General practitioners' and nurses' experiences of using computerised decision support in screening for diabetic foot disease:implementing Scottish Clinical Information - Diabetes Care in routine clinical practice

<strong>Objective</strong> The Scottish Care Information - Diabetes Collaboration (SCI-DC) developed a computer- based information system to create a shared electronic record for use by all involved in the care of patients with diabetes mellitus. The objectives of this study were to understand primary care practitioners' views towards screening for diabetic foot disease and their experience of the SCI-DC system. <strong>Method</strong> We conducted an exploratory study using qualitativemethods. Semi-structured interviews were audiotape-recorded, transcribed and subjected to thematic analysis. Seven practice nurses and six general practitioners (GPs) with special responsibility for diabetes care inNHS Lothian participated. <strong>Results</strong> Primary care clinicians reported good systems in place to screen for diabetes-related complications and to refer their patients to specialist care. Foot ulceration was rarely observed; other diabetesrelated conditions were seen as a higher priority. Most had heard of the SCI-DC foot assessment tool, but its failure to integrate with other primary care information technology (IT) systems meant it was not used in these general practices. <strong>Conclusions</strong> Adoption of the SCI-DC foot assessment tool in primary care is not perceived as clinically necessary. Although information recorded by specialist services on SCI-DC is helpful, important structural barriers to its implementation mean the potential benefits associated with its use are unlikely to be realised; greater engagement with primary care priorities for diabetes management is needed to assist its successful implementation and adoption

Systematic review of topical treatments for fungal infections of the skin and nails of the feet

OBJECTIVE: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. DESIGN: Systematic review. INTERVENTIONS: Topical treatments for superficial fungal infections. MAIN OUTCOME MEASURES: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. RESULTS: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cure skin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0.11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), but four reports in foreign languages showed no difference between the two drugs (1.01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. CONCLUSIONS: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails

The 10-year follow-up of a community-based cohort of people with diabetes : the incidence of foot ulceration and death

Funding: This work was funded as part of a wider project by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (HTA project: 15/171/01).Background: Identifying people with diabetes who are likely to experience a foot ulcer is an important part of preventative care. Many cohort studies report predictive models for foot ulcerations and for people with diabetes, but reports of long-term outcomes are scarce. Aim: We aimed to develop a predictive model for foot ulceration in diabetes using a range of potential risk factors with a follow-up of 10 years after recruitment. A new foot ulceration was the outcome of interest and death was the secondary outcome of interest. Design: A 10-year follow-up cohort study. Methods:  1193 people with a diagnosis of diabetes who took part in a study in 2006–2007 were invited to participate in a 10-year follow-up. We developed a prognostic model for the incidence of incident foot ulcerations using a survival analysis, Cox proportional hazards model. We also utilised survival analysis Kaplan–Meier curves, and relevant tests, to assess the association between the predictor variables for foot ulceration and death. Results: At 10-year follow-up, 41% of the original study population had died and more than 18% had developed a foot ulcer. The predictive factors for foot ulceration were an inability to feel a 10 g monofilament or vibration from a tuning fork, previous foot ulceration and duration of diabetes.  Conclusions: The prognostic model shows an increased risk of ulceration for those with previous history of foot ulcerations, insensitivity to a 10 g monofilament, a tuning fork and duration of diabetes. The incidence of foot ulceration at 10-year follow-up was 18%; however, the risk of death for this community-based population was far greater than the risk of foot ulceration.Publisher PDFPeer reviewe

