Is foot ulcer simulation training (FUST) really effective? Participants’ supervisors speak out

Background Foot ulcers are a common reason for diabetes-related hospitalisation. Foot ulcer simulation training (FUST) programs have increased podiatry participants self-confidence to manage foot ulcers. However, supervisors’ perspectives on their participants attending these simulation programs have not been investigated. This mixed method (quantitative and qualitative) study aimed to investigate home clinical supervisors’ perspectives on any changes to their participants’ competence and practice following FUST. Methods Clinical supervisors of fifteen podiatrists, who participated in a two-day Foot Ulcer Simulation Training (FUST) course, were recruited. Supervisors completed quantitative surveys evaluating their participants’ foot ulcer competence pre-FUST and 6-months post-FUST, via a purposed designed 21-item survey using a five-point Likert scale (1=Very limited, 5=Highly competent). Supervisors also attended a semi-structured qualitative group interview to investigate supervisors’ perspectives on FUST. Results Supervisors surveys returned were pre-FUST (n=10) and post-FUST (n=12). Significant competence improvements were observed at the 6-month survey (mean scores 2.84 cf. 3.72, p < 0.05). Five supervisors attended the group interview. Five sub-themes emerged: i) FUST provided a good foundation for future learning, ii) FUST modelled good clinical behaviour, iii) clinical practice improvement was evident in most participants, iv) clinical improvements were dependent on participant’s willingness to change and existing workplace culture, v) FUST needs to be reinforced back in the home clinic. Conclusion Overall, supervisors of FUST participants indicated that the course improved their participants’ competence and clinical practice. However, the degree of improvement appears dependant on the participants’ home workplace culture and willingness to embrace change.

Developing an evidence-based clinical pathway for the assessment, diagnosis and management of acute Charcot Neuro-Arthropathy : a systematic review

Background: Charcot Neuro-Arthropathy (CN) is one of the more devastating complications of diabetes. To the best of the authors' knowledge, it appears that no clinical tools based on a systematic review of existing literature have been developed to manage acute CN. Thus, the aim of this paper was to systematically review existing literature and develop an evidence-based clinical pathway for the assessment, diagnosis and management of acute CN in patients with diabetes. Methods: Electronic databases (Medline, PubMed, CINAHL, Embase and Cochrane Library), reference lists, and relevant key websites were systematically searched for literature discussing the assessment, diagnosis and/or management of acute CN published between 2002-2012. At least two independent investigators then quality rated and graded the evidence of each included paper. Consistent recommendations emanating from the included papers were then fashioned in a clinical pathway. Results: The systematic search identified 267 manuscripts, of which 117 (44%) met the inclusion criteria for this study. Most manuscripts discussing the assessment, diagnosis and/or management of acute CN constituted level IV (case series) or EO (expert opinion) evidence. The included literature was used to develop an evidence-based clinical pathway for the assessment, investigations, diagnosis and management of acute CN. Conclusions: This research has assisted in developing a comprehensive, evidence-based clinical pathway to promote consistent and optimal practice in the assessment, diagnosis and management of acute CN. The pathway aims to support health professionals in making early diagnosis and providing appropriate immediate management of acute CN, ultimately reducing its associated complications such as amputations and hospitalisations.

Dying feet in ICU : why might extracorporeal membrane oxygenation machines cause necrotic feet?

Background Extracorporeal membrane oxygenation (ECMO) is used for severe lung and/or heart failure in intensive care units (ICU). The Prince Charles Hospital (TPCH) has one of the largest ECMO units in Australia. Its use rapidly increased during the H1N1 (“swine flu”) pandemic and an increase in pedal complications resulted. The relationship between ECMO and pedal complications has been described, particularly in children, though no strong data exists. This paper presents a case series of foot complications in patients having received ECMO treatment. Methods We present nine cases of severe foot complications resulting from patients receiving ECMO treatment at TPCH in 2009–2012. Results Case ages ranged from 16 - 58 years and three were male. Six cases had an unremarkable medical history prior to H1N1 or H1N2 infection, one had Cardiomyopathy, one had received a lung transplant, and one had multi-organ failure post-sepsis. Common medications prescribed included vasopressors, antibiotics, and sedatives. All cases showed signs of markedly impaired peripheral perfusion whilst on ECMO and seven developed increasing areas of foot necrosis. Outcomes include two bilateral below knee amputations, two multiple digital amputations, one Reflex Sympathetic Dystrophy Syndrome, three pressure injuries, and three deaths. Conclusion Necrosis of the feet appears to occur more readily in younger people requiring ECMO treatment than others in ICU. The authors are conducting further studies to investigate associations between particular infections, medical history, medications, or machine techniques and severe foot complications. Some of these early results will also be presented at this conference.

