Poster session 1: Education and prevention

Poster session 1: Education and prevention
P1.01
Self care in prevention of the diabetic foot in women with healed foot ulcer: Patients’
opinions about living with high risk feet
Magdalena Annersten Gershater, Malmö University, MALMÖ, Sverige, Sweden
Lejla Mehica, Skåne University Hospital, MALMÖ, Sverige, Sweden
Carin Alm Roijer, Malmö University, MALMÖ, Sverige, Sweden
Jan Apelqvist, Skane University Hospital, MALMÖ, Sverige, Sweden
Aim: This study aimed to explore what topics were described as important in the prevention
of high risk feet by participants in a patient driven group education about prevention of
diabetes foot ulcers.
Method: Recordings from patient driven group education were analyzed using content
analysis. Participants were 14 women (divided into 3 groups) with diabetes (type 1 or 2),
peripheral neuropathy and a previous healed foot ulcer. Age: 51-78, median 63. They met in
a 1 hour participant driven session together with a facilitator (diabetes specialist nurse) to
discuss and learn together how to protect the feet from future injuries.
Result: Different themes evolved during the analysis process: Self perceived reasons for
ulceration, background factors: long standing diabetes and neuropathy, self care habits and
obstacles to perform good self care, the importance of seeking help early and different social
consequences of living with diabetes and vulnerable high risk feet.
Conclusion: Patients self care is a corner stone in the prevention of diabetic foot ulcers.
Educational programs need to be developed according to the patients’ perceived needs in
order to improve learning outcomes and self care habits.
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Page 1 of 10
P1.02
Self-screening of the foot with the web application ”MyFoot, diabetes”
John Alnemo, Sahlgrenska Academy, University of Gothenburg, Borås, Sweden, Sweden
Ulla Hellstrand Tang, Sahlgrenska Academy, University of Gothenburg, Gothenburg,
Sweden
Aim: The aim was to construct a simple and useful eHealth tool, a web application for selfscreening and risk assessment for diabetes patients. MyFoot, diabetes is designed to give
the patients advice and knowledge about their foot health and to prevent foot complications.
Method: The creative process to design the app MyFoot, diabetes, took place in a
“hackathon” organized by a non-government organization “Forum för Välfärd, (FfV)”. The risk
factors was identified with easy-to- answer questions. The informative illustrations were
created as a help for the patients in the screening procedure. Risk factors such as signs of
peripheral angiopathy and/or neuropathy are identified. Foot deformities, acute
osteoarthropathy and gait deviation are recognized, present and earlier ulcers or amputation
noted and callosities registered. The risk assessment was based on Swedish national
guidelines in diabetes together with long clinical and research experience in the team.
Results: When the test is finalized the app MyFoot, diabetes delivers:
A risk assessment which identify if the patient have a high, medium, low or no risk to develop
foot complications
Information about the patients risk factors
Customised advice about self-care of the feet
Custumised advice about socks and shoes
Advice to attend to the primary care or be referred to podiatry/Department of Proshetics &
Orthotics depending on the assessment
A report with a summary of the foot assessment is created and can be saved by e-mail o
sms to the patient
A link to a search-function allows the patient to search nearest Primary Care Unit.
Conclusion: The app won FfV and the jury motivation was that it shows that mobile technic
can be integrated in health care in a way that highlights the importance of patients
participation thus improving the care in the patients perspective. Our intention is to release
the app free of charge to people with diabetes. Our vision is to build a network with national
and international diabetes associations and together with caregivers work for the prevention
of diabetic foot complication.
Acknowledgement
MyFoot Diabetes was evolved during leisure time in an inter-disciplinary team consisted by
Certified Prosthetists & Orthotists, web designers and graphic designer, Gothenburg,
Sweden
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P1.03
An evaluation of self-care practices and knowledge in patients living with Type 2
diabetes attending primary healthcare settings
Alfred Gatt, University of Malta, Msida, Malta, Malta
Ryan Muscat, University of Malta, Msida, Malta, Malta
Cynthia Formosa, University of Malta, Msida, Malta, Malta
Aims: The aims of this study were to identify both the nature and extent of diabetes-related
knowledge and self-care practices in people living with type-2 diabetes, attending primary
care clinics and to determine whether a correlation between the two exists.