Ankle brachial index for the diagnosis of lower limb peripheral arterial disease

Background Peripheral arterial disease (PAD) of the lower limb is common, with prevalence of both symptomatic and asymptomatic disease estimated at 13% in the over 50 age group. Symptomatic PAD affects about 5% of individuals in Western populations between the ages of 55 and 74 years. The most common initial symptom of PAD is muscle pain on exercise that is relieved by rest and is attributed to reduced lower limb blood flow due to atherosclerotic disease (intermittent claudication). The ankle brachial index (ABI) is widely used by a variety of healthcare professionals, including specialist nurses, physicians, surgeons and podiatrists working in primary and secondary care settings, to assess signs and symptoms of PAD. As the ABI test is non‐invasive and inexpensive and is in widespread clinical use, a systematic review of its diagnostic accuracy in people presenting with leg pain suggestive of PAD is highly relevant to routine clinical practice. Objectives To estimate the diagnostic accuracy of the ankle brachial index (ABI) ‐ also known as the ankle brachial pressure index (ABPI) ‐ for the diagnosis of peripheral arterial disease in people who experience leg pain on walking that is alleviated by rest. Search methods We carried out searches of the following databases in August 2013: MEDLINE (Ovid SP),Embase (Ovid SP), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCO), Latin American and Caribbean Health Sciences (LILACS) (Bireme), Database of Abstracts of Reviews of Effects and the Health Technology Assessment Database in The Cochrane Library, the Institute for Scientific Information (ISI) Conference Proceedings Citation Index ‐ Science, the British Library Zetoc Conference search and Medion. Selection criteria We included cross‐sectional studies of ABI in which duplex ultrasonography or angiography was used as the reference standard. We also included cross‐sectional or diagnostic test accuracy (DTA) cohort studies consisting of both prospective and retrospective studies.Participants were adults presenting with leg pain on walking that was relieved by rest, who were tested in primary care settings or secondary care settings (hospital outpatients only) and who did not have signs or symptoms of critical limb ischaemia (rest pain, ischaemic ulcers or gangrene).The index test was ABI, also called the ankle brachial pressure index (ABPI) or the Ankle Arm Index (AAI), which was performed with a hand‐held doppler or oscillometry device to detect ankle vessels. We included data collected via sphygmomanometers (both manual and aneroid) and digital equipment. Data collection and analysis Two review authors independently replicated data extraction by using a standard form, which included an assessment of study quality, and resolved disagreements by discussion. Two review authors extracted participant‐level data when available to populate 2×2 contingency tables (true positives, true negatives, false positives and false negatives).After a pilot phase involving two review authors working independently, we used the methodological quality assessment tool the Quality Assessment of Diagnostic Accuracy Studies‐2 (QUADAS‐2), which incorporated our review question ‐ along with a flow diagram to aid reviewers' understanding of the conduct of the study when necessary and an assessment of risk of bias and applicability judgements. Main results We screened 17,055 records identified through searches of databases. We obtained 746 full‐text articles and assessed them for relevance. We scrutinised 49 studies to establish their eligibility for inclusion in the review and excluded 48, primarily because participants were not patients presenting solely with exertional leg pain, investigators used no reference standard or investigators used neither angiography nor duplex ultrasonography as the reference standard. We excluded most studies for more than one reason.Only one study met the eligibility criteria and provided limb‐level accuracy data from just 85 participants (158 legs). This prospective study compared the manual doppler method of obtaining an ABI (performed by untrained personnel) with the automated oscillometric method. Limb‐level data, as reported by the study, indicated that the accuracy of the ABI in detecting significant arterial disease on angiography is superior when stenosis is present in the femoropopliteal vessels, with sensitivity of 97% (95% confidence interval (CI) 93% to 99%) and specificity of 89% (95% CI 67% to 95%) for oscillometric ABI, and sensitivity of 95% (95% CI 89% to 97%) and specificity of 56% (95% CI 33% to 70%) for doppler ABI. The ABI threshold was not reported. Investigators attributed the lower specificity for doppler to the fact that a tibial or dorsalis pedis pulse could not be detected by doppler in 12 of 27 legs with normal vessels or non‐significant lesions. The superiority of the oscillometric (automated) method for obtaining an ABI reading over the manual method with a doppler probe used by inexperienced operators may be a clinically important finding. Authors' conclusions Evidence about the accuracy of the ankle brachial index for the diagnosis of PAD in people with leg pain on exercise that is alleviated by rest is sparse. The single study included in our review provided only limb‐level data from a few participants. Well‐designed cross‐sectional studies are required to evaluate the accuracy of ABI in patients presenting with early symptoms of peripheral arterial disease in all healthcare settings. Another systematic review of existing studies assessing the use of ABI in alternative patient groups, including asymptomatic, high‐risk patients, is required.Publisher PDFPeer reviewe

Reliability of the evidence to guide decision-making in foot ulcer prevention in diabetes : an overview of systematic reviews

Funding: This overview was funded as part of a wider project by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) Programme (HTA project: 15/171/01). The views expressed are those of the authors and not necessarily those of the NIHR or UK Department of Health and Social Care.Background: Reliable evidence on the effectiveness of interventions to prevent diabetes-related foot ulceration is essential to inform clinical practice. Well-conducted systematic reviews that synthesise evidence from all relevant trials offer the most robust evidence for decision-making. We conducted an overview to assess the comprehensiveness and utility of the available secondary evidence as a reliable source of robust estimates of effect with the aim of informing a cost-effective care pathway using an economic model. Here we report the details of the overview. [PROSPERO Database (CRD42016052324)]. Methods: Medline (Ovid), Embase (Ovid), Epistomonikos, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE), and the Health Technology Assessment Journals Library were searched to 17th May 2021, without restrictions, for systematic reviews of randomised controlled trials (RCTs) of preventive interventions in people with diabetes. The primary outcomes of interest were new primary or recurrent foot ulcers. Two reviewers independently extracted data and assessed the risk of bias in the included reviews. Findings: The overview identified 30 systematic reviews of patient education, footwear and of-loading, complex and other interventions. Many are poorly reported and have fundamental methodological shortcomings associated with increased risk of bias. Most concerns relate to vague inclusion criteria (60%), weak search or selection strategies (70%) and quality appraisal methods (53%) and inexpert conduct and interpretation of quantitative and narrative evidence syntheses (57%). The 30 reviews have collectively assessed 26 largely poor-quality RCTs with substantial overlap. Interpretation: The majority of these systematic reviews of the effectiveness of interventions to prevent diabetic foot ulceration are at high risk of bias and fail to provide reliable evidence for decision-making. Adherence to the core principles of conducting and reporting systematic reviews is needed to improve the reliability of the evidence generated to inform clinical practice.Publisher PDFPeer reviewe

