The British Journal of Diabetes & Vascular Disease

Athorough clinical assessment and evaluation of foot perfusion is essential in managing diabetic foot disease. The treatment of macrovascular disease is key to reducing the high amputation rates seen in diabetic patients, particularly as small vessel dysfunction may make diabetic individuals more vulnerable to the effects of macrovascular, atherosclerotic disease. The clinical assessment remains paramount in the management of diabetic foot disease. The confounding effects of peripheral neuropathy on the symptoms and signs of lower limb arterial insufficiency can make assessment difficult. This article provides a resume of the clinical manifestation of lower limb ischaemia and neuropathy and the importance of accurate evaluation of the diabetic foot.

Type 2 diabetes is associated with an increased risk of coronary heart disease (CHD). The association between CHD and abnormal plasma lipid levels has led current guidelines to recommend pharmacological modification of the lipid profile. Statins are particularly effective at reducing cholesterol levels, with additional benefits on other components of the lipid profile. Lipid-modifying therapy should be used routinely to reduce the risk of CHD in patients with type 2 diabetes.

The Steno-2 study and UKPDS showed that targeted intensified intervention on modifiable cardiovascular risk factors in patients with type 2 diabetes reduces morbidity and mortality. The Alphabet POEM strategy (Practice Of Evidence-based Medicine) assessed the effect of systematic application of the Alphabet Strategy to care of patients with type 2 diabetes. In comparison to the Steno-2 intensive cohort, Alphabet POEM fared similarly with regard to diastolic blood pressure (BP), HbA1C, aspirin and angiotensin-converting enzyme (ACE) inhibitor use, but less well with respect to systolic BP, total cholesterol and use of statins. Alphabet POEM achieved better systolic and diastolic BP than UKPDS but glycaemic control was significantly worse. The standards achieved in the Steno-2 study and UKPDS are in principle, at least, partially achievable in a district general hospital in the UK, but fully achieving them in practice will probably need a radical restructuring, and greater provision of resources.

Diabetes mellitus causes significant morbidity and mortality, and up to 50% of people with diabetes may be as yet undiagnosed. Additionally impaired glucose tolerance (IGT) is known to increase vascular risk and the risk of developing diabetes.

The aim of this study was to look for IGT and/or impaired fasting glucose (IFG) and undiagnosed diabetes amongst patients with hypertension and patients with ischaemic heart disease (IHD) as part of an annual structured assessment.

In IHD patients the uptake was 83.45% with a yield of 2.47% for undiagnosed diabetes and 12.39% for IGT/IFG. In hypertensive patients the uptake was 75.84% with a yield of 2.01% for undiagnosed diabetes and 18.54% for IGT/IFG.

We concluded that looking for undiagnosed type 2 diabetes and patients with IGT/IFG in primary care may be worthwhile amongst patients with hypertension or IHD.

Aims

To conduct a survey examining issues relating to implementation of the diabetes NSF (National Service Framework) in primary care.

Methods

Fifty-two general practices were sent a questionnaire (14 questions) to investigate issues relating to implementation of the NSF for diabetes.

Results

A completed questionnaire was returned by 32 (≥ 60%) of practices. Of these, 30 (93.7%) had a practice register for diabetes, 18 (56.2%) had a screening policy for undiagnosed diabetes and 23 (71.9%) had specific diabetes clinics (SDC).

The practice nurse was at the front line of diabetes care, with the general practitioner, podiatrist and dietitian playing an increased role when patients had uncontrolled risk factors, or complications. In SDC lack of funding, specialist personnel and time were the main barriers to implementing the diabetes NSF.

In most practices holding SDC, patients with diabetes (65.2%) were not seen in the same clinics as patients with other cardiovascular risk problems, but without diabetes (34.8%). In those general practices not holding SDC, the majority reported they did not wish to develop these clinics (60%), due mainly to time restrictions. Only a minority (24%) of general practices referred patients with psychological problems, related to diabetes, to clinical psychology services.

Conclusion

Many general practices lack the necessary infrastructure to deliver comprehensive diabetes care and will struggle, without additional resources, to meet standards of care required, following NSF implementation.

Background

Patients with peripheral arterial disease (PAD) are at increased risk for stroke, myocardial infarction (MI) and cardiovascular death. Prior studies have focused on the prevalence of PAD, but the rate of ischaemic outcomes among a diverse group of patients with PAD has received less attention. In addition, the assessment of ischaemic outcomes with the use of a survey in place of casenote review, to our knowledge, has not been defined. The purpose of this pilot study was to develop an ischaemic outcomes survey that could be used in place of the labour-intensive casenote review, for data collection as part of a large epidemiological study.

Methods

A data abstraction form was used as a guide in blinded casenote reviews to compare the patient's reported medical history to casenote documented ischaemic events. The proportion agreement and Cohen's kappa were used to measure the agreement and the statistical significance of this agreement between the questionnaire and casenote review items. Fifty-one patients with a history of PAD were consented and interviewed using a 23-item questionnaire that focused on the ischaemic events of unstable angina, MI, cerebral vascular accident, transient ischaemic attacks, lower extremity revascularisation, or lower extremity amputation.

Results

Of the 23 patient survey items, proportion agreement was ≥ 70% on more than half of the items with kappa statistics that were fair-to-moderate. For ischaemic outcomes such as lower extremity bypass surgery, there were no yes responses from the patient or within the medical record, which reflects the low prevalence of this outcome.

Conclusions

Overall, the ischaemic outcomes questionnaire was a valid research tool. It yielded statistically significant kappa values on several items. Although additional work is needed, the present survey provides a good framework on which to develop the final questionnaire, which will be used in a large prospective cohort study to capture ischaemic events in patients with PAD.

Children, like adults of South Asian origin are at increased risk of developing type 2 diabetes and other conditions associated with insulin resistance. The rising prevalence of excess body weight in children is of special concern as a promoter of insulin resistance. This article considers the evidence and need to develop and implement healthy lifestyle interventions in schools.