screening tool, particularly for the exclusion of DSPN. VibraTip performs very well at both NDS thresholds, but particularly well at the NDS ≥ 6 threshold. There appears to be no need to examine sites other than the hallux site with Vibratip.
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Affiliation(s)
- Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece.
| | - Kalliopi Pafili
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria Demetriou
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Stella Papachristou
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Soultana Kyroglou
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Dimitrios Papazoglou
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Efstratios Maltezos
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
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An Application for Skin Macules Characterization Based on a 3-Stage Image-Processing Algorithm for Patients with Diabetes. JOURNAL OF HEALTHCARE ENGINEERING 2019; 2018:9397105. [PMID: 30651950 PMCID: PMC6311831 DOI: 10.1155/2018/9397105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/28/2018] [Indexed: 11/17/2022]
Abstract
Diabetic skin manifestations, previous to ulcers and wounds, are not highly accounted as part of diagnosis even when they represent the first symptom of vascular damage and are present in up to 70% of patients with diabetes mellitus type II. Here, an application for skin macules characterization based on a three-stage segmentation and characterization algorithm used to classify vascular, petechiae, trophic changes, and trauma macules from digital photographs of the lower limbs is presented. First, in order to find the skin region, a logical multiplication is performed on two skin masks obtained from color space transformations; dynamic thresholds are stabilised to self-adjust to a variety of skin tones. Then, in order to locate the lesion region, illumination enhancement is performed using a chromatic model color space, followed by a principal component analysis gray-scale transformation. Finally, characteristics of each type of macule are considered and classified; morphologic properties (area, axes, perimeter, and solidity), intensity properties, and a set of shade indices (red, green, blue, and brown) are proposed as a measure to obviate skin color differences among subjects. The values calculated show differences between macules with a statistical significance, which agree with the physician's diagnosis. Later, macule properties are fed to an artificial neural network classifier, which proved a 97.5% accuracy, to differentiate between them. Characterization is useful in order to track macule changes and development along time, provides meaningful information to provide early treatments, and offers support in the prevention of amputations due to diabetic feet. A graphical user interface was designed to show the properties of the macules; this application could be the background of a future Diagnosis Assistance Tool for educational (i.e., untrained physicians) and preventive assistance technology purposes.
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16
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Subrata SA, Phuphaibul R. Diabetic foot ulcer care: a concept analysis of the term integrated into nursing practice. Scand J Caring Sci 2019; 33:298-310. [PMID: 30604889 DOI: 10.1111/scs.12645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Diabetic foot ulcer care demonstrates a beneficial approach to overcoming problems in patients with diabetes. This approach is frequently given but is not always successfully implemented due to its fragmentation amid healthcare providers. What's more, there are a number of different understandings, interchangeable languages and an absence of uniformity overlapping terminologies of meaning for diabetic foot ulcer care. Therefore, analysing the concept of diabetic foot ulcer care is important to provide a wider nursing knowledge, synthesise a greater theoretical model and drive more effective care of diabetic foot ulcer. OBJECTIVE This article aimed to analyse how the concept of diabetic foot ulcer care is clearly defined in the relevant evidence as it has several implications in nursing practice. METHOD Walker and Avant's (1995) method of concept analysis was systematically used in this study. FINDINGS Three critical attributes of diabetic foot ulcer care were determined consisting of assessment, intervention and evaluation. Constructed cases are also presented to differentiate the concept of diabetic foot ulcer care from other concepts. This concept analysis results in the critical attributes of diabetic foot ulcer care, defines an operational definition and describes common goals that improve clarity, consistency and understanding of the concept amid healthcare professionals along with researchers. CONCLUSION Effective implementation of the concept of DFU care into clinical nursing practice may undoubtedly improve patient outcomes and prevent the complexities of DFU in the years to come. Future research needs to be developed for evaluating the current use of this concept.
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Affiliation(s)
- Sumarno A Subrata
- Doctor of Philosophy Program in Nursing (International and Collaborative Program with Foreign Universities), Mahidol University, Thailand.,Department of Nursing, Faculty of Health Sciences, Universitas Muhammadiyah Magelang, Central Java, Indonesia
| | - Rutja Phuphaibul
- Doctor of Philosophy Program in Nursing (International and Collaborative Program with Foreign Universities), Mahidol University, Thailand.,Ramathibodi School of Nursing, Mahidol University, Bangkok, Thailand
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Subrata SA, Phuphaibul R, Kanogsunthornrat N, Siripitayakunkit A. ADIE - Nursing Interventions of Diabetic Foot Ulcer: An Integrative Review of the Literature. Curr Diabetes Rev 2019; 16:40-51. [PMID: 30848205 DOI: 10.2174/1573399815666190307164119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 01/31/2019] [Accepted: 02/27/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIMS Diabetic foot ulcer is recognized as a consequence of peripheral neuropathy and peripheral arterial disease amid individuals with diabetes. As is well known, this situation still remains a crucial problem in nursing practice. Available studies describing an algorithm of inter- related nursing interventions concerned with diabetic foot ulcers are limited. Therefore, this integrative review was aimed to present evidence-based practice for overcoming the complications of diabetic foot ulcer as well as preventing lower extremity amputation. METHODS This integrative review retrieved scientific literature from PubMed, CINAHL, ProQuest, SAGE Publishing and ScienceDirect databases as published from 2008 to 2017. Thirty-seven studies that met the inclusion criteria were included in this study. RESULTS Our findings present that neurologic and circulatory assessments were considered as primary steps prior to conducting interventions. Formulating a diagnosis based upon the assessment results is a principal part to determine appropriate interventions. Multiple experimental studies displayed the effectiveness of certain interventions consist of applying wound cleansing, advanced modern wound dressing, topical therapy, offloading, intensive diabetes education and advanced treatment modalities. Hemoglobin A1c, high-density lipoprotein, procalcitonin, the potential of hydrogen of wound fluid, wound size, neurological and circulatory status were determined as the outcomes measurement which must be correctly evaluated. CONCLUSION This review contributes an algorithm for intervening diabetic foot ulcer thereby generating the given name: ADIE (Assessment, Diagnosis, Interventions, and Evaluation). A collaborative care amid multidisciplinary diabetes team is needed for implementing along with evaluating the feasibility of the study findings. Moreover, active family participation also plays a crucial role to achieve successful management of diabetic foot ulcer at home.
