Diabetes and its long-term complications in general practice: a survey in a well-defined population

Marginal bone loss around dental implants: comparison between diabetic and non-diabetic patients-a retrospective clinical study

OBJECTIVES

The aim of the present retrospective study was to compare the marginal bone loss (MBL) around dental implants in a group of diabetic patients in relation to a matched group of non-diabetic patients.

MATERIALS AND METHODS

The present dental record-based retrospective study included patients selected from individuals treated with dental implants at one specialist clinic in Malmö, Sweden. Patients were excluded if they had history of periodontitis and/or were treated for periodontal disease. The study group included 710 implants installed in 180 patients (mean age 60.3±13.0 years), 349 implants in 90 diabetic (21 T1DM and 69 T2DM patients), and 361 implants in 90 non-diabetic patients.

RESULTS

The results suggested that jaw (greater MBL in the maxilla), diabetes (greater MBL for diabetic patients, and worse for T1DM patients), bruxism (greater MBL for bruxers), and smoking (greater MBL for smokers and former smokers) had a statistically significant influence on MBL over time.

CONCLUSIONS

Patients with diabetes have an estimated greater MBL over time compared to non-diabetic patients. The difference was greater in patients with diabetes type 1 compared to patients with diabetes type 2. Bruxism, smoking, and implant location (maxilla) were also associated with a higher loss of marginal bone around implants over time.

CLINICAL RELEVANCE

Awareness of the possible influence of diabetes on the long-term outcomes of dental implant treatment is important, in order to be able to minimize the possibility of a high MBL with time, which can eventually lead to the loss of the implant.

Diabetes Mellitus and Dental Implants: A Systematic Review and Meta-Analysis

The present review aimed to evaluate the impact of diabetes mellitus on dental implant failure rates and marginal bone loss (MBL). An electronic search was undertaken in three databases, plus a manual search of journals. Meta-analyses were performed as well as meta-regressions in order to verify how the odds ratio (OR) and MBL were associated with follow-up time. The review included 89 publications. Altogether, there were 5510 and 62,780 implants placed in diabetic and non-diabetic patients, respectively. Pairwise meta-analysis showed that implants in diabetic patients had a higher failure risk in comparison to non-diabetic patients (OR 1.777, p < 0.001). Implant failures were more likely to occur in type 1 diabetes patients than in type 2 (OR 4.477, p = 0.032). The difference in implant failure between the groups was statistically significant in the maxilla but not in the mandible. The MBL mean difference (MD) between the groups was 0.776 mm (p = 0.027), with an estimated increase of 0.032 mm in the MBL MD between groups for every additional month of follow-up (p < 0.001). There was an estimated decrease of 0.007 in OR for every additional month of follow-up (p = 0.048). In conclusion, implants in diabetic patients showed a 77.7% higher risk of failure than in non-diabetic patients.

The impact of COVID-19 in diabetic kidney disease and chronic kidney disease: A population-based study

BACKGROUND

The spectrum of pre-existing renal disease is known as a risk factor for severe COVID-19 outcomes. However, little is known about the impact of COVID-19 on patients with diabetic nephropathy in comparison to patients with chronic kidney disease.

METHODS

We used the Mexican Open Registry of COVID-19 patients 11 to analyze anonymized records of those who had symptoms related to COVID-19 to analyze the rates of SARS-CoV-2 infection, development of COVID-19 pneumonia, admission, intubation, Intensive Care Unit admission and mortality. Robust Poisson regression was used to relate sex and age to each of the six outcomes and find adjusted prevalences and adjusted prevalence ratios. Also, binomial regression models were performed for those outcomes that had significant results to generate probability plots to perform a fine analysis of the results obtained along age as a continuous variable.

RESULTS

The adjusted prevalence analysis revealed that that there was a a 87.9% excess probability of developing COVID-19 pneumonia in patients with diabetic nephropathy, a 5% excess probability of being admitted, a 101.7% excess probability of intubation and a 20.8% excess probability of a fatal outcome due to COVID-19 pneumonia in comparison to CKD patients (p<0.01).  Conclusions: Patients with diabetic nephropathy had nearly a twofold rate of COVID-19 pneumonia, a higher probability of admission, a twofold probability of intubation and a higher chance of death once admitted compared to patients with chronic kidney disease alone. Also, both diseases had higher COVID-19 pneumonia rates, intubation rates and case-fatality rates compared to the overall population.

Blood Viscosity in Patients with Diabetic Nephropathy Versus Blood Viscosity in Healthy Patients

Diabetic nephropathy is the major cause of severe renal impairment and even chronic terminal renal failure requiring dialysis. Blood viscosity is clearly modified in diabetic patients, and particularly in those with severe renal impairment

The purpose of this study is to highlight blood viscosity values at different shear rates in patients with diabetic nephropathy compared to the control group.

There is a significant increase in blood viscosity in patients with definite renal impairment.

Prevalence and clinical correlates of depression in chronic kidney disease patients in a tertiary care hospital

BACKGROUND

Prognosis and associated complications of chronic kidney disease (CKD) may result in psychological distress and mood disorders especially depression. Prevalence and clinical correlates of depression in CKD patients in the Indian context are not well studied and established.