Methods: A non-experimental prospective study was conducted on 50 subjects living with
type-2 diabetes attending a primary health care setting. The Diabetes Knowledge
Questionnaire [DKQ-24] and the Summary of Diabetes Self-care Activities [SDSCA] were
used to assess knowledge and self-management in the study population.
Results: The mean DKQ-24 score was 14.40 out of a total of 24 and the mean self-care
activities score was 2.89 out of a total of 7, indicating a deficit in a number of key areas in
the management of diabetes. There was no statistically significant correlation between
diabetes knowledge score and diabetes self-care activities in the study group.
Discussion: The authors suggest a move away from traditional, didactic, diabetes-related
education, which has failed in a number of settings, towards innovative approaches that are
person-centred to improve metabolic outcomes and quality of life for individuals with
diabetes. Integrating theories of behavioural change in educational interventions, including
psychosocial concepts such as patient-centred care, self-efficacy and empowerment, may
translate in improved care at primary care setting, reduce long-term complications and
improve quality of life.
Conclusion: This study has highlighted knowledge deficits and inadequate levels of
adherence to certain areas of self-care in the study group. The authors advocate for not only
improvements with regards to patients’ awareness and availability of diabetes educational
classes within primary care settings, but emphasizes that educational sessions should also
undergo changes to improve their effectiveness, sustainability and scalability translating in
better behavioural and health outcomes. Providing adequate education in a primary care
setting – in which most people with diabetes receive their care – is imperative in order to
reduce the burden of this condition.
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P1.04
'Decision Navigation' in diabetic foot ulcer patients: A randomised controlled trial
Emily McBride, NHS Lothian, Edinburgh, United Kingdom
Matthew Young, NHS Lothian, Edinburgh, United Kingdom
Belinda Hacking, NHS Lothian, Edinburgh, United Kingdom
Ronan O'Carroll, University of Stirling, Stirling, United Kingdom
Objectives: This study primarily aimed to explore whether the use of ‘Decision Navigation’ in
diabetic foot ulcer patients increased: (i) the patient’s confidence related to treatment
decision making and (ii) treatment adherence.
Methods: 'Decision Navigation’ (DN) is a multi-component decision aid intervention which
consists of eliciting a list of personally relevant treatment questions from the patient, for use
within their consultation, and providing them with a post-consultation written summary and
audio recording of what was discussed in their consultation. Forty two diabetic foot ulcer
patients have been randomised to receive decision navigation (n = 22) or usual care (n = 20)
to date; 60 patients will be recruited in total. Primary outcomes included decisional selfefficacy (DSE), adherence to foot treatment as reported by the patient, and adherence to
foot treatment as reported by the clinician. Secondary outcomes included foot ulcer healing
rate, health-related quality of life (HRQoL), decisional conflict (DCS), decisional regret (DR)
and acceptability of Decision Navigation.
Results: Interim analysis on available data indicated that diabetic foot patients' confidence
related to treatment decision making was higher in those receiving the intervention
(M=88.64, SD=12.32) compared to usual care (M=72.32, SD=23.7), F=4.13, p=0.05, d=0.74.
Adherence to treatment, as reported by both the clinician and patient, yielded no significant
difference between intervention and TAU; however this may be due to limited statistical
power from the number of recruits to date (d=0.36 in favour of the intervention).
Conclusions: DN facilitates shared decision making and informed care in the diabetic foot
population through increasing patients' confidence in their ability to source information
related to treatment options and foot self-care. This emphasises the potential for DN to
assist in achieving the national shift urged towards patient-centered care in this population
(NICE, 2009), whereby increasing patient involvement may have wider implications for
health-related outcomes such as adherence to foot treatment and wound healing rate.