Queensland’s high risk foot database : tracking the length and width of Queensland’s foot ulcers

Background Foot ulcers are a leading cause of avoidable hospital admissions and lower extremity amputations. However, large clinical studies describing foot ulcer presentations in the ambulatory setting are limited. The aim of this descriptive observational paper is to report the characteristics of ambulatory foot ulcer patients managed across 13 of 17 Queensland Health & Hospital Services. Methods Data on all foot ulcer patients registered with a Queensland High Risk Foot Form (QHRFF) was collected at their first consult in 2012. Data is automatically extracted from each QHRFF into a Queensland high risk foot database. Descriptive statistics display age, sex, ulcer types and co-morbidities. Statewide clinical indicators of foot ulcer management are also reported. Results Overall, 2,034 people presented with a foot ulcer in 2012. Mean age was 63(±14) years and 67.8% were male. Co-morbidities included 85% had diabetes, 49.7% hypertension, 39.2% dyslipidaemia, 25.6% cardiovascular disease, 13.7% kidney disease and 12.2% smoking. Foot ulcer types included 51.6% neuropathic, 17.8% neuro-ischaemic, 7.2% ischaemic, 6.6% post-surgical and 16.8% other; whilst 31% were infected. Clinical indicator results revealed 98% had their wound categorised, 51% received non-removable offloading, median ulcer healing time was 6-weeks and 37% had ulcer recurrence. Conclusion This paper details the largest foot ulcer database reported in Australia. People presenting with foot ulcers appear predominantly older, male with several co-morbidities. Encouragingly it appears most patients are receiving best practice care. These results may be a factor in the significant reduction of Queensland diabetes foot-related hospitalisations and amputations recently reported.

Queensland diabetic foot hospitalisations (2005-10) : in what state is our foot hospital problem?

Background Diabetes foot complications are a leading cause of overall avoidable hospital admissions. Since 2006, the Queensland Diabetes Clinical Network has implemented programs aimed at reducing diabetes-related hospitalisation. The aim of this retrospective observational study was to determine the incidence of diabetes foot-related hospital admissions in Queensland from 2005 to 2010. Methods Data on all primary diabetes foot-related admissions in Queensland from 2005-2010 was obtained using diabetes foot-related ICD-10-AM (hospital discharge) codes. Queensland diabetes foot-related admission incidences were calculated using general population data from the Australian Bureau of Statistics. Furthermore, diabetes foot-related sub-group admissions were analysed. Chi-squared tests were used to assess changes in admissions over time. Results Overall, 24,917 diabetes foot-related admissions occurred, resulting in the use of 260,085 bed days or 1.4% of all available Queensland hospital bed days (18,352,152). The primary reasons for these admissions were foot ulcers (49.8%), cellulitis (20.7%), peripheral vascular disease (17.8%) and osteomyelitis (3.8%). The diabetes foot-related admission incidence among the general population (per 100,000) reduced by 22% (103.0 in 2005, to 80.7 in 2010, p < 0.001); bed days decreased by 18% (1,099 to 904, p < 0.001). Conclusion Diabetes foot complications appear to be the primary reason for 1.4 out of every 100 hospital beds used in Queensland. There has been a significant reduction in the incidence of diabetes foot-related admissions in Queensland between 2005 and 2010. This decrease has coincided with a corresponding decrease in amputations and the implementation of several diabetes foot clinical programs throughout Queensland.