MATERIALS AND METHODS

This cross-sectional study included 84 CKD patients. The diagnosis was made based on the diagnostic and statistical manual, 4^th edition criteria; psychiatric disorders were ruled out through the mini-neuropsychiatric interview. Montgomery-Asberg Depression Rating Scale was used to assess the severity of depression. Suicidal ideations were evaluated by using a modified scale of suicidal ideations. Data were analyzed using Epi Info 7 software.

RESULTS

The prevalence of major depression was 44.05%, while the prevalence of depressive symptoms was 82.14%. Age of the patients (P = 0.0065), patients on dialysis (P < 0.0001), and serum creatinine levels >5 (P = 0.0180) showed a statistically significant association with depression. The prevalence of depression was significantly associated with dialysis (P < 0.0001). The severity of depression and the severity of suicidal ideations were well correlated with each other (P < 0.0001).

CONCLUSION

The increased prevalence of depression and suicidal ideations was observed in CKD patients. We strongly recommend initiating screening of depression in CKD patients for appropriate rehabilitation and improved the quality of life.

Resistant Hypertension in Adults With Type 1 or 2 Diabetes: A Structured Diagnostic Approach

People with diabetes often have difficulty reaching their blood pressure targets and are labelled as having resistant hypertension. Clinicians often move quickly to screen such people for secondary causes of hypertension; however, such causes are rare, and resistant hypertension usually has other explanations that are significantly more common. By using a structured approach to resistant hypertension, clinicians can assist patients to reach their target blood pressure levels. Step 1 is to determine out-of-office blood pressure measurements using home or ambulatory blood pressure monitors. Step 2 is to determine the level of adherence to prescribed medications. Step 3 is to identify interfering substances. Step 4 is to check that the prescribed medications are synergistic and optimally dosed. Finally, if all other steps fail to get patients to their blood pressure targets, we consider possible secondary causes of hypertension. This approach is particularly useful in helping people with diabetes to reach their blood pressure targets.

Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis †

Diabetic foot is a severe public health issue, yet rare studies investigated its global epidemiology. Here we performed a systematic review and meta-analysis through searching PubMed, EMBASE, ISI Web of science, and Cochrane database. We found that that global diabetic foot ulcer prevalence was 6.3% (95%CI: 5.4-7.3%), which was higher in males (4.5%, 95%CI: 3.7-5.2%) than in females (3.5%, 95%CI: 2.8-4.2%), and higher in type 2 diabetic patients (6.4%, 95%CI: 4.6-8.1%) than in type 1 diabetics (5.5%, 95%CI: 3.2-7.7%). North America had the highest prevalence (13.0%, 95%CI: 10.0-15.9%), Oceania had the lowest (3.0%, 95% CI: 0.9-5.0%), and the prevalence in Asia, Europe, and Africa were 5.5% (95%CI: 4.6-6.4%), 5.1% (95%CI: 4.1-6.0%), and 7.2% (95%CI: 5.1-9.3%), respectively. Australia has the lowest (1.5%, 95%CI: 0.7-2.4%) and Belgium has the highest prevalence (16.6%, 95%CI: 10.7-22.4%), followed by Canada (14.8%, 95%CI: 9.4-20.1%) and USA (13.0%, 95%CI: 8.3-17.7%). The patients with diabetic foot ulcer were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot ulceration. Our results provide suggestions for policy makers in deciding preventing strategy of diabetic foot ulceration in the future. Key messages Global prevalence of diabetic foot is 6.3% (95%CI: 5.4-7.3%), and the prevalence in North America, Asia, Europe, Africa and Oceania was 13.0% (95%CI: 10.0-15.9%), 5.5% (95%CI: 4.6-6.4%), 5.1% (95%CI: 4.1-6.0%), 7.2% (95%CI: 5.1-9.3%), and 3.0% (95% CI: 0.9-5.0%). Diabetic foot was more prevalent in males than in females, and more prevalent in type 2 diabetic foot patients than in type 1 diabetic foot patients. The patients with diabetic foot were older, had a lower body mass index, longer diabetic duration, and had more hypertension, diabetic retinopathy, and smoking history than patients without diabetic foot.

Complex interventions for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can lead to the amputation of feet and legs, is a major problem for people with diabetes mellitus, and can cause substantial economic burden. Single preventive strategies have not been shown to reduce the incidence of foot ulceration to a significant extent. Therefore, in clinical practice, preventive interventions directed at patients, healthcare providers and/or the structure of health care are often combined (complex interventions).

OBJECTIVES

To assess the effectiveness of complex interventions in the prevention of foot ulcers in people with diabetes mellitus compared with single interventions, usual care or alternative complex interventions. A complex intervention is defined as an integrated care approach, combining two or more prevention strategies on at least two different levels of care: the patient, the healthcare provider and/or the structure of health care.