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Page 4 of 10
P1.05
Amputation feared more than death: an evaluation of patients with diabetic foot
disease
Katherine Raspovic, MedStar Georgetown University Hospital, Washington, DC, DC, United
States
Dane Wukich, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
Brett Chatman, MedStar Washington Hospital Center, Washington, DC, United States
Aim: Patients with DM are at risk for cardiovascular disease, Charcot neuroarthropathy
(CN), neuropathy and renal disease resulting in significant morbidity and premature
mortality. Diabetic foot disease increases the risk of amputation and mortality. The aim of
this study was to identify the greatest fears in patients with diabetic foot disease.
Methods: 161 patients with diabetic foot disease (CN, foot infection or ulcers) were
compared to 155 diabetic patients without diabetic foot disease (evaluated for for
nondiabetic foot problems [i.e. tendonitis, flatfoot deformity] or routine screening. Patients
ranked five complications (major amputation, blindness, death from heart attack or stroke,
foot infection or dialysis), with a score of 5 as their greatest fear and 1 as their lowest fear.
None of the patients in either group had previously undergone major amputation, were
receiving dialysis or blind. Results: (Table 1) The greatest fears in patients with diabetic foot
disease were blindness and major amputation (p= 0.24). Patients with diabetic foot disease
expressed a greater fear of major amputation (3.74) than death (2.42)[p=0.0001] and were
2.2 more likely to rank amputation as their greatest fear compared to death (2.26, 95% CI
1.34-3.82, p <0.01). Patients with diabetic foot disease were 2.6 times more likely to rank
amputation as their greatest fear when compared to patients without diabetic foot problems
(OR 2.6, 95% CI 1.51-4.50, p< 0.001).
Conclusion: Patients with established diabetic foot problems fear major amputation more
than diabetic patients without diabetic foot problems and were 2.6 times more likely to rank
amputation as their greatest fear than patients without diabetic foot problems. Both groups
have a similarly high fear of blindness.
Table without patients
with Amputation,
Blindness or Dialysis
Age
Gender (N,% Males)
Type (Type 1 N, %)
Duration
Insulin
BMI
Michigan Neuropathy
Index
Amputation (Mean
Score)
Blindness (Mean Score)
Death (Mean Score)
Foot Infection (Mean
Score)
Dialysis (Mean Score)
Transplant (N, %)
Ulcer (N,%)
Charcot (N,%)
PAD (N,%)
Overall N=316
Diabetic Foot 161
Non Diabetic Foot 155
60.5± 11.4
99, 61.9%
18, 11.2%
17.5± 10.5
121, 75.2%
33.9± 7.6
7.2± 1.6
60.8± 10.4
65, 41.9%
8, 5.2%
10.2± 9.7
59, 38.1%
33.5± 7.1
2.3± 2.0
P= 0.83
P= 0.0005
P= 0.06
P < 0.0001
P< 0.0001
P= 0.57
P < 0.0001
3.52
3.74± 1.12
3.30± 1.09
P= 0.0004
3.81
2.43
2.06
3.88± 1.07
2.42± 1.57
2.11± 1.15
3.73± 1.24
2.89± 1.79
2.02± 1.06
P= 0.24
P= 0.0126
P= 0.49
2.96
2.88± 1.18
2 of 161 , 1.2%
112 of 161, 69.6%
62 of 161, 42.2%
41 of 161, 26.2%
3.05± 1.22
0
0
0
0
P= 0.21
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Page 5 of 10
P1.06
Motivational interviewing to improve footwear adherence in diabetic patients
Renske Keukenkamp, Academic Medical Centre, Amsterdam, Netherlands
Tessa Busch, Academic Medical Centre, Amsterdam, Netherlands
Maarten Merkx, Academic Medical Centre, Amsterdam, Netherlands
Sicco Bus, Academic Medical Centre, Amsterdam, Netherlands
Aim: In diabetic patients who are at high risk of developing foot complications such as
ulcers, adherence to wearing prescription footwear is low, in particular inside the house. To
be effective in ulcer prevention, footwear adherence must be assured. The aim of this pilot
RCT was to assess the effect of motivational interviewing to improve footwear adherence in
high-risk diabetic patients.