Reduction in the incidence of diabetes lower extremity amputations in Queensland : 2005-2010

Background Lower extremity amputation is a common end stage complication among people with diabetes. Since 2006, the Queensland Diabetes Clinical Network has implemented programs aimed at reducing diabetes-related amputations. The aim of this retrospective observational study was to determine the incidence of diabetes lower extremity amputations in Queensland from 2005 to 2010. Methods Data on all Queensland diabetes-related lower extremity amputation admissions from 2005-2010 was obtained using diabetes amputation-related ICD-10-AM (hospital discharge) codes. Queensland diabetes amputation incidences were calculated for both general and diabetes populations using population data from the Australian Bureau of Statistics and National Diabetes Services Scheme respectively. Chi-squared tests were used to assess changes in amputation incidence over time. Results Overall, 4,443 admissions for diabetes-related amputation occurred; 32% (1,434) were major amputations. The diabetes-related amputation incidence among the general population (per 100,000) reduced by 18% (18.2 in 2005, to 15.0 in 2010, p < 0.001); major amputations decreased by 24% (6.6 to 4.7, p < 0.01). The incidence among the diabetes population (per 1,000) reduced by 40% (6.7 in 2005, to 4.0 in 2010, p < 0.001); major amputations decreased by 45% (2.3 to 1.2, p < 0.001). Conclusion This paper appears to be the first to report a significant reduction in diabetes amputation incidence in an Australian state. This decrease has coincided with the implementation of several diabetes foot clinical programs throughout Queensland. Whilst these results are encouraging in the Australian context, further efforts are required to decrease to levels reported internationally.

Foot ulcer simulation training (FUST) : are podiatrists FUST with long-term clinical confidence?

Background Foot ulcers are a leading cause of diabetes-related hospitalisations. Clinical training has been shown to be beneficial in foot ulcer management. Recently, improved self-confidence in podiatrists was reported immediately after foot ulcer simulation training (FUST) pilot programs. This study aimed to investigate the longer-term impacts of the FUST program on podiatrists’ self-confidence over 12 months in a larger sample. Methods Participants were podiatrists attending a two-day FUST course comprising web-based interactive learning, low-fidelity part-tasks and high-fidelity full clinical scenarios. Primary outcome measures included participants’ self-confidence measured pre-, (immediately) post-, 6-month post- and 12-month post-course via a purpose designed 21-item survey using a five-point Likert scale (1=Very limited, 5=Highly confident). Participants’ perceptions of knowledge gained, satisfaction, relevance and fidelity were also investigated. ANOVA and post hoc tests were used to test any differences between groups. Results Thirty-four participants completed FUST. Survey response rates were 100% (pre), 82% (post), 74% (6-month post), and 47% (12-month post). Overall mean scores were 3.13 (pre), 4.49 (post), 4.35 (6-month post) and 4.30 (12-month post) (p < 0.05); post hoc tests indicated no differences between the immediately, 6-month and 12-month post group scores (p > 0.05). Satisfaction, knowledge, relevance and fidelity were all rated highly. Conclusion This study suggests that significant short-term improvements in self-confidence to manage foot ulcers via simulation training are retained over the longer term. It is likely that improved self-confidence leads to improved foot ulcer clinical practice and outcomes; although this requires further research.

Is the clinical Queensland High Risk Foot Form valid or reliable for research?

Background High-risk foot complications such as neuropathy, ischaemia, deformity, infections, ulcers and amputations consume considerable health care resources and typically result from chronic diseases. This study aimed to develop and test the validity and reliability of a Queensland High Risk Foot Form (QHRFF) tool. Methods Phase one involved developing a QHRFF using an existing diabetes high-risk foot tool, literature search, expert panel and several state-wide stakeholder groups. Phase two tested the criterion-related validity along with inter- and intra-rater reliability of the final QHRFF. Three cohorts of patients (n = 94) and four clinicians, representing different levels of expertise, were recruited. Validity was determined by calculating sensitivity, specificity and positive predictive values (PPV). Kappa and intra-class correlation (ICC) statistics were used to establish reliability. Results A QHRFF tool containing 46-items across seven domains was developed and endorsed. The majority of QHRFF items achieved moderate-to-perfect validity (PPV = 0.71 – 1) and reliability (Kappa/ICC = 0.41 – 1). Items with weak validity and/or reliability included those identifying health professionals previously attending the patient, other (non-listed) co-morbidity, previous foot ulcer, foot deformity, optimum offloading and optimum footwear. Conclusions The QHRFF had moderate-to-perfect validity and reliability across the majority of items, particularly identifying individual co-morbidities and foot complications. Items with weak validity or reliability need to be re-defined or removed. Overall, the QHRFF appears to be a valid and reliable tool to assess, collect and measure clinical data pertaining to high-risk foot complications for clinical or research purposes.