SEARCH METHODS

For the second update we searched the Cochrane Wounds Group Specialised Register (searched 22 May 2015), The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2015, Issue 4), The Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library 2015, Issue 4), The Health Technology Assessment Database (HTA) (The Cochrane Library 2015, Issue 4), The NHS Economic Evaluation Database (NHS EED) (The Cochrane Library 2015, Issue 4), Ovid MEDLINE (1946 to 22 May 2015), Ovid MEDLINE (In-Process & Other Non-Indexed Citations 21 May, 2015), Ovid EMBASE (1974 to 21 May, 2015) and EBSCO CINAHL (1982 to 22 May, 2015).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which compared the effectiveness of combinations of preventive strategies, not solely patient education, for the prevention of foot ulcers in people with diabetes mellitus, with single interventions, usual care or alternative complex interventions.

DATA COLLECTION AND ANALYSIS

Two review authors were assigned to independently select studies, to extract study data and to assess risk of bias of included studies, using predefined criteria.

MAIN RESULTS

Only six RCTs met the criteria for inclusion. The study characteristics differed substantially in terms of healthcare settings, the nature of the interventions studied and outcome measures reported. In three studies that compared the effect of an education-centred complex intervention with usual care or written instructions, only little evidence of benefit was found. Three studies compared the effect of more intensive and comprehensive complex interventions with usual care. One study found a significant and cost-effective reduction, one of lower extremity amputations (RR 0.30, 95% CI 0.31 to 0.71). One other study found a significant reduction of both amputation and foot ulcers. The last study reported improvement of patients' self care behaviour. All six included RCTs were at high risk of bias, with hardly any of the predefined quality assessment criteria met.

AUTHORS' CONCLUSIONS

There is no high-quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH METHODS

We searched The Cochrane Wounds Group Specialised Register (searched 03 September 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 8).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) that evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of risk of bias. Primary end points were foot ulceration or ulcer recurrence and amputation.

MAIN RESULTS

Of the 12 RCTs included, the effect of patient education on primary end points was reported in only five. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. One of the RCTs showed reduced incidence of foot ulceration (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.14 to 0.66) and amputation (RR 0.33, 95% CI 0.15 to 0.76) during one-year follow-up of diabetes patients at high risk of foot ulceration after a one-hour group education session. However, one similar study, with lower risk of bias, did not confirm this finding (RR amputation 0.98, 95% CI 0.41 to 2.34; RR ulceration 1.00, 95% CI 0.70 to 1.44). Three other studies, also did not demonstrate any effect of education on the primary end points, but were most likely underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self-reported self-care behaviour in the short term in seven of nine RCTs. Callus, nail problems and fungal infections improved in only one of five RCTs. Only one of the included RCTs was at low risk of bias.

AUTHORS' CONCLUSIONS

In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. Yet, based on the only two sufficiently powered studies reporting the effect of patient education on primary end points, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.

Dapagliflozin for the treatment of Type 2 diabetes

Dapagliflozin is a sodium glucose co-transporter 2 inhibitor that causes glucose to be lost in the urine. This mechanism of action lowers glucose levels throughout the day and is associated with significant weight loss and moderate blood pressure lowering without increasing heart rate. This class of medications are well tolerated but have a higher incidence of genital tract fungal infections and a slight increase in urinary tract infections that are usually easily treated and not recurrent. Dapagliflozin represents a new medication that should help many individuals with Type 2 diabetes achieve their therapeutic targets.

Prevalence of diabetic retinopathy in Type 2 diabetes in developing and developed countries

BACKGROUND

As the global prevalence of diabetes increases, so will the numbers of people with diabetic retinopathy. Our review aimed to provide a comprehensive picture of available studies of diabetic retinopathy and how prevalence varies around the developed and developing world.

METHODS

A detailed literature search using PubMed was undertaken. The following search term was used: 'diabetic retinopathy AND prevalence'. The titles and abstracts of all publications identified by the search were reviewed and 492 studies were retrieved. Inclusion and exclusion criteria were applied.

RESULTS

A total of 72 articles from 33 countries were included. There were only 26 population-based studies using fundus photography (12 in developing countries), of which only 16 (eight in developing countries) were published since 2000. Prevalence estimates varied from as low as 10% to as high as 61% in persons with known diabetes and from 1.5 to 31% in newly diagnosed diabetes. Across all the studies, the median (interquartile range) prevalence of any diabetic retinopathy in known diabetes was 27.9% (22-37%) and 10.5% (6-16%) in newly diagnosed diabetes. Prevalence of diabetic retinopathy was higher in developing countries.

CONCLUSION

Significant gaps exist in that reliable population-based data from developing nations and indigenous populations in particular are lacking. Major differences in study characteristics and methodologies make comparisons very difficult. More research is required and study methodologies must be better standardized. This will provide important information for prevention and treatment strategies.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH METHODS

Eligible studies were identified by searching The Cochrane Wounds Group Specialised Register (searched 1 August 2012); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 7); Ovid MEDLINE (2009 to July Week 3 2012); Ovid MEDLINE (In-Process & Other Non-Indexed Citations, July 31, 2012); Ovid EMBASE (2009 to 2012 Week 30); and EBSCO CINAHL (2009 to 26 July 2012).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) that evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of risk of bias. Primary end points were foot ulceration or ulcer recurrence and amputation.