Methods: Based on the objective 7-day measurement of footwear adherence using shoeworn temperature sensors (@monitor, Department of Medical Technology and Innovation,
Academic Medical Center, Amsterdam, the Netherlands) and ankle-worn step activity
monitors (StepWatch, Orthocare Innovations LLC, Oklahoma, United States), 13 diabetic
patients with a history of foot ulceration and a low adherence (i.e. <80% of steps were taken
in prescription footwear) were randomly assigned to standard education (i.e. verbal and
written instructions) or to standard education added with two 45-minute sessions of
Motivational Interviewing (MI), performed by two trained investigators. Adherence at home
and away from home were assessed at baseline and at one week and 3 months post
intervention.
Results: Five intervention and 5 control group patients were analysed. In the MI group,
baseline adherence at home was 49 [4-62]% (median [minmax]), which improved to 84 [399]% at one week, but decreased to 40 [6-80]% at 3 months. In the standard education
group, baseline adherence at home was 35 [9-62]%, 33 [15-55]% at one week and 31 [366]% at 3 months.
Footwear adherence away from home for the MI group was 91 [88-100]%, 99 [84-99]% and
95 [90-95]% at baseline, one week and 3 months, respectively. In the standard education
group this was 77 [32-97]%, 91 [28-98]% and 93 [49-100]%, respectively. Patients were
more active inside their homes compared to being away.
Conclusion: In the short-term, motivational interviewing appears to be effective for
improving footwear adherence at home in high-risk diabetic patients. However, the effect
seems to diminish over 3 months, and therefore additional or adjunctive therapy may be
needed. Footwear adherence away from home is already sufficient in these patients. Studies
with a larger sample size are needed to confirm our findings.
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P1.07
Evaluation of health-related quality of life (QOL) and depression in patients with
diabetic foot lesions in Japan
Nakagawachi Reiko, Kyoto Medical Center diabetic center, Kyoto, Japan
Kono Shigeo, Kyoto Medical Center diabetic center, WHO Coraborating Center, kyoto,
Japan
Background: In Western countries, a decrease in the quality of life (QOL) and a high
prevalence of depression in patients with diabetic foot (DF) lesions have been reported.
However, in Japan, the situation remains unclear.
Aim: The purpose of this study was to clarify the health-related QOL and status of
depression in DF patients in Japan.
Subjects: The subjects consisted of 49 DF patients (31 males and 18 females) aged 62.7 ±
12.3 years (mean) during follow-up at our department. The duration of diabetes mellitus was
18.9 ± 9.7 years, and the HbA1c level was 7.3 ± 1.1 (%).
Methods: (1) A survey of health-related quality of life (QOL) and depression was performed
using the 36-item Short Form Health Survey (SF-36) and the Self-rating Questionnaire for
Depression (SRQ-D) in 49 DF patients who visited our outpatient clinic in October and
November 2013. In addition, the results of this survey were compared among age groups,
between the presence and absence of recurrence, and among foot lesions (3 groups with
ulceration ∙ osteomyelitis requiring amputation, that not requiring amputation, or Charcot
foot). (2) The results were compared between the 11 patients surveyed in 2013 and 11
surveyed using similar methods in 2008.
Results: (1) The QOL survey involving all DF patients showed a decrease in the PCS score
(28.4 ± 15.5) but no decrease in the MCS score (55.6 ± 10.0) compared with the mean score
in healthy persons aged 60-69 years (PCS, 47.2 ± 10.9; MCS, 52 ± 10.0). (2) There was no
depression tendency in any DF patient. However, in patients aged < 50 years, the
prevalence of depression was significantly higher. (3) The PCS score was markedly
decreased in the amputation group (23.6 ± 15.3) and Charcot foot group (20.0 ± 15.6). (4)
Comparison between the survey in 2008 and that in 2013 showed a significant decrease in
the PCS score (36.6 ± 3.2 vs. 24.8 ± 4.1, respectively, p = 0.002).
Conclusion: DF patients showed a marked decrease in the physical QOL, but no decrease
in the mental QOL nor a depression tendency.