High risk feet in subacute rehabilitation facilities : how many are there?

Background Australian subacute rehabilitation facilities face significant challenges from the ageing population with increased burden of chronic disease. High risk foot complications are a negative consequence of many chronic diseases. With the rapid expansion of subacute services, it seems imperative to investigate the prevalence of foot complications in this population. The primary aim of this study was to quantify the high risk foot complication prevalence in a subacute rehabilitation population. Methods Eligible participants were all adults admitted overnight, over two 4 week periods, into a large Australian subacute rehabilitation facility. Consenting participants underwent a short non-invasive foot examination by a podiatrist. The standard Queensland Health High Risk Foot Form collected data on age, sex, co-morbidities and foot complications. Descriptive statistics, logistic regression and odds ratios were used to determine the prevalence of foot complications and associations with explanatory variables. Results Overall, 85 of 97 eligible participants consented; mean age 80(9) and 71% were female. At least one foot complication was present in 56.5% participants; including 21.2% defined as high risk and 11.8% current foot ulcer. A previous diagnosis of neuropathy increased the risk of presenting with a high risk foot by 13-fold (OR 13.504, p = 0.001). Conclusion This study highlights the significance of foot complications in the subacute population. It appears that one in every two patients present with a foot complication and one in eight with a foot ulcer. It is suggested all patients admitted to subacute rehabilitation services should be screened for foot complications.

Evaluating the impact of high risk foot training on undergraduate podiatry students

Background Diabetes is the leading cause of high risk foot (HRF) complications, admissions and lower limb amputation. Best practice training of podiatrists is known to have a beneficial impact on such outcomes; however, there has been a paucity of studies into undergraduate diabetes podiatry training. The primary aim of this paper was to investigate the changes in final year podiatry students’ confidence, knowledge and clinical practice in the management of HRF complications. Methods This was a prospective longitudinal study of final year podiatry students (n=25) at the Queensland University of Technology. All participants throughout 2011 undertook an intervention of a series of “hands on” HRF workshops, on-campus clinics and external clinical rotations. Outcome measures included customised confidence and knowledge surveys in HRF management across four time points. A timed simulated case scenario was used to evaluate changes in clinical practice at two time points. Friedman and Wilcoxon Signed Rank Tests were used to calculate differences between time points Results Overall improvements between the first and last time points were demonstrated in 20/21 confidence items (p<0.001), 12/27 clinical practice items (p<0.05) and 3/12 knowledge items (p<0.001). Although 8/12 knowledge items recorded high baseline scores of over 80%. Conclusions Overall, it appears student confidence and clinical practice improved with the introduction of designated HRF activities, whilst knowledge remained high. This suggests “hands on” practice and not didactic lectures improve students’ clinical confidence and practice. Results from the 2012 student cohort will also be presented at this conference.

Australian Diabetes Foot Network : practical guideline on the provision of footwear for people with diabetes

Trauma, in the form of pressure and/or friction from footwear, is a common cause of foot ulceration in people with diabetes. These practical recommendations regarding the provision of footwear for people with diabetes were agreed upon following review of existing position statements and clinical guidelines. The aim of this process was not to re-invent existing guidelines but to provide practical guidance for health professionals on how they can best deliver these recommendations within the Australian health system. Where information was lacking or inconsistent, a consensus was reached following discussion by all authors. Appropriately prescribed footwear, used alone or in conjunction with custom-made foot orthoses, can reduce pedal pressures and reduce the risk of foot ulceration. It is important for all health professionals involved in the care of people with diabetes to both assess and make recommendations on the footwear needs of their clients or to refer to health professionals with such skills and knowledge. Individuals with more complex footwear needs (for example those who require custom-made medical grade footwear and orthoses) should be referred to health professionals with experience in the prescription of these modalities and who are able to provide appropriate and timely follow-up. Where financial disadvantage is a barrier to individuals acquiring appropriate footwear, health care professionals should be aware of state and territory based equipment funding schemes that can provide financial assistance. Aboriginal and Torres Strait Islanders and people living in rural and remote areas are likely to have limited access to a broad range of footwear. Provision of appropriate footwear to people with diabetes in these communities needs be addressed as part of a comprehensive national strategy to reduce the burden of diabetes and its complications on the health system.

