Multidisciplinary review of teaching and assessing competency attainment by non-medical prescribers

Background Prescribing is a complex task, requiring specific knowledge and skills, and the execution of effective, context-specific clinical reasoning. Systematic reviews indicate medical prescribing errors have a median rate of 7% [IQR 2%-14%] of medication orders [1-3]. For podiatrists pursuing prescribing rights, a clear need exists to ensure practitioners develop a well-defined set of prescribing skills, which will contribute to competent, safe and appropriate practice. Aim To investigate the methods employed to teach and assess the principles of effective prescribing in the undergraduate podiatry program and compare and contrast these findings with four other non-medical professions who undertake prescribing after training at Queensland University of Technology. Method The NPS National Prescribing Competency Standards were employed as the prescribing standard. A curriculum mapping exercise was undertaken to determine whether the prescribing principles articulated in the competency standards were addressed by each profession. Results A range of methods are currently utilised to teach prescribing across disciplines. Application of prescribing competencies to the context of each profession appears to influence the teaching methods used. Most competencies were taught using a multimodal format, including interactive lectures, self-directed learning, tutorial sessions and clinical placement. In particular clinical training was identified as the most consistent form of educating safe prescribers across all five disciplines. Assessment of prescribing competency utilised multiple techniques including written and oral examinations and research tasks, case studies, objective structured clinical examination exercises and the assessment of clinical practice. Effective and reliable assessment of prescribing undertaken by students in diverse settings remains challenging e.g. that occurring in the clinical practice environment. Conclusion Recommendations were made to refine curricula and to promote efficient cross-discipline teaching by staff from the disciplines of podiatry, pharmacy, nurse practitioner, optometry and paramedic science. Students now experience a sophisticated level of multidisciplinary learning in the clinical setting which integrates the expertise and skills of experience prescribers combined with innovative information technology platforms (CCTV and live patient assessments). Further work is required to establish a practical, effective approach to the assessment of prescribing competence especially between the university and clinical settings.

Limitations of the manual supination resistance test

The aim of this study was to asses results obtained from a range of commonly performed lower extremity “open and closed” chain kinetic tests used for predicting foot function and correlate these test findings to data obtained from the Zebris WinFDM-T system®. When performed correctly these tests are thought to be indicators of lower extremity function. Podiatrists frequently perform examinations of joint and muscle structures to understand biomechanical function; however the relationship between these routine tests and forces generated during the gait cycle are not always well understood. This can introduce a degree of variability in clinical interpretation which creates conjecture regarding the value of these tests.

The effect of flexor tenotomy on healing and prevention of neuropathic diabetic foot ulcers on the distal end of the toe

Background Flexor tenotomy is a minimally invasive surgical alternative for the treatment of neuropathic diabetic foot ulcers on the distal end of the toe. The influence of infection on healing and time to heal after flexor tenotomy is unknown. Flexor tenotomy can also be used as a prophylactic treatment. The effectiveness as a prophylactic treatment has not been described before. Methods A retrospective study was performed with the inclusion of all consecutive flexor tenotomies from one hospital between January 2005 and December 2011. Results From 38 ulcers, 35 healed (92%), with a mean time to heal of 22 ± 26 days. The longest duration for healing was found for infected ulcers that were penetrating to bone (35 days; p = .042). Cases of prophylactic flexor tenotomies (n=9) did not result in any ulcer or other complications during follow-up. Conclusions The results of this study suggest that flexor tenotomy may be beneficial for neuropathic diabetic foot ulcers on the distal end of the toe, with a high healing percentage and a short mean time to heal. Infected ulcers that penetrated to bone took a significantly longer time to heal. Prospective research, to confirm the results of this retrospective study, should be performed.

The genetic associations of acute anterior uveitis and their overlap with the genetics of ankylosing spondylitis

Acute anterior uveitis (AAU) involves inflammation of the iris and ciliary body of the eye. It occurs both in isolation and as a complication of ankylosing spondylitis (AS). It is strongly associated with HLA-B*27, but previous studies have suggested that further genetic factors may confer additional risk. We sought to investigate this using the Illumina Exomechip microarray, to compare 1504 cases with AS and AAU, 1805 with AS but no AAU and 21 133 healthy controls. We also used a heterogeneity test to test the differences in effect size between AS with AAU and AS without AAU. In the analysis comparing AS+AAU+ cases versus controls, HLA-B*27 and HLA-A*02:01 were significantly associated with the presence of AAU (P<10−300 and P=6 × 10−8, respectively). Secondary independent association with PSORS1C3 (P=4.7 × 10−5) and TAP2 (P=1.1 × 10−5) were observed in the major histocompatibility complex. There was a new suggestive association with a low-frequency variant at zinc-finger protein 154 in the AS without AAU versus control analysis (zinc-finger protein 154 (ZNF154), P=2.2 × 10−6). Heterogeneity testing showed that rs30187 in ERAP1 has a larger effect on AAU compared with that in AS alone. These findings also suggest that variants in ERAP1 have a differential impact on the risk of AAU when compared with AS, and hence the genetic risk for AAU differs from AS.