However, patients aged < 50 years with intractable ulcers tended to develop depression due
to social factors (such as difficulty in finding employment), and therefore, psychological
support for them is important.
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P1.08
Development of a software for decision making support to identify the clinical severity
of diabetic polyneuropathy
Cristina Sartor, University of Sao Paulo, Sao Paulo, Brazil
Eneida Suda, University of Sao Paulo, Sao Paulo, Brazil
Ricky Watari, University of Sao Paulo, Sao Paulo, Brazil
Neli Ortega, University of Sao Paulo, Sao Paulo, Brazil
José Roveda, Sao Paulo State University, Sorocaba, Brazil
Joao Helaehil, Sao Paulo State University, Sorocaba, Brazil
Antônio Martins, Sao Paulo State University, Sorocaba, Brazil
Gil Konno, University of Sao Paulo, Sao Paulo, Brazil
Isabel Sacco, University of Sao Paulo, Sao Paulo, Brazil
Aim: To develop a software as a decision support tool to be used by health professionals in
the identification of severity degree of diabetic neuropathy (DPN). It is intended to serve as a
specialists’ opinion in DPN, aiding in the decision on the best clinical conduct accordingly to
the patient’s condition.
Methods: An open and bilingual software was created based on an algorithm developed in a
MATLAB routine. The patient’s clinical information should be filled up in 5 topic pages
containing: (i) general information and DPN symptoms (ii) tactile sensitivity; (iii) vibratory
sensitivity and (v) feet inspection. The fuzzy model uses the previous clinical measures
acquired as inputs, which are classified into fuzzy linguistic sets (fuzzyfication process).
Then, it performs a combinatory analysis of those variables, using and if-then rule base,
linking them with fuzzy output sets (Mamdani inference process). Those output sets are
transformed into a numerical value by the center of area defuzzification method, resulting in
a “neuropathy degree score” (0-10 points), that represents the main product of the software
[1].
The rules and decisions were determined by the consensual opinion of 4 specialists in DPN.
The performance of the fuzzy system was tested in a dataset of 231 real cases of diabetic
patients by assessing the agreement between the classification according to the software
output and the opinion of the specialists, using the Pearson coefficient, and the sensitivity
and specificity with a ROC curve analysis.
Results: The correlation revealed a very strong positive relationship (r = 0.943) between the
fuzzy system output and the consensual classifications, with an excellent accuracy (ROC
curve of 0.985).
Conclusion: The software is easily managed and reliable. We recommend its use as a
support system for research and clinical purposes. General practitioners and other
specialized health care settings could use the software to standardize and speed up the
procedures, without depending on a specialist committee. It also helps to spread the
knowledge about the DPN affections in groups that do not focus on treating diabetic foot.
Aknowledgments:FAPESP(2013/06123-7) CNPq(556374/2010-0&151531/2013-7)
References:
[1] Watari et al. J Neuroeng Rehabil 8:11-11 2014.
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Page 8 of 10
P1.09
The impact of self-reported diabetic neuropathy or antecedent feet ulcerations on the
quality of life
Ioan Andrei Veresiu, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca,
Romania
Cosmina Bondor, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca,
Romania
Norina Gavan, Romanian Society of Diabetic Neuropathy, Cluj-Napoca, Romania
Bogdan Florea, IMOGEN Institute, Cluj-Napoca, Romania
Vinik Etta, Eastern Virginia Medical School, EVMS Strelitz Diabetes Center, Norfolk, VA,
United States
Aaron Vinik, Eastern Virginia Medical School, EVMS Strelitz Diabetes Center, Norfolk, VA,
United States
Aim: This is a report from the QoL-DN Romania study (Quality of life in patients with diabetic
neuropathy in Romania) that enrolled 25000 patients., QoL-DN Romania was a crosssectional study of QoL in patients with self-reported diabetes using the Norfolk QoL-DN
“fiber-specific” questionnaire, professionally translated in Romanian language.