Prevalence of childhood sexual abuse among 2508 college students in 6 provinces of China [中国6省市2508名大学生儿童期性虐待经历回顾性调查]

OBJECTIVE To assess the prevalence of childhood sexual abuse (CSA) in college students and to explore the association of CSA with youth mental health problem. METHODS A retrospective survey was conducted among 2508 students (females 1360, males 1148) in Nov. 2003 to Mar. 2004. The students were from 6 colleges/universities in Beijing, Hebei, Shanxi, Jiangsu, Shaanxi and Anhui provinces of China. RESULTS Of the 2508 students, 24.8% of females and 17.6% of males reported one or more types of nonphysical contact CSA (females 20.0% vs. males 14.6%) or/and physical contact CSA (females 14.1% vs. males 7.8%) before the age of 16 years. Risk of any CSA was not associated with the existence of siblings (one-child vs. two-or more child families), rural/non-rural residence during childhood, or parental education. Compared with their peers who had no CSA, the students with CSA showed significantly higher mean scores of psychological symptoms of somatization, obsessiveness, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation and psychoticism. CONCLUSION The problem of CSA was not uncommon and there was a significant correlation between CSA experience and students mental health problems. More attention should be paid on CSA prevention and provision of health services for the victims.

Secretome and degradome profiling shows that Kallikrein-related peptidases 4, 5, 6, and 7 induce TGFβ-1 signaling in ovarian cancer cells

Kallikrein-related peptidases, in particular KLK4, 5, 6 and 7 (4-7), often have elevated expression levels in ovarian cancer. In OV-MZ-6 ovarian cancer cells, combined expression of KLK4-7 reduces cell adhesion and increases cell invasion and resistance to paclitaxel. The present work investigates how KLK4-7 shape the secreted proteome ("secretome") and proteolytic profile ("degradome") of ovarian cancer cells. The secretome comparison consistently identified >900 proteins in three replicate analyses. Expression of KLK4-7 predominantly affected the abundance of proteins involved in cell-cell communication. Among others, this includes increased levels of transforming growth factor β-1 (TGFβ-1). KLK4-7 co-transfected OV-MZ-6 cells share prominent features of elevated TGFβ-1 signaling, including increased abundance of neural cell adhesion molecule L1 (L1CAM). Augmented levels of TGFβ-1 and L1CAM upon expression of KLK4-7 were corroborated in vivo by an ovarian cancer xenograft model. The degradomic analysis showed that KLK4-7 expression mostly affected cleavage sites C-terminal to arginine, corresponding to the preference of kallikreins 4, 5 and 6. Putative kallikrein substrates include chemokines, such as growth differentiation factor 15 (GDF 15) and macrophage migration inhibitory factor (MIF). Proteolytic maturation of TGFβ-1 was also elevated. KLK4-7 have a pronounced, yet non-degrading impact on the secreted proteome, with a strong association between these proteases and TGFβ-1 signaling in tumor biology. © 2013 Federation of European Biochemical Societies.

Ghrelin O-acyltransferase (GOAT) is expressed in prostate cancer tissues and cell lines and expression is differentially regulated in vitro by ghrelin