MAIN RESULTS

Of the 12 RCTs included, the effect of patient education on primary end points was reported in only five. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. One of the RCTs showed reduced incidence of foot ulceration (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.14 to 0.66) and amputation (RR 0.33, 95% CI 0.15 to 0.76) during one-year follow-up of diabetes patients at high risk of foot ulceration after a one-hour group education session. However, one similar study, with lower risk of bias, did not confirm this finding (RR amputation 0.98, 95% CI 0.41 to 2.34; RR ulceration 1.00, 95% CI 0.70 to 1.44). Three other studies, also did not demonstrate any effect of education on the primary end points, but were most likely underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self-reported self-care behaviour in the short term in seven of nine RCTs. Callus, nail problems and fungal infections improved in only one of five RCTs. Only one of the included RCTs was at low risk of bias.

AUTHORS' CONCLUSIONS

In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. Yet, based on the only two sufficiently powered studies reporting the effect of patient education on primary end points, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effects of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH STRATEGY

Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register (22 December 2009), the Cochrane Central Register of Controlled Trials (Cochrane Library 2009 Issue 4 ), Ovid MEDLINE (1950 to November Week 3 2009), Ovid MEDLINE In-Process & Other Non-Indexed Citations (Searched 22/12/09), Ovid EMBASE (1980 to 2009 Week 51) and EBSCO CINAHL (1982 to December 22 2009).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which evaluated educational programmes for preventing foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications.

DATA COLLECTION AND ANALYSIS

Two review authors independently undertook data extraction and assessment of risk of bias. Primary end-points were foot ulceration or ulcer recurrence and amputation.

MAIN RESULTS

Eleven RCTs were included. Three studies described the effect of foot care education as part of general diabetes education compared with usual care. Two studies examined the effect of foot care education tailored to educational needs compared with no intervention. Finally, six studies described the effect of intensive compared with brief educational interventions. Pooling of outcome data was precluded by marked, mainly clinical, heterogeneity. Four RCTs assessed the effect of patient education on primary end-points: foot ulceration and amputations. One of these studies reported a statistically significant benefit of one hour group education after one year of follow-up in people with diabetes who were at high risk for foot ulceration; RR amputation 0.33 (95% CI 0.15 to 0.76); RR ulceration 0.31 (95% CI 0.14 to 0.66), however this study was at high risk of bias and may have overestimated the effect due to a unit of analysis error. One similar, but methodologically superior study did not confirm this finding; RR amputation 0.98 (95% CI 0.41 to 2.34); RR ulceration 1.00 (95% CI 0.70 to 1.44). The other two studies did not detect any effect of education on ulcer incidence or amputation but were underpowered. Patients' foot care knowledge was improved in the short term in five of eight RCTs in which this outcome was assessed, as was patients' self reported self care behaviour in the short term in seven of nine RCTs. The effects on callus, nail problems and fungal infections were described in five of the included studies, of which only two reported temporary improvements after an educational intervention.Only one of the included RCTs was considered to be at low risk of bias.

AUTHORS' CONCLUSIONS

Most of the RCTs included in this review are at high or unclear risk of bias. In some trials, foot care knowledge and self reported patient behaviour seem to be positively influenced by education in the short term. This, however, must be viewed with caution. The ultimate goal of educational interventions is preventing foot ulceration and amputation but only four RCTs reported these outcomes and only two reported sufficient data to examine this. Based on these two studies, we conclude that there is insufficient robust evidence that limited patient education alone is effective in achieving clinically relevant reductions in ulcer and amputation incidence.Future research should focus on evaluating the effect of more comprehensive and/or intensive prevention strategies which may also include patient education (complex interventions).

Complex interventions for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can lead to the amputation of feet and legs, is a major problem for people with diabetes mellitus, and can cause substantial economic burden. Single preventive strategies have not been shown to reduce the incidence of foot ulceration to a significant extent. Therefore, in clinical practice, preventive interventions directed at patients, health care providers and/or the structure of health care are often combined (complex interventions).

OBJECTIVES

To assess the effectiveness of complex interventions on the prevention of foot ulcers in people with diabetes mellitus compared with single interventions, usual care or alternative complex interventions. A complex intervention is defined as an integrated care approach, combining two or more prevention strategies on at least two different levels of care: the patient, the healthcare provider and/or the structure of healthcare.

SEARCH STRATEGY

Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register (28/05/09), the Cochrane Central Register of Controlled Trials (CENTRAL, 28 May 2009), Ovid MEDLINE (1950 to May Week 3 2009), Ovid EMBASE (1980 to 2009 Week 21) and EBSCO CINAHL (1982 to May Week 4 2009).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which compared the effectiveness of combinations of preventive strategies, not solely patient education, for the prevention of foot ulcers in people with diabetes mellitus, with single interventions, usual care or alternative complex interventions.

DATA COLLECTION AND ANALYSIS

Two review authors were assigned to independently select studies, to extract study data and to assess risk of bias of included studies, using predefined criteria.

MAIN RESULTS

Only five RCTs met the criteria for inclusion. The study characteristics differed substantially in terms of health care settings, the nature of the interventions studied and outcome measures reported. In three studies that compared the effect of an education centred complex intervention with usual care or written instructions only, little evidence of benefit was found. Two studies compared the effect of more intensive and comprehensive complex interventions with usual care. One of these reported improvement of patients' self care behaviour. In the other study a significant and cost-effective reduction of lower extremity amputations (RR 0.30 (95% CI 0.13 to 0.71)) was achieved. All five included RCTs were at high risk of bias; with hardly any of the predefined quality assessment criteria met.