D-dimer test for excluding the diagnosis of pulmonary embolism

Background Pulmonary embolism (PE) can occur when a thrombus (blood clot) travels through the veins and lodges in the arteries of the lungs, producing an obstruction. People who are thought to be at risk include those with cancer, people who have had a recent surgical procedure or have experienced long periods of immobilisation and women who are pregnant. The clinical presentation can vary, but unexplained respiratory symptoms such as difficulty breathing, chest pain and an increased respiratory rate are common. D‐dimers are fragments of protein released into the circulation when a blood clot breaks down as a result of normal body processes or with use of prescribed fibrinolytic medication. The D‐dimer test is a laboratory assay currently used to rule out the presence of high D‐dimer plasma levels and, by association, venous thromboembolism (VTE). D‐dimer tests are rapid, simple and inexpensive and can prevent the high costs associated with expensive diagnostic tests. Objectives To investigate the ability of the D‐dimer test to rule out a diagnosis of acute PE in patients treated in hospital outpatient and accident and emergency (A&E) settings who have had a pre‐test probability (PTP) of PE determined according to a clinical prediction rule (CPR), by estimating the accuracy of the test according to estimates of sensitivity and specificity. The review focuses on those patients who are not already established on anticoagulation at the time of study recruitment. Search methods We searched 13 databases from conception until December 2013. We cross‐checked the reference lists of relevant studies. Selection criteria Two review authors independently applied exclusion criteria to full papers and resolved disagreements by discussion. We included cross‐sectional studies of D‐dimer in which ventilation/perfusion (V/Q) scintigraphy, computerised tomography pulmonary angiography (CTPA), selective pulmonary angiography and magnetic resonance pulmonary angiography (MRPA) were used as the reference standard. • Participants: Adults who were managed in hospital outpatient and A&E settings and were suspected of acute PE were eligible for inclusion in the review if they had received a pre‐test probability score based on a CPR. • Index tests: quantitative, semi quantitative and qualitative D‐dimer tests. • Target condition: acute symptomatic PE. • Reference standards: We included studies that used pulmonary angiography, V/Q scintigraphy, CTPA and MRPA as reference standard tests. Data collection and analysis Two review authors independently extracted data and assessed quality using Quality Assessment of Diagnostic Accuracy Studies‐2 (QUADAS‐2). We resolved disagreements by discussion. Review authors extracted patient‐level data when available to populate 2 × 2 contingency tables (true‐positives (TPs), true‐negatives (TNs), false‐positives (FPs) and false‐negatives (FNs)). Main results We included four studies in the review (n = 1585 patients). None of the studies were at high risk of bias in any of the QUADAS‐2 domains, but some uncertainty surrounded the validity of studies in some domains for which the risk of bias was uncertain. D‐dimer assays demonstrated high sensitivity in all four studies, but with high levels of false‐positive results, especially among those over the age of 65 years. Estimates of sensitivity ranged from 80% to 100%, and estimates of specificity from 23% to 63%. Authors' conclusions A negative D‐dimer test is valuable in ruling out PE in patients who present to the A&E setting with a low PTP. Evidence from one study suggests that this test may have less utility in older populations, but no empirical evidence was available to support an increase in the diagnostic threshold of interpretation of D‐dimer results for those over the age of 65 years.Publisher PDFPeer reviewe

United Kingdom drug situation. Focal Point annual report 2016.

The United Kingdom (UK) Focal Point on Drugs is based at Public Health England (PHE). It is the national partner of the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and provides comprehensive information to the centre on the drug situation in England, Scotland, Wales and Northern Ireland. The Focal Point works closely with the Home Office, other government departments and the devolved administrations. In addition to this annual report, it collates an extensive range of data in the form of standard tables (STs) and responses to structured questionnaires, which are submitted regularly to the EMCDDA. It also contributes to other elements of the EMCDDA’s work such as the development and implementation of its five key epidemiological indicators, the Exchange on Drug Demand Reduction Action and the implementation of the Council Decision on New Psychoactive Substances (NPS)