Background Ghrelin is a 28 amino acid peptide hormone that is expressed in the stomach and a range of peripheral tissues, where it frequently acts as an autocrine/paracrine growth factor. Ghrelin is modified by a unique acylation required for it to activate its cognate receptor, the growth hormone secretagogue receptor (GHSR), which mediates many of the actions of ghrelin. Recently, the enzyme responsible for adding the fatty acid residue (octanoyl/acyl group) to the third amino acid of ghrelin, GOAT (ghrelin O-acyltransferase), was identified. Methods We used cell culture, quantitative real-time reverse transcription (RT)-PCR and immunohistochemistry to demonstrate the expression of GOAT in prostate cancer cell lines and tissues from patients. Real-time RT-PCR was used to demonstrate the expression of prohormone convertase (PC)1/3, PC2 and furin in prostate cancer cell lines. Prostate-derived cell lines were treated with ghrelin and desacyl ghrelin and the effect on GOAT expression was measured using quantitative RT-PCR. Results We have demonstrated that GOAT mRNA and protein are expressed in the normal prostate and human prostate cancer tissue samples. The RWPE-1 and RWPE-2 normal prostate-derived cell lines and the LNCaP, DU145, and PC3 prostate cancer cell lines express GOAT and at least one other enzyme that is necessary to produce mature, acylated ghrelin from proghrelin (PC1/3, PC2 or furin). Finally, ghrelin, but not desacyl ghrelin (unacylated ghrelin), can directly regulate the expression of GOAT in the RWPE-1 normal prostate derived cell line and the PC3 prostate cancer cell line. Ghrelin treatment (100nM) for 6 hours significantly decreased GOAT mRNA expression two-fold (P < 0.05) in the PC3 prostate cancer cell line, however, ghrelin did not regulate GOAT expression in the DU145 and LNCaP prostate cancer cell lines. Conclusions This study demonstrates that GOAT is expressed in prostate cancer specimens and cell lines. Ghrelin regulates GOAT expression, however, this is likely to be cell-type specific. The expression of GOAT in prostate cancer supports the hypothesis that the ghrelin axis has autocrine/paracrine roles. We propose that the RWPE-1 prostate cell line and the PC3 prostate cancer cell line may be useful for investigating GOAT regulation and function.

Glycerol carbonate as green solvent for pretreatment of sugarcane bagasse

Background Pretreatment of lignocellulosic biomass is a prerequisite for effective saccharification to produce fermentable sugars. We have previously reported an effective low temperature (90 °C) process at atmospheric pressure for pretreatment of sugarcane bagasse with acidified mixtures of ethylene carbonate (EC) and ethylene glycol (EG). In this study, “greener” solvent systems based on acidified mixtures of glycerol carbonate (GC) and glycerol were used to treat sugarcane bagasse and the roles of each solvent in deconstructing biomass were determined. Results Pretreatment of sugarcane bagasse at 90 °C for only 30 min with acidified GC produced a solid residue having a glucan digestibility of 90% and a glucose yield of 80%, which were significantly higher than a glucan digestibility of 16% and a glucose yield of 15% obtained for bagasse pretreated with acidified EC. Biomass compositional analyses showed that GC pretreatment removed more lignin than EC pretreatment (84% vs 54%). Scanning electron microscopy (SEM) showed that fluffy and size-reduced fibres were produced from GC pretreatment whereas EC pretreatment produced compact particles of reduced size. The maximal glucan digestibility and glucose yield of GC/glycerol systems were about 7% lower than those of EC/ethylene glycol (EG) systems. Replacing up to 50 wt% of GC with glycerol did not negatively affect glucan digestibility and glucose yield. The results from pretreatment of microcrystalline cellulose (MCC) showed that (1) pretreatment with acidified alkylene glycol (AG) alone increased enzymatic digestibility compared to pretreatments with acidified alkylene carbonate (AC) alone and acidified mixtures of AC and AG, (2) pretreatment with acidified GC alone slightly increased, but with acidified EC alone significantly decreased, enzymatic digestibility compared to untreated MCC, and (3) there was a good positive linear correlation of enzymatic digestibility of treated and untreated MCC samples with congo red (CR) adsorption capacity. Conclusions Acidified GC alone was a more effective solvent for pretreatment of sugarcane bagasse than acidified EC alone. The higher glucose yield obtained with GC-pretreated bagasse is possibly due to the presence of one hydroxyl group in the GC molecular structure, resulting in more significant biomass delignification and defibrillation, though both solvent pretreatments reduced bagasse particles to a similar extent. The maximum glucan digestibility of GC/glycerol systems was less than that of EC/EG systems, which is likely attributed to glycerol being less effective than EG in biomass delignification and defibrillation. Acidified AC/AG solvent systems were more effective for pretreatment of lignin-containing biomass than MCC.