AUTHORS' CONCLUSIONS

There is no high quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit.

Neuro-otologic symptoms in patients with type 2 diabetes mellitus

To assess the prevalence of balance symptoms in type-2 diabetes mellitus (DM2), at the first level of health care. Compared to 101 controls, 101 patients showed a higher frequency of all the symptoms investigated through a standardized questionnaire (p<0.01). In DM2 patients, balance symptoms should be intentionally investigated.

Improving foot self-care behaviors with Pies Sanos

Participants who received Pies Sanos, a 15-min intervention designed to improve diabetes self-efficacy and foot self-care behaviors in adult patients with type 2 diabetes who lived in a predominantly Mexican American community, performed more-complete foot self-care 1 month later in their homes. Recruited when they presented for nonurgent care to the emergency department in two community hospitals near the U.S.-Mexico border, participants were randomized into one of three groups. At follow-up, there was a significant difference in observed foot self-care behaviors between groups, F(2, 135) = 2.99, p < .05, as well as a significant difference within the intervention, t (47) = -4.32, p < .01, and control group, t (46) = -2.06, p < .05, for baseline and follow-up self-reported foot self-care behaviors. Baseline diabetes self-efficacy was significantly and positively correlated with both baseline (r = .335, p < .001) and follow-up ( r = .174, p < .05) foot self-care behaviors.

Improving outcomes in diabetes and chronic kidney disease: the basis for Canadian guidelines

The prevalence of diabetes is on the rise in Canada, and there has been a corresponding increase in the rate of micro- and macrovascular complications. Among the worst of these is chronic kidney disease (CKD). It may be diagnosed either through the detection of persistent albuminuria or an estimated glomerular filtration rate that is persistently less than 60 mL/min/1.73 m2. Patients with diabetes and CKD have a lower quality of life and higher health care costs, and face the prospect of end-stage renal disease requiring dialysis. More importantly, this group has an extremely elevated cardiovascular risk and correspondingly reduced survival. Research over several decades has led to two important conclusions. First, progressive worsening of kidney disease is not inevitable in people with diabetes; it can be slowed or even stopped. Second, the elevated cardiovascular risk in this population can be significantly reduced through an aggressive approach to cardiovascular risk factor reduction. These conclusions have prompted Canadian guideline groups, such as the Canadian Diabetes Association and the Canadian Hypertension Education Program, to release clinical practice guidelines that address the management of people with diabetes and CKD. In the present article, the studies that have influenced these Canadian guidelines are examined, and areas in which further research is still required are identified.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effectiveness of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH STRATEGY

Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register, (September 2004) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2004).

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which evaluated educational programmes for the prevention of foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications.

DATA COLLECTION AND ANALYSIS

Two reviewers undertook data extraction and assessment of study quality independently.

MAIN RESULTS

Nine RCTs were included. Four trials compared the effect of intensive with brief educational interventions; two of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (Peto OR: 0.28 (95% CI 0.13 - 0.59)) and amputation rate (Peto OR: 0.32 (95% CI 0.14 - 0.71)) after one year. The other RCT did not find an effect at seven years follow-up. Participants' foot care knowledge significantly improved with education in two trials. In one trial foot care knowledge improved significantly in the control group, in contrast to the intervention group. Non-calcaneal callus was significantly reduced by education in one trial. One RCT did not find that patient foot care education, as part of a general diabetes education program, reduced foot ulceration compared with usual care. Patient education as part of a complex intervention, targeted at both people with diabetes and doctors, reduced the number of serious foot lesions at one year in one RCT (OR: 0.41(95% CI 0.16 -1.00)) and improved foot care behaviour. Evidence from three RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting.The methodological quality of the nine included RCTs was poor. The internal validity score (range 0 - 10) of individual RCTs ranged from 2 to 5.

AUTHORS' CONCLUSIONS

RCTs evaluating education for people with diabetes, aimed at preventing diabetic foot ulceration, are mostly of poor methodological quality. Weak evidence suggests that patient education may reduce foot ulceration and amputations, especially in high-risk patients. Foot care knowledge and behaviour of patients seem positively influenced by patient education in the short term. Because of conflicting results and the methodological shortcomings more RCTs are needed.

Patient education for preventing diabetic foot ulceration. A systematic review

OBJECTIVE

Ulceration of the feet, which can result in loss of limbs and death, is a major health problem for people with diabetes mellitus. The objective of this review is to assess the effectiveness of patient education to prevent diabetic foot ulcers.

RESEARCH DESIGN AND METHODS

We conducted a systematic review of randomized controlled trials (RCTs) that evaluated educational programmes for the prevention of foot ulcers in people with diabetes mellitus. We used standard search methods of the Cochrane "Wounds Groups". Two reviewers working independently extracted data and assessed study quality.