What kind of sick person would see a Foot Doctor! The Foot Disease in Inpatients Study (FDIS)

Background Many different guidelines recommend people with foot complications, or those at risk, should attend multiple health professionals for foot care each year. However, few studies have investigated the characteristics of those attending health professionals for foot care and if those characteristics match those requiring foot care as per guideline recommendations. The aim of this paper was to determine the associated characteristics of people who attended a health professional for foot care in the year prior to their hospitalisation. Methods Eligible participants were all adults admitted overnight, for any reason, into five diverse hospitals on one day; excluding maternity, mental health and cognitively impaired patients. Participants underwent a foot examination to clinically diagnose different foot complications; including wounds, infections, deformity, peripheral arterial disease and peripheral neuropathy. They were also surveyed on social determinant, medical history, self-care, foot complication history, and, past health professional attendance for foot care in the year prior to hospitalisation. Results Overall, 733 participants consented; mean(±SD) age 62(±19) years, 408 (55.8%) male, 172 (23.5%) diabetes. Two hundred and fifty-six (34.9% (95% CI) (31.6-38.4)) participants had attended a health professional for foot care; including attending podiatrists 180 (24.5%), GPs 93 (24.6%), and surgeons 36 (4.9%). In backwards stepwise multivariate analyses attending any health professional for foot care was independently associated (OR (95% CI)) with diabetes (3.0 (2.1-4.5)), arthritis (1.8 (1.3-2.6)), mobility impairment (2.0 (1.4-2.9)) and previous foot ulcer (5.4 (2.9-10.0)). Attending a podiatrist was independently associated with female gender (2.6 (1.7-3.9)), increasing years of age (1.06 (1.04-1.08), diabetes (5.0 (3.2-7.9)), arthritis (2.0 (1.3-3.0)), hypertension (1.7 (1.1-2.6) and previous foot ulcer (4.5 (2.4-8.1). While attending a GP was independently associated with having a foot ulcer (10.4 (5.6-19.2). Conclusions Promisingly these findings indicate that people with a diagnosis of diabetes and arthritis are more likely to attend health professionals for foot care. However, it also appears those with active foot complications, or significant risk factors, may not be more likely to receive the multi-disciplinary foot care recommended by guidelines. More concerted efforts are required to ensure all people with foot complications are receiving recommended foot care.

Mobility impairment and bad feet … who'd of guessed? The Foot Disease in Inpatients Study (FDIS)

Background Foot complications have been found to be predictors of mobility impairment and falls in community dwelling elderly patients. However, fewer studies have investigated the link between foot complications and mobility impairment in hospital in patient populations. The aim of this paper was to investigate the associations between mobility impairment and various foot complications in general inpatient populations. Methods Eligible participants were all adults admitted overnight, for any reason, into five diverse hospitals on one day; excluding maternity, mental health and cognitively impaired patients. Participants underwent a foot examination to clinically diagnose different foot complications; including foot wounds, infections, deformity, peripheral arterial disease and peripheral neuropathy. They were also surveyed on social determinant, medical history, self-care, footwear, foot complication history risk factors, and, mobility impairment defined as requiring a mobility aid for mobilisation prior to hospitalisation. Results Overall, 733 participants consented; mean(±SD) age 62(±19) years, 408 (55.8%) male, 172 (23.5%) diabetes. Mobility impairment was present in 242 (33.2%) participants; diabetes populations reported more mobility impairment than non-diabetes populations (40.7% vs 30.9%, p < 0.05). In a backwards stepwise multivariate analysis, and controlling for other risk factors, those people with mobility impairment were independently associated with increasing years of age (OR = 1.04 (95% CI) (1.02-1.05)), male gender (OR = 1.7 (1.2-2.5)), being born in Australia (OR = 1.7 (1.1-2.8), vision impairment (2.0 (1.2-3.1)), peripheral neuropathy (OR = 3.1 (2.0-4.6) and foot deformity (OR = 2.0 (1.3-3.0). Conclusions These findings support the results of other large studies investigating community dwelling elderly patients that peripheral neuropathy and foot deformity are independently associated with mobility impairment and potentially falls. Furthermore the findings suggest routine clinical diagnosis of foot complications as defined by national diabetic foot guidelines were sufficient to determine these associated foot complication risk factors for mobility impairment. Further research is required to establish if these foot complication risk factors for mobility impairment are predictors of actual falls in the inpatient environment.

