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

DETECT schools study protocol: A prospective observational cohort surveillance study investigating the impact of COVID-19 in Western Australian schools

Introduction: Amidst the evolving COVID-19 pandemic, understanding the transmission dynamics of the SARS-CoV-2 virus is key to providing peace of mind for the community and informing policy-making decisions. While available data suggest that school-aged children are not significant spreaders of SARS-CoV-2, the possibility of transmission in schools remains an ongoing concern, especially among an aging teaching workforce. Even in low-prevalence settings, communities must balance the potential risk of transmission with the need for students\u27 ongoing education. Through the roll out of high-throughput school-based SARS-CoV-2 testing, enhanced follow-up for individuals exposed to COVID-19 and wellbeing surveys, this study investigates the dynamics of SARS-CoV-2 transmission and the current psychosocial wellbeing impacts of the pandemic in school communities. Methods: The DETECT Schools Study is a prospective observational cohort surveillance study in 79 schools across Western Australia (WA), Australia. To investigate the incidence, transmission and impact of SARS-CoV-2 in schools, the study comprises three “modules”: Module 1) Spot-testing in schools to screen for asymptomatic SARS-CoV-2; Module 2) Enhanced surveillance of close contacts following the identification of any COVID-19 case to determine the secondary attack rate of SARS-CoV-2 in a school setting; and Module 3) Survey monitoring of school staff, students and their parents to assess psycho-social wellbeing following the first wave of the COVID-19 pandemic in WA. Clinical Trial Registration: Trial registration number: ACTRN1262000092297

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Barriers and enablers to structured care delivery in Australian rural primary care

Objective The primary aim of this study was to explore the barriers and enablers to structured care delivery in rural primary care, reflecting on Australian research findings. Design CINAHL and Scopus databases were searched in August 2021. Inclusion criteria included English language, full-text studies, published since 2011, reporting on the barriers and enablers to the delivery of structured care within rural and remote primary care. Structured care was conceptualised as care that was organised, integrative and planned. Findings A total of 435 studies were screened. Thirty-four met the inclusion criteria. Barriers to the provision of structured care related to workforce shortages, limited health care services and health care professional capacity, cultural safety and competency, limited resourcing, insufficient knowledge and education, geographical isolation, inadequate care coordination, unclear roles and responsibilities and poor health professional–patient relationships. Discussion Health care system and geographical barriers and enablers encountered in rural areas are complex and multidimensional. Identification of the specific challenges to structured care delivery highlights the need for a focussed review of workforce supply and distribution challenges as well as the investigation of system integration, leadership, governance and funding reform that would be required to support rural primary care

Insomnia, depression and anxiety in patients urgently referred with suspicion of head and neck cancer

Objective: To determine differences in insomnia, depression, and anxiety between ENT patients with benign and malignant conditions prior to and after an Urgent Suspicion of Cancer (USOC) appointment. Methods: USOC outpatients completed three psychometric questionnaires prior to their appointment and 2-4 weeks post-diagnosis. Results: There was no significant difference in questionnaire scores between malignant and benign patients prior to the appointment (p>0.05 for all questionnaires). In benign patients, there was significant improvement in scores for all questionnaires (p Conclusion: Prior to appointments, patients with benign and malignant conditions experience similar levels of insomnia, depression and anxiety. Following diagnosis, cancer patients have significantly poorer scores indicating worsening of these symptoms. In patients with benign diagnoses, all questionnaire scores improved, indicating resolution of their symptoms and possible association between the appointment and their baseline scores

Barriers and enablers to delivering preventative and early intervention footcare to people with diabetes: a scoping review of healthcare professionals’ perceptions

The aim of this study is to examine barriers and enablers to delivering preventative and early intervention footcare to people with diabetes, from the perspective of healthcare professionals within primary care. MEDLINE, CINAHL and Scopus databases, as well as Google Scholar, were searched in September 2018. Inclusion criteria included: English language, qualitative and quantitative studies, since 1998, reporting on barriers or enablers, as reported by primary care health professionals, to delivering preventative or early intervention footcare to people with diabetes. In total, 339 studies were screened. Eight studies met criteria. Perceived barriers to providing footcare included: geographical, administrative and communication factors; referral and care guideline availability and implementation challenges; limited availability of specialists and high-risk foot services; and limited resources including time and funding. Enablers to footcare were: implementation of footcare programs; education; clear definition of staff roles; development of foot assessment reminder systems; and reminders for people with diabetes to remove their shoes at appointments. Barriers and enablers to footcare are multifaceted. Healthcare professionals are affected by health system and individual factors. By implementing strategies to address barriers to footcare delivery, it is possible to improve outcomes for people with diabetes, thus reducing the effect of diabetes-related foot disease

Preventative and early intervention diabetes-related food care practices in primary care

The aim of this study was to identify current preventative and early intervention diabetes-related foot care practices among Australian primary care healthcare professionals. A survey was developed to obtain information about preventative and early intervention foot care actions, priorities of care, access and referral to expert multidisciplinary foot care teams and adherence to best-practice diabetes-related foot care recommendations. The survey was distributed to GPs and Credentialled Diabetes Educators (CDEs). Surveys were completed by 10 GPs and 84 CDEs. Only 45% of all respondents reported removing the shoes and socks of their patients with diabetes at a consultation. Eighty-one percent of participants reported having access to specialist multidisciplinary foot care teams. Those in urban settings were significantly more likely to report access than those in rural areas (P = 0.04). Median scores indicated that participants did not often utilise specialist teams to refer patients with diabetes-related foot ulceration and Charcot’s neuroarthropathy. Only 16% of participants reported having access to specialist foot care telehealth services; patients with diabetes-related foot ulceration and Charcot’s neuroarthropathy were rarely referred to these services. This study is the first Australian study to elicit information about preventative and early intervention diabetes-related foot care practices by GPs and CDEs working in Australian primary care. In the presence of acute diabetes-related foot complications, primary healthcare practitioners are not always adhering to best practice foot care recommendations. Further studies are required to understand the reasons for this and ensure evidence-based best practice foot care delivery to people with diabetes

Preventing Patient Falls Overnight Using Video Monitoring: A Clinical Evaluation

Inpatient falls are devastating for patients and their families and an ongoing problem for healthcare providers worldwide. Inpatient falls overnight are particularly difficult to predict and prevent. The aim of this cohort study was to evaluate effectiveness of overnight portable video monitoring as an adjunct falls prevention strategy for high falls risk patients in inpatient clinical units. Over three months, three clinical inpatient wards were provided with baby monitor equipment to facilitate portable video monitoring. Portable video monitoring registers were completed nightly and nursing staff were invited to complete surveys (n = 31) to assess their experiences of using portable video monitoring. A total of 494 episodes of portable video monitoring were recorded over the three-month period, with clinical areas reporting a total of four inpatient falls from monitoring participants (0.8% of total portable video monitoring episodes). Overall, there was a statistically significant reduction in total inpatient falls overnight on the target wards. Surveyed nursing staff reported feeling better equipped to prevent falls and indicated they would like to continue using portable monitoring as a falls prevention strategy. This study provides evidence to support the use of portable video monitoring as an effective falls prevention strategy in the hospital environment