RESULTS

The methodologic quality of the 8 included RCTs was poor. The internal validity score (range 0-10) of individual RCTs ranged from 2 to 4. Four trials compared the effect of intensive with brief educational interventions; 2 of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (OR 0.28, 95% confidence interval [CI] 0.13-0.59) and amputation rate (OR 0.32, 95% CI 0.14-0.71) after 1 year. The other RCT did not find an effect after 7 years of follow-up. Two trials showed that participants' foot care knowledge significantly improved with education. In one trial, foot care knowledge was significantly worse at 6 months, although foot care behavior improved significantly. One RCT, that compared patient foot care education as part of a general diabetes education program to usual care, showed no reduction in the risk of foot ulceration. In one RCT, patient education as part of a complex intervention targeted at both people with diabetes and doctors reduced the prevalence of serious foot lesions at 1 year (OR 0.41, 95% CI 0.16-1.00) and improved foot care behavior. Evidence from two RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting.

SUMMARY

Evidence, limited by poor methodologic quality and conflicting results, suggests that patient education may have positive but short-lived effects on foot care knowledge and behavior of patients and may reduce foot ulceration and amputations, especially in high-risk patients. High-quality randomized controlled trials are needed to establish the efficacy of patient education to prevent diabetic foot ulcerations.

Foot ulceration and lower limb amputation in type 2 diabetic patients in dutch primary health care

OBJECTIVE

To determine the incidence of foot ulceration and lower limb amputation in type 2 diabetic patients in primary health care.

RESEARCH DESIGN AND METHODS

Data on type 2 diabetes were collected by the Nijmegen Monitoring Project between 1993 and 1998 as part of a study of chronic diseases. The records of all patients recorded as having diabetic foot problems and those who died, moved to a nursing home, or were under specialist care were included. The annual incidence of foot ulceration was defined as the number of type 2 diabetic patients per patient-year who developed a new foot ulcer. Incidence of lower limb amputation was similarly defined. Additional information was collected on treatment of foot ulcers.

RESULTS

The study population of type 2 diabetic patients increased from 511 patient-years in 1993 to 665 in 1998. The annual incidence of foot ulceration varied between 1.2 and 3.0% (mean 2.1) per year; 25% of the patients had recurrent episodes. The annual incidence of lower limb amputation varied between 0.5 and 0.8% (mean 0.6). Ten of the 15 amputees died, and 12 of 52 (23%) patients with ulceration had a subsequent amputation or a previous history of amputation. In 35 of the 73 (48%) episodes of ulceration, only the family physician provided treatment. Patients with foot problems were older and had more cardiovascular disease, retinopathy, and absent peripheral pulses.

CONCLUSIONS

The incidence of foot ulceration and lower limb amputation in type 2 diabetes is low; nevertheless, recurrence rates of ulceration and risk of amputation are high, with high mortality.

Patient education for preventing diabetic foot ulceration

BACKGROUND

Ulceration of the feet, which can result in loss of limbs and even death, is one of the major health problems for people with diabetes mellitus.

OBJECTIVES

To assess the effectiveness of patient education on the prevention of foot ulcers in patients with diabetes mellitus.

SEARCH STRATEGY

Eligible studies were identified by searching the Wounds Group Specialised Trials Register, which is compiled from regular searches of the major health care databases including MEDLINE, Cinahl and EMBASE, hand searching of wound care journals and relevant conference proceedings. For this review the Register was searched up to March 2001.

SELECTION CRITERIA

Prospective randomised controlled trials (RCTs) which evaluated educational programmes for the prevention of foot ulcers in people with diabetes mellitus. There was no restriction on language of the publications.

DATA COLLECTION AND ANALYSIS

Data extraction and assessment of study quality were undertaken by two reviewers independently.

MAIN RESULTS

The methodological quality of the 8 included RCTs was poor. The internal validity score (range 0 - 10) of individual RCTs ranged from 2 to 4. Four trials compared the effect of intensive with brief educational interventions; 2 of these reported clinical endpoints. One study involving high-risk patients reported a reduction in ulcer incidence (Peto OR: 0.28 (95% CI 0.13,0.59)) and amputation rate (Peto OR: 0.32 (0.14,0.71)) after 1 year. The other RCT did not find an effect at seven years follow-up. Participants' foot care knowledge significantly improved with education in 2 trials. In one trial, foot care knowledge was significantly worse at 6 months, although foot care behaviour improved significantly. Non-calcaneal callus was significantly reduced by education in one trial. One RCT did not find that patient foot care education, as part of a general diabetes education program reduced foot ulceration compared with usual care. Patient education as part of a complex intervention targeted at both people with diabetes and doctors reduced the number of serious foot lesions at one year, in one RCT (OR: 0.41(0.16-1.00)) and improved foot care behaviour. Evidence from 2 RCTs comparing the effect of patient-tailored education in addition to usual care was conflicting.

REVIEWER'S CONCLUSIONS

RCTs evaluating education for people with diabetes, aimed at preventing diabetic foot ulceration, are mostly of poor methodological quality. Existing data suggests that patient education may reduce foot ulceration and amputations, especially in high-risk patients. Foot care knowledge and behaviour of patients seem positively influenced by patient education in the short term. Because of conflicting results and the methodological shortcomings more RCTs are needed.

