Interprofessional Education: An evaluation of a joint learning workshop for podiatry and pharmacy students

"Interprofessional Education occurs when two or more professionals learn with, from and about each other to improve collaboration and the quality of care" (CAIPE 2002). Interprofessional education forms part of the Standards for the Initial Education and Training of Pharmacists. Working with and understanding the role of another profession has been shown to positively impact on the quality of care of the patient. Following positive pharmacy student feedback from visits to podiatry clinics an interprofessional learning workshop with case - based scenarios was developed. These were based on patients with high risk medical conditions that would impact on the work of both professions. Data from the feedback forms was evaluated and analysed to determine whether the workshop increased knowledge of the British National Formulary (BNF), the prescribing process and gave an insight in to the role of other healthcare professionals. We discuss how the student’s learning has been enhanced by the contribution of another professional group. The workshop was positively received. Students were observed working together discussing the patients’ conditions and issues relating to their care. This initially revolved around the students’ area of knowledge; however, as the session progressed it became apparent that the students were learning with, from and about each other for the benefit of patient care

Diagnosis and Management of Iliac Artery Endofibrosis: Results of a Delphi Consensus Study

Objective Iliac endofibrosis is a rare condition that may result in a reduction of blood flow to the lower extremity in young, otherwise healthy individuals. The data to inform everyday clinical management are weak and therefore a Delphi consensus methodology was used to explore areas of consensus and disagreement concerning the diagnosis and management of patients with suspected iliac endofibrosis. Methods A three-round Delphi questionnaire approach was used among vascular surgeons, sports physicians, sports scientists, radiologists, and clinical vascular scientists with experience of treating this condition to explore diagnosis and clinical management issues for patients with suspected iliac artery endofibrosis. Analysis is based on 18 responses to round 2 and 14 responses to round 3, with agreement reported when 70% of respondents were in agreement. Results Initially there was agreement on the typical symptoms at presentation and the need for an exercise test in the diagnosis. Round 3 clarified that duplex ultrasound was a useful tool in the diagnosis of endofibrosis. There was consensus on the most appropriate type of surgery (endarterectomy and vein patch) and that endovascular interventions were inadvisable. The final round helped to inform aspects of the natural history and post-operative surveillance. Progression of the disease was likely with continued exercise but cessation may prevent progression. Surveillance after surgery is generally recommended yearly with at least a clinical assessment. Conclusions There is broad agreement about the presenting symptoms and the investigations required to confirm (or exclude) the diagnosis of iliac endofibrosis. There was consensus on the surgical approach to repair. Disagreement existed about the specific diagnostic criteria that should be applied during non-invasive testing and about post-operative care and resumption of exercise

Effectiveness of bedside investigations to diagnose peripheral artery disease among people with diabetes mellitus: a systematic review

Non-invasive tests for the detection of peripheral artery disease (PAD) among individuals with diabetes mellitus are important to estimate the risk of amputation, ulceration, wound healing and the presence of cardiovascular disease, yet there are no consensus recommendations to support a particular diagnostic modality over another and to evaluate the performance of index non-invasive diagnostic tests against reference standard imaging techniques (magnetic resonance angiography, computed tomography angiography, digital subtraction angiography and colour duplex ultrasound) for the detection of PAD among patients with diabetes. Two reviewers independently screened potential studies for inclusion and extracted study data. Eligible studies evaluated an index test for PAD against a reference test. An assessment of methodological quality was performed using the quality assessment for diagnostic accuracy studies instrument. Of the 6629 studies identified, ten met the criteria for inclusion. In these studies, the patients had a median age of 60-74 years and a median duration of diabetes of 9-24years. Two studies reported exclusively on patients with symptomatic (ulcerated/infected) feet, two on patients with asymptomatic (intact) feet only, and the remaining six on patients both with and without foot ulceration. Ankle brachial index (ABI) was the most widely assessed index test. Overall, the positive likelihood ratio and negative likelihood ratio (NLR) of an ABI threshol

IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes

Recommendations Examine a patient with diabetes annually for the presence of peripheral artery disease (PAD); this should include, at a minimum, taking a history and palpating foot pulses. (GRADE strength of recommendation: strong; quality of evidence: low) Evaluate a patient with diabetes and a foot ulcer for the presence of PAD. Determine, as part of this examination, ankle or pedal Doppler arterial waveforms; measure both ankle systolic pressure and systolic ankle brachial index (ABI). (strong; low) We recommend the use of bedside non-invasive tests to exclude PAD. No single modality has been shown to be optimal. Measuring ABI (with In patients with a foot ulcer in diabetes and PAD, no specific symptoms or signs of PAD reliably predict healing of the ulcer. However, one of the following simple bedside tests should be used to inform the patient and healthcare professional about the healing potential of the ulcer. Any of the following findings increases the pre-test probability of healing by at least 25%: a skin perfusion pressure 40mmHg, a toe pressure 30mmHg or a transcutaneous oxygen pressure (TcPO2) 25mmHg. (strong; moderate) Consider urgent vascular imaging and revascularisation in patients with a foot ulcer in diabetes where the toe pressure is Consider vascular imaging and revascularisation in all patients with a foot ulcer in diabetes and PAD, irrespective of the results of bedside tests, when the ulcer does not improve within 6weeks despite optimal management. (strong; low) Diabetic microangiopathy should not be considered to be the cause of poor wound healing in patients with a foot ulcer. (strong; low) In patients with a non-healing ulcer with either an ankle pressure Colour Doppler ultrasound, computed tomography angiography, magnetic resonance angiography or intra-arterial digital subtraction angiography can each be used to obtain anatomical information when revascularisation is being considered. The entire lower extremity arterial circulation should be evaluated, with detailed visualisation of below-the-knee and pedal arteries. (strong; low) The aim of revascularisation is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound, with the aim of achieving a minimum skin perfusion pressure 40mmHg, a toe pressure 30mmHg or a TcPO2 25mmHg. (strong; low) A centre treating patients with a foot ulcer in diabetes should have the expertise in and rapid access to facilities necessary to diagnose and treat PAD; both endovascular techniques and bypass surgery should be available. (strong; low) There is inadequate evidence to establish which revascularisation technique is superior, and decisions should be made in a multidisciplinary team on a number of individual factors, such as morphological distribution of PAD, availability of autogenous vein, patient co-morbidities and local expertise. (strong; low) After a revascularisation procedure for a foot ulcer in diabetes, the patient should be treated by a multidisciplinary team as part of a comprehensive care plan. (strong; low) Patients with signs of PAD and a foot infection are at particularly high risk for major limb amputation and require emergency treatment. (strong; moderate) Avoid revascularisation in patients in whom, from the patient perspective, the risk-benefit ratio for the probability of success is unfavourable. (strong; low) All patients with diabetes and an ischaemic foot ulcer should receive aggressive cardiovascular risk management including support for cessation of smoking, treatment of hypertension and prescription of a statin as well as low-dose aspirin or clopidogrel. (strong; low

Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review

Prediction of wound healing and major amputation in patients with diabetic foot ulceration is clinically important to stratify risk and target interventions for limb salvage. No consensus exists as to which measure of peripheral artery disease (PAD) can best predict outcomes. To evaluate the prognostic utility of index PAD measures for the prediction of healing and/or major amputation among patients with active diabetic foot ulceration, two reviewers independently screened potential studies for inclusion. Two further reviewers independently extracted study data and performed an assessment of methodological quality using the Quality in Prognostic Studies instrument. Of 9476 citations reviewed, 11 studies reporting on 9 markers of PAD met the inclusion criteria. Annualized healing rates varied from 18% to 61%; corresponding major amputation rates varied from 3% to 19%. Among 10 studies, skin perfusion pressure 40mmHg, toe pressure 30mmHg (and 45mmHg) and transcutaneous pressure of oxygen (TcPO2) 25mmHg were associated with at least a 25% higher chance of healing. Four studies evaluated PAD measures for predicting major amputation. Ankle pressur