The tired foot. The effects of physical activity, energy expenditure and sleep on the diabetic foot population

Background The most common pathway to development of diabetes foot ulcers is repetitive daily activity stress on the plantar surface of the neuropathic foot. Studies suggest an association between different diabetic foot complications and physical activity. However, to the best of the authors knowledge the steps/day and sleep patterns of people with diabetic foot ulcers has yet to be investigated. This observational study aims to investigate the physical activity and sleep patterns of three groups of adults with type 2 diabetes and different foot complications Methods Participants with type 2 diabetes were recruited into three groups: 1. those with no reported foot complications (DNIL), 2. those with diagnosis of neuropathy (DPN) and 3. those with a neuropathic ulcer (DFU). Exclusion criteria included peripheral arterial disease and mobility aid use. Participants wore a SenseWear Pro 3 Armband continuously for 7 days and completed an Epworth Sleepiness Scale. The Armband is a validated automated measure of activity (walking steps, average Metabolic Equivalent Task (MET), physical activity (>3 METs) duration), energy expenditure(kJ) (total and physical activity (>3 METs)) and sleep (duration). Data on age, sex, BMI, diabetes duration and HbA1c were also collected. Results Sixty-Six (14 DNIL, 22 DPN and 30 DFU's participants were recruited; 71% males, mean age 61(±12) years, diabetes duration 13(±9) years, HbA1c 8.3(±2.8), BMI 32.6(±5.9), average METs 1.2(0.2). Significant differences were reported in mean(SD) steps/day (5,859(±2,381) in DNIL; 5,007(±3,349) in DPN and 3,271(±2,417) in DFU's and daily energy expenditure (10,868(±1,307)kJ in DNIL; 11,060(±1,916)kJ in DPN and 13,006(± 3,559) in DFU's(p <0.05). No significant differences were reported for average METs, physical activity duration or energy expenditure, sleep time or Epworth score (p>0.1). Conclusions Preliminary findings suggest people with diabetes are sedentary. Results indicate that patients with a diabetic foot ulcer work significantly less than those with neuropathy or nil complications and use significantly more energy to do so. Sleep Parameters showed no differences. Recruitment is still on going.

Innovative telemedicine and mobile phone technology in the management of diabetic foot ulcers

Background Diabetic foot ulcers (DFU) are a leading cause of diabetes-related hospitalisation and can be costly to manage without access to appropriate expert care. Within Queensland and indeed across many parts of Australia, there is an inequality in accessing specialist services for individuals with DFU. Recent National Health and Medical Research Council (NHMRC) diabetic foot guidelines recommend remote expert consultation with digital imaging should be made available to people with DFU to improve their clinical outcomes. Telemedicine appears to show promise in improving access to diabetic foot specialist services; however diabetic foot telemedicine models to date have relied upon videoconferencing, store and forward technology and/or customised appliances to obtain digital imagery which all require either expensive infrastructure or a timed reply to the request for advice. Whilst mobile phone advice services have been used with success in general diabetes management and telehealth services have improved diabetic foot outcomes, the rapid emergence in the use of mobile phones has established a need to review the role that various forms of telemedicine play in the management of DFU. The aim of this paper is to review traditional telemedicine modalities that have been used in the management of DFU and to compare that to new and innovative technology that are emerging. Process Studies investigating the management of DFU using various forms of telemedicine interventions will be included in this review. They include the use of videoconferencing technology, hand held digital still photography purpose built imaging devices and mobile phone imagery. Electronic databases (Pubmed, Medline and CINAHL) will be searched using broad MeSH terms and keywords that cover the intended area of interest. Findings It is anticipated that the results of this narrative review will provide delegates of the 2015 Australasian Podiatry Conference an insight into the types of emerging innovative diagnostic telemedicine technologies in the management of DFU against the backdrop of traditional and evidence based modalities. It is anticipated that the findings will drive further research in the area of mobile phone imagery and innovation in the management of DFU.

Social determinants of health and diabetic foot disease

Background Diabetic foot disease (DFD) is the leading cause of hospitalisation and lower extremity amputation (LEA) in people with diabetes. Many studies have established the relationship between DFD and clinical risk factors, such as peripheral neuropathy and peripheral arterial disease. Other studies have identified the relationship between diabetes and non-clinical risk factors termed social determinants of health (SDoH), such as socioeconomic status. However, it appears very few studies have investigated the relationship between DFD and SDoH. This paper aims to review the existing literature investigating the relationship between DFD and the SDoH factors socioeconomic status (SES), race and geographical remoteness (remoteness). Process Electronic databases (MEDLINE, CINAHL, and PubMed) were searched for studies reporting SES, race (including Aboriginal and Torres Strait Islander in Australia) and remoteness and their relationship to DFD and LEA. Exclusion criteria were studies conducted in developing countries and studies published prior to 2000. Findings Forty-eight studies met the inclusion criteria and were reviewed; 10 in Australia. Overall, 28 (58%) studies investigated LEA, 10 (21%) DFD, and 10 (21%) DFD and LEA as the DFD-related outcome. Thirty-six (75%) studies investigated the SDoH risk factor of race, 22 (46%) SES, and 20 (42%) remoteness. SES, race and remoteness were found to be individually associated with LEA and DFD in the majority of studies. Only four studies investigated interactions between SES, race and remoteness and DFD with contrasting findings. All four studies used only LEA as their investigated outcome. No Australian studies investigate the interaction of all three SDoH risk factors on DFD outcomes. Conclusions The SDoH risk factors of SES, race and GR appear to be individually associated with DFD. However, only few studies investigated the interaction of these three major SDoH risk factors and DFD outcomes with contrasting results. There is a clear gap in this area of DFD research and particularly in Australia. Until urgent future research is performed, current practice and policy does not adequately take into consideration the implication of SDoH on DFD.