Relative activity and referral patterns for diabetes and non-diabetes in general practice

AIMS

To describe and compare general practice (GP) activity for patients with and without diabetes using a survey of general practices representing over 10% of the Welsh population.

METHODS

The Welsh GP Morbidity Database Project (GPMDP) collected data including demographic and lifestyle information and consultation data such as diagnosis, referral and surgical procedures. These data were analysed to establish the annual period prevalence of diabetes and compare the relative number of consultations and referrals.

RESULTS

A total of 4,182 diabetic patients were recorded (prevalence 1.41%) and accounted for 77,371 (4.4%) consultations. Patients with diabetes were four-times more likely to be referred to community services (relative risk (RR) 4.1, 95% CI 3.7-4.7), in particular district nursing (RR 3.8, 1.9-7.7), optician services (RR 8.9, 5.0-15.7), chiropody (RR 8.2 6.4-10.5) and dietician services (RR 21.2, 17.6-25.5). Patients with diabetes were also more likely to be followed-up in general practice (RR 6.7, 6.2-7.2) both within 1 month (RR 6.7, 6.2-7.2) and 1 month to 1 year (RR 9.7, 8.9-10.7). Emergency admissions were also more likely for patients with diabetes (RR 6.8, 6.2-7.5) as were elective admissions to general medicine (RR 5.6, 4.6-6.7), surgery (RR 1.8, 1.5-2.0) and opthalmology (4.2, 3.4-5.2).

CONCLUSION

The increased utilization of health services apparent in secondary care was confirmed in primary care. Further research is required to determine levels of community activity after initial referral.

Prevalence of diabetic eye disease in an inner city population: the Liverpool Diabetic Eye Study

PURPOSE

To measure the population prevalence of diabetic eye disease in an inner city setting.

METHODS

As part of a systematic screening programme all adult diabetic patients in four general practices were invited to attend for slit-lamp biomicroscopy by a retinal specialist. Data on non-attenders were available from community-based photography.

RESULTS

Of 395 diabetic patients identified, 326 attended biomicroscopy with photographic data available on a further 31, giving a 90% compliance rate. Point prevalence of diabetes in the target population was 12.4/ 1000. Demographic data included: mean age 60 years (range 13-92 years); type of control: type I 49, type II insulin-requiring (IR) 40, type II non-insulin-requiring (NIR) 268. Prevalences were as follows: any retinopathy: of all diabetic patients 33.6%, type I 36.7%, type II IR 45.0%, type II NIR 31.3%; proliferative/ advanced: all 1.1%, type I 2.0%, type II IR 0, type II NIR 1.1%; clinically significant macular oedema: all 6.4%, type I 2.3%, type II IR 16.2%, type II NIR 5.7%. The percentage of patients with retinopathy requiring follow-up by an opthalmologist was 4.5%, and 9.2% had macular exudates within 1 disc diameter of fixation or significant circinate maculopathy. Sight-threatening diabetic eye disease (STED) was found in 13.4%. A visual acuity of < or = 6/24 in the better eye occurred in 12 (3.4%) patients and of < or = 6/60 in the better eye in 3 (0.8%).

CONCLUSIONS

Compared with previous population studies, prevalences appear to have declined in type I, but remain high in type II diabetic patients and especially in those requiring insulin.

The prevalence and determinants of foot ulceration in type II diabetic patients in a primary health care setting

The purpose of the study was to assess the prevalence of foot (pre-)ulcers and their determinants in type II diabetic patients in a primary health care setting. Six hundred and nine patients (246 men, mean age 64.8 (range, 40-94) years, diabetes duration, 4.3 (0-44.9) years) from 22 general practices attended a regional shared care project in Amsterdam. At first visit all patients were examined by a podiatrist. Amputations, active fool ulcers (Wagner stage 1 or 2) and pre-ulcers (Wagner stage 0, hard skin with or without macerating changes) were recorded in 0 (0%), 11 (1.8%) and 79 (12.9%) patients, respectively. In multivariate logistic regression analysis, after adjustment for age and gender, diabetes duration, cigarette smoking, peripheral vascular disease (assessed by calculating ankle/brachial index), sensory neuropathy (by Semmes-Weinstein monofilament 5.07), dry feet and severe hammer toes were independently and significantly associated (pre-)ulceration. In conclusion, one of every seven type II diabetic patients in primary health care has a foot (pre-)ulcer. Patients at risk for foot ulceration can be identified by inspection and the use of simple instruments.

The impact of diabetes-related lower-extremity amputations in The Netherlands

The purpose of this study is to identify the incidence of diabetes-related lower-extremity amputations in the Netherlands. We used discharge records from SIG Health Care Information for every hospitalization for a lower-extremity amputation in all hospitals in the Netherlands in 1992. Age- and gender-specific population figures and diagnosed cases of diabetes were obtained from the Central Bureau of Statistics. Age- and gender-adjusted amputation incidences were identified at four different levels (toe, foot, leg, and thigh). Multiple amputations were analyzed by the highest level. Of all lower-extremity amputations, 1,575 (47%) were in persons with diabetes mellitus. Age- and gender-adjusted lower-extremity amputation rates per 10,000 persons with diabetes by level were the following: toe 12.39, foot 2.42, leg 7.82, thigh 2.54, and total 25.17. People with diabetes were 20.3 times more likely to experience a lower-extremity amputation than people without diabetes. Males were at a significantly higher risk of experiencing an amputation than females. There was a significant increase in the age-specific incidence of amputations as age increased. The most common amputation procedure performed was the toe amputation. There was a significant increase in thigh amputations as age increased, indicating that as people get older they suffer higher levels of amputations. Although the incidence of lower-extremity amputations was lower than previous reports, they still have a serious impact on the health-care system in the Netherlands.

