Prioritisation of diabetes-related footcare amongst primary care healthcare professionals

Aims and objectives To assess primary healthcare professionals’ priority for managing diabetic foot disease (DFD) over the progressive course of the condition compared to other aspects of diabetes care. Background DFD affects up to 60 million people globally. Evidence suggests that comprehensive preventative footcare may reduce serious complications of DFD, such as amputation. Design A cross-sectional quantitative study reported according to STROBE statement. Methods General Practitioners (GPs) and Credentialled Diabetes Educators (CDEs) working within Australian primary care were invited to complete an online survey, to obtain information about preventative and early intervention footcare priorities and practices. Ten GPs and 84 CDEs completed the survey. Results On diagnosis of type 2 diabetes, haemoglobin A1c (HbA1c) review was identified to be one of the top three priorities of care by 57 (61%) of participants whilst at 20-year history of diabetes 73 (78%) participants indicated its priority. Foot assessments became a priority for 78% (n = 73) of participants and podiatry referrals a priority for 53% (n = 50) of participants only when a “foot concern” was raised. Referrals to specialist high-risk foot podiatrists or services were a first priority for 56% (n = 53), when the person had significant amputation risk factors. Conclusion Diabetes-related preventative footcare assessments and management remain a low priority amongst primary healthcare professionals. Preventative care for asymptomatic complications, such as DFD, may be overlooked in favour of monitoring HbA1c or medication management. Limited prioritisation of footcare in primary care is concerning given the risks for amputation associated with DFD. Relevance to clinical practice This study reveals the need for primary healthcare decision makers and clinicians to ensure preventative footcare is a focused priority earlier in the diabetes care continuum. Collaborative and widespread promotion of the importance of proactive rather than reactive footcare practices is required to support prevention of foot ulcers and amputation

Using On-line Guided-Self Determination to Provide High Quality Diabetes Self-Management: An analysis with Activity Theory

This paper presents and evaluation of the use of a developed on line guided Self-Determination (GSD) solution for young adults with Type 1 diabetes. Activity theory is proffered as a suitable analysis lens to highlight and unpack key social interactions. An exploratory descriptive design with four stages that involved: (1) developing the GSD program online; (2) training diabetes educators to use the GSD program in an online format; (3) implementing and pilot testing the GSD program; and (d) evaluating the online version formed the adopted methodology

Transition to motherhood in type 1 diabetes : design of the pregnancy and postnatal well-being in transition questionnaires

Background : Life transitions are associated with high levels of stress affecting health behaviours among people with Type 1 diabetes. Transition to motherhood is a major transition with potential complications accelerated by pregnancy with risks of adverse childbirth outcomes and added anxiety and worries about pregnancy outcomes. Further, preparing and going through pregnancy requires vigilant attention to a diabetes management regimen and detailed planning of everyday activities with added stress on women. Psychological and social well-being during and after pregnancy are integral for good pregnancy outcomes for both mother and baby. The aim of this study is to establish the face and content validity of two novel measures assessing the well-being of women with type 1 diabetes in their transition to motherhood, 1) during pregnancy and 2) during the postnatal period. Methods : The approach to the development of the Pregnancy and Postnatal Well-being in T1DM Transition questionnaires was based on a four-stage pre-testing process; systematic overview of literature, items development, piloting testing of questionnaire and refinement of questionnaire. The questionnaire was reviewed at every stage by expert clinicians, researchers and representatives from consumer groups. The cognitive debriefing approach confirmed relevance of issues and identified additional items. Results : The literature review and interviews identified three main areas impacting on the women&rsquo;s postnatal self-management; (1) psychological well-being; (2) social environment, (3) physical (maternal and fetal) well-being. The cognitive debriefing in pilot testing of the questionnaire identified that immediate postnatal period was difficult, particularly when the women were breastfeeding and felt depressed. Conclusions : The questionnaires fill an important gap by systematically assessing the psychosocial needs of women with type 1 diabetes during pregnancy and in the immediate postnatal period. The questionnaires can be used in larger data collection to establish psychometric properties. The questionnaires potentially play a key role in prospective research to determine the self-management and psychological needs of women with type 1 diabetes transitioning to motherhood and to evaluate health education interventions.<br /