Method: 21174 patients who responded “yes” to the question “Do you have diabetes?” were
included in the study., We used as “cut-off values” for scores the mean ± SD from previous
studies in subjects without neuropathy. 2694 (12.72%) reported that they have neuropathy
and they had ulcerations (group A), 10953 (51.72%) reported that they have neuropathy and
don’t had ulcerations (group B), 299 (1.41%) reported no neuropathy but antecedent foot
ulcerations (group C) and 6130 (28.95%) had no neuropathy and no history of foot
ulcerations (group D). We tested with two-way ANOVA and Chi square for differences.
Results: Self-reported neuropathy or self-reported antecedent feet ulcers (groups A, B and
C) had the greatest influence on “Small fibers” and for “Activities of Daily Living” scores., A
significantly (p<0.001) higher percentage of the patients in group A, B and C than from group
D had equal or higher “Total score” that the “normal values” (98.1, 93.2, 85.3 respectively
54.3). The same significant differences (p<0.001) was also for the scores on all subdomains, “Physical Functioning/ large-fiber neuropathy” (95.7, 86.6, 78.3 respectively 48.2),
“Symptoms” (97.5, 94.7, 93.3 respectively 48.8), “Activities of Daily Living” (81.1, 63.4, 51.8
respectively 25.1), “Autonomic neuropathy” (80.8, 64.2, 59.2 respectively 34.9) and “Small
fibers” (85.4, 66.1, 50.2 respectively 22.0)., The differences between groups A, B and C are
also statistically significant.
Conclusions: This study on quality of life in patients with diabetic neuropathy enrolled the
greatest number of patients in Romania (and, at least in our knowledge, in the world). Selfreported diabetic neuropathy or self-reported antecedent feet ulceration has the same great
impact on QoL. We need to confirm our observation also in a prospective study, using
instrumental criteria for diagnosing diabetic neuropathy.
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Page 9 of 10
P1.10
Frequency of depression and effect of antidepressant treatment on the outcome of
diabetic foot ulcer
Muhammad Saif Ulhaque, Baqai Institute of Diabetology and Endocrinology, Baqai Medical
University, Karachi, Pakistan
Muhammad Yakoob Ahmedani, Baqai Institute of Diabetology and Endocrinology, Baqai
Medical University, Karachi, Pakistan
Shahid Ahsan, Hamdard College of Medicine and Dentistry, Hamdard University, Karachi,
Pakistan
Background: Depression is adversely associated with diabetes complications.
Aim: To determine the frequency of depression and the effect of antidepressant treatment
on depression and outcomes of diabetic foot ulcers.
Method: This prospective, double blinded, non-placebo control study was conducted at the
foot clinic of Baqai Institute of Diabetology and Endocrinology (BIDE) after ethical approval.
All diabetic patients attending the foot clinic were invited to participate. Patients on dialysis or
having creatinine above normal range and pregnant women were excluded from the study.
Diabetic foot ulcers were classified according to University of Texas classification criteria.
Depression was accessed by Patient Health Questionnaire-9(PHQ-9). Both depressed and
non-depressed groups (PHQ score ≥9 and <9 respectively) were given standard diabetes
and foot care treatment. In addition antidepressant treatment was given to the depressed
patients, for three months. After three months, PHQ-9 was again administered to the
depressed group.
Result: Of the total inducted patients (n=105) nearly half of them were found to be
depressed (n= 53, 50.4%). At baseline no significant difference was fund in the distribution
of hypertension, history of smoking and duration, grading and type of ulcers between
depressed and non -depressed groups.
Three months of antidepressant treatment brought significant improvement in the mean
depression score (p≤0.05). Though, more foot ulcers healed completely in non-depressed
than in the depressed group (60% vs 40%, p>0.05), their healing time, rate of minor and
major amputations, patients on treatment and patients lost to follow up were comparable
findings between the groups.
Conclusion: Presence of high frequency of depression in patients with diabetic foot ulcers,
underscores the need of screening for depression. Antidepressant treatment lifts depression
and made diabetic foot ulcer outcome comparable to non-depressed patients.
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