Practice patterns of rural family physicians based on the American Diabetes Association standards of care

The purpose of this study was to examine practice patterns of rural family physicians in the care of non-insulin-dependent diabetes mellitus based on the standards of care of the American Diabetes Association (ADA). One hundred patient charts were randomly chosen, twenty for each physician, from the practices of five family physicians in rural Ohio. A standardized collection protocol was used, based upon the ADA recommendations. The charts were reviewed for compliance with the ADA parameters. The patients' records demonstrated 66% compliance with dietary counseling and 33% with counseling about exercise. Moreover, there was low compliance with physical examination guidelines. Specifically, 66% of the patients had fundoscopic examination and 64% had a complete foot examination done. With respect to the laboratory guidelines, 70% of the charts reviewed had a urinalysis ordered and 45% annual lipids measured. However, glycosylated hemoglobin was performed in only 15% of the patients. The results suggest that rural family physicians do not consistently follow the ADA standards of care.

Validating long term morbidity recording

STUDY OBJECTIVE

To assess the validity of diagnosis made in a general practice based morbidity recording from 1967-90.

DESIGN

Clinical features of patients with a diagnosis of migraine headache and diabetes mellitus were compared with international diagnostic criteria for these conditions. For migraine headache the International Classification of Health Problems in Primary Care (ICHPPC) definition was used, while diabetes mellitus was defined according to World Health Organization (WHO) criteria.

SETTING

The continuous morbidity registry of the Department of General Practice and Social Medicine, University of Nijmegen, has been recording data from four general practices (12,000 patients) continuously since 1967. The database is used for longitudinal clinical research.

PATIENTS

All patients with migraine headache and living in the practice area at the time of study and matched controls with tension headache received a questionnaire asking about ICHPPC criteria symptoms of migraine. The medical records of all patients with diabetes mellitus at the time of diagnosis were compared with WHO criteria.

MAIN RESULTS

In 85% of patients with migraine headache, the questionnaire confirmed the ICHPPC defined criteria. Twenty nine per cent of the matched controls reported migraine features. In 74% of the patients with diabetes mellitus the diagnosis was made in agreement with the WHO criteria: in 12% no clinical information from the time of diagnosis could be traced.

CONCLUSIONS

The diagnoses of migraine headache and diabetes mellitus in the registry largely agreed with international criteria. The quality control of recorded data is satisfactory, and the registry might serve as a model for other primary care based databases.

Cardiovascular morbidity and mortality in type 2 diabetic patients: a 22-year historical cohort study in Dutch general practice

A historical cohort study was performed to assess cardiovascular morbidity and mortality in Type 2 (non-insulin-dependent) diabetic patients. The data were collected from 1967 to 1989 in four Dutch general practices performing the Continuous Morbidity Registration Nijmegen. Each newly diagnosed Type 2 diabetic patient fulfilling the WHO criteria (n = 265) was matched to a control patient for practice, sex, age, and social class. Inclusion started in 1967, the first year of the still ongoing, Continuous Morbidity Registration Nijmegen. On average, a follow-up of 6.8 years (range 1 month-22 years) was realized. Compared to the non-diabetic control patients, the Type 2 diabetic patients showed higher cardiovascular morbidity (risk ratio 1.76, 95% CI 1.34-2.30) and a higher mortality rate (risk ratio 1.54, 95% CI 1.07-2.23). Mortality after 10 years was 36% vs 20% (p < 0.01), the median survival time 16 years vs 19 years. The cumulative survival rates were significantly different (p < 0.01) between patients and controls in the age group 65-74 years. The higher mortality in Type 2 diabetic patients was completely due to an excess of cardiovascular death (risk ratio 2.05, 95% CI 1.24-3.37).

Comorbidity of chronic diseases in general practice

With the increasing number of elderly people in The Netherlands the prevalence of chronic diseases will rise in the next decades. It is recognized in general practice that many older patients suffer from more than one chronic disease (comorbidity). The aim of this study is to describe the extent of comorbidity for the following diseases: hypertension, chronic ischemic heart disease, diabetes mellitus, chronic nonspecific lung disease, osteoarthritis. In a general practice population of 23,534 persons, 1989 patients have been identified with one or more chronic diseases. Only diseases in agreement with diagnostic criteria were included. In persons of 65 and older 23% suffer from one or more of the chronic diseases under study. Within this group 15% suffer from more than one of the chronic diseases. Osteoarthritis and diabetes mellitus are the diseases with the highest rate of comorbidity. Comorbidity restricts the external validity of results from single-disease intervention studies and complicates the organization of care.