Transversus Abdominis Plane Catheter Bolus Analgesia after Major Abdominal Surgery

Purpose. Transversus abdominis plane (TAP) blocks have been shown to reduce pain and opioid requirements after abdominal surgery. The aim of the present case series was to demonstrate the use of TAP catheter injections of bupivacaine after major abdominal surgery. Methods. Fifteen patients scheduled for open colonic resection surgery were included. After induction of anesthesia, bilateral TAP catheters were placed, and all patients received a bolus dose of 20 mL bupivacaine 2.5 mg/mL with epinephrine 5 μg/mL through each catheter. Additional bolus doses were injected bilaterally 12, 24, and 36 hrs after the first injections. Supplemental pain treatment consisted of paracetamol, ibuprofen, and gabapentin. Intravenous morphine was used as rescue analgesic. Postoperative pain was rated on a numeric rating scale (NRS, 0–10) at regular predefined intervals after surgery, and consumption of intravenous morphine was recorded. Results. The TAP catheters were placed without any technical difficulties. NRS scores were ≤3 at rest and ≤5 during cough at 4, 8, 12, 18, 24, and 36 hrs after surgery. Cumulative consumption of intravenous morphine was 28 (23–48) mg (median, IQR) within the first 48 postoperative hours. Conclusion. TAP catheter bolus injections can be used to prolong analgesia after major abdominal surgery

Severe Metformin Poisoning Successfully Treated with Simultaneous Venovenous Hemofiltration and Prolonged Intermittent Hemodialysis

Metformin poisoning is a life-threatening condition with a high mortality rate. We present a patient case of metformin poisoning following intake of 80 g metformin resulting in severe lactate acidosis with a nadir pH of 6.73 and circulatory collapse, successfully treated with addition of prolonged intermittent hemodialysis (HD) to continuous venovenous hemofiltration (CVVH). The patient’s pH became normal 48 hours after metformin ingestion during simultaneous CVVH and addition of 22 hours of intermittent HD in the ICU. The highest metformin level was found to be 991 μmol/L (therapeutic range 3.9–23.2 μmol/L). We conclude that in cases of severe metformin poisoning with circulatory shock and extreme lactic acidosis, the usual CVVH modality might not efficiently clear metformin. Therefore, additional prolonged HD should be considered even in the state of cardiovascular collapse with vasopressor requirement

Assisted ventilation in COPD:association between previous hospitalizations and mortality

BACKGROUND: In general, previous studies have shown an association between prior exacerbations and mortality in COPD, but this association has not been demonstrated in the subpopulation of patients in need of assisted ventilation. We examined whether previous hospitalizations were independently associated with mortality among patients with COPD ventilated for the first time. PATIENTS AND METHODS: In the Danish National Patient Registry, we established a cohort of patients with COPD ventilated for the first time from 2003 to 2011 and previously medicated for obstructive airway diseases. We assessed the number of hospitalizations for COPD in the preceding year, age, sex, comorbidity, mode of ventilation, survival to discharge, and days to death beyond discharge. RESULTS: The cohort consisted of 6,656 patients of whom 66% had not been hospitalized for COPD in the previous year, 18% once, 8% twice, and 9% thrice or more. In-hospital mortality was 45%, and of the patients alive at discharge, 11% died within a month and 39% within a year. In multivariate models, adjusted for age, sex, mode of ventilation, and comorbidity, odds ratios for in-hospital death were 1.26 (95% confidence interval [CI]: 1.11–1.44), 1.43 (95% CI: 1.19–1.72), and 1.56 (95% CI: 1.30–1.87) with one, two, and three or more hospitalizations, respectively. Hazard ratios for death after discharge from hospital were 1.32 (95% CI: 1.19–1.46), 1.76 (95% CI: 1.52–2.02), and 2.07 (95% CI: 1.80–2.38) with one, two, and three or more hospitalizations, respectively. CONCLUSION: Preceding hospitalizations for COPD are associated with in-hospital mortality and after discharge in the subpopulation of patients with COPD with acute exacerbation treated with assisted ventilation for the first time