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Affiliation(s)
- Sumarno Adi Subrata
- Doctor of Philosophy Program in Nursing, International Program, Mahidol University, Bangkok, Thailand
- Universitas Muhammadiyah Magelang, Central Java, Indonesia
| | - Rutja Phuphaibul
- Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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18
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Vogt EC, Øksnes M, Suleiman F, Juma BA, Thordarson HB, Ommedal O, Søfteland E. Assessment of diabetic polyneuropathy in Zanzibar: Comparison between traditional methods and an automated point-of-care nerve conduction device. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2017; 10:9-14. [PMID: 29204366 PMCID: PMC5691212 DOI: 10.1016/j.jcte.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/12/2017] [Accepted: 09/12/2017] [Indexed: 01/19/2023]
Abstract
We screened for signs of neuropathy in a diabetes population in Zanzibar. Nerve conduction study by NC-stat DPNCheck found neuropathy in 45%. Monofilament results suggestive of neuropathy in 61%. Compared to nerve conduction study, monofilament had a 59% specificity. Hyperglycaemia and hypertension are highly prevalent risk factors in this population.
Aim Scant information is available about the prevalence of diabetic polyneuropathy, as well as the applicability of screening tools in sub-Saharan Africa. We aimed to investigate these issues in Zanzibar (Tanzania). Methods One hundred consecutive diabetes patients were included from the diabetes clinic at Mnazi Mmoja Hospital. Clinical characteristics were recorded. Further, we investigated: a) self-reported numbness of the lower limbs, b) ten-point monofilament test, c) the Sibbald 60-s Tool and d) nerve conduction studies (NCS, using an automated handheld point-of-care device, the NC-stat DPNCheck). Results Mean age was 54 years, 90% had type 2 diabetes, and with 9 year average disease duration. Mean HbA1c was 8.5% (69 mmol/mol), blood pressure 155/88 mmHg. Sixty-two% reported numbness, 61% had positive monofilament and 79% positive Sibbald tool. NCS defined neuropathy in 45% of the patients. Only the monofilament showed appreciable concordance with the NCS, Cohen’s κ 0.43. Conclusions The patient population was characterised by poor glycaemic control and hypertension. In line with this, neuropathy was rampant. The monofilament test tended to define more cases of probable neuropathy than the NCS, however specificity was rather low. Plantar skin thickening may have led to false positives in this population. Overall concordance was, however, appreciable, and could support continued use of monofilament as a neuropathy screening tool. The NC-stat DPNCheck could be useful in cases of diagnostic uncertainty or for research purposes in a low resource setting.
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Affiliation(s)
- Elinor C. Vogt
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
- Corresponding author at: Haukeland University Hospital, Department of Medicine, PO Box 1400, N-5021 Bergen, Norway.Haukeland University HospitalDepartment of MedicinePO Box 1400N-5021 BergenNorway
| | - Marianne Øksnes
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, Norway
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Faiza Suleiman
- Medical Department, Mnazi Mmoja Hospital, Stone Town, Zanzibar, Tanzania
| | - Buthayna Ali Juma
- Medical Department, Mnazi Mmoja Hospital, Stone Town, Zanzibar, Tanzania
| | | | - Ola Ommedal
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Eirik Søfteland
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
- Hormone Laboratory, Haukeland University Hospital, 5021 Bergen, Norway
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Woodbury MG. Diabetic foot risk assessment. Diabetes Metab Res Rev 2016; 32:376-8. [PMID: 26825436 DOI: 10.1002/dmrr.2784] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 01/17/2016] [Accepted: 01/18/2016] [Indexed: 11/08/2022]
Abstract
Diabetes is a serious chronic disease that results in foot complications for many people world-wide. In 2014, the World Health Organization estimated the global prevalence of diabetes in adults to be 9%. To ascertain the risk that an individual patient might develop a diabetic foot ulcer that could lead to an amputation, clinicians are strongly encouraged to perform a risk assessment. Monteiro-Soares and Dinis-Ribeiro have presented a new DIAbetic FOot Risk Assessment with the acronym DIAFORA. It is different from other risk assessments in that it predicts the risk of developing both diabetic foot ulcers and amputation specifically. The risk variables were derived by regression analysis based on a data set of 293 patients from a high-risk setting, a Hospital Diabetic Foot Clinic, who had diabetes and a diabetic foot ulcers. Clear descriptions of the risk variables are provided as well as sensitivity, specificity, positive and negative predictive values for the risk categories. As an added benefit, likelihood ratios are provided that will help clinicians determine the risk of amputation for individual patients. Having a risk assessment form is important for clinician use and examples exist. A question is raised about the effectiveness of risk assessment and how effectiveness might be determined.
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Affiliation(s)
- M Gail Woodbury
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Ontario, Canada
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