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Clinical vascular screening of the foot Online CPD activity Visit www.pcdsa.com.au/cpd to record your answers and gain a certificate of participation Participants should read the preceding article before answering the multiple choice questions below. There is ONE correct answer to each question. After submitting your answers online, you will be immediately notified of your score. A pass mark of 70% is required to obtain a certificate of successful participation; however, it is possible to take the test a maximum of three times. A short explanation of the correct answer is provided. Before accessing your certificate, you will be given the opportunity to evaluate the activity and reflect on the module, stating how you will use what you have learnt in practice. The CPD centre keeps a record of your CPD activities and provides the option to add items to an action plan, which will help you to collate evidence for your annual appraisal. 1. In what percentage of sudden cardiac deaths are there no previously determined cardiovascular risk factors? Select ONE option only. A. 1% B. 10% C. 25% D. 50% 2. The risk of mortality with peripheral arterial disease (PAD) is similar to the risk of mortality in which of the following groups of people? Select ONE option only. A. People who smoke cigarettes B. People who have diabetes C. People with a history of a previous cardiovascular or cerebrovascular event D. People with renal disease 3. According to Caro et al (2005), what is the estimated range of prevalence of PAD? Select ONE option only. 5. Of the visual signs of PAD, which of the following has the highest sensitivity? Select ONE option only. A. Colour B. Pallor C. Skin atrophy D. Buerger’s sign 6. The ankle–brachial index (ABI) is useful for identifying cardiovascular disease risk in the general population; however, it has reduced sensitivity in proportion to the degree of vascular stenosis present in an individual. Which of the following factors reduces the sensitivity of the ABI for PAD screening? Select ONE option only. A. Diabetes B. Neuropathy C. Renal disease D. Advanced age E. All of the above 8. In a recent meta-analysis of inter-arm differences in brachial systolic blood pressures (Clarke et al, 2012), what was the threshold shown to be a marker of cardiovascular mortality in the presence of a CVD risk score of >20%? Select ONE option only. A. A 45 mmHg difference B. A 25 mmHg difference C. A 10 mmHg difference D. A 5 mmHg difference 9. Using a handheld Doppler ultrasound, the result of a monophasic signal (sound or waveform) is indicative of the following diagnosis? Select ONE option only. A. A normal result B. PAD is highly likely C. An ambiguous outcome with regard to PAD D. PAD is very unlikely A.
Article Antimicrobial management of diabetic foot infection Roy Rasalam, Caroline McIntosh, Aonghus O’Loughlin Diabetic foot infections (DFIs) are a frequent and costly complication associated with diabetes mellitus. Osteomyelitis is present in 44–68% of patients admitted to hospital and DFIs account for 60% of lower extremity amputations in developed countries. Diagnosis of DFIs should be based upon the presence of local and systemic signs and symptoms, and the management and outcomes of DFIs are superior through the involvement of a multidisciplinary team. This article presents an overview of the current evidence for diagnosis and management of DFIs in practice. The prevalence of diabetes mellitus has increased dramatically in recent decades, as have the complications associated with the condition (Lipsky et al, 2016). It is estimated there are currently 415 million, or one in 11, people with diabetes globally (International Diabetes Federation, 2015). Chronic hyperglycaemia associated with diabetes mellitus is known to have a detrimental effect on human immune function; specifically, cellular immunity and polymorphonuclear leukocytes are affected, and phagocytosis is impaired (Akkus et al, 2016). Thus, people with diabetes are at increased risk of diabetic foot infections (DFIs). According to Peters (2016), the incidence of foot infections in people with diabetes ranges from an overall lifetime risk of 4% to a yearly risk of 7%. Additionally, approximately 60% of diabetic foot ulcers (DFUs) are infected on presentation (Markakis et al, 2016). DFIs usually occur when pathogens enter the foot through a break in the skin’s integrity, such as a neuropathic or neuroischaemic foot ulceration (Peters, 2016). DFIs are associated with significant morbidity and mortality, as infection can spread rapidly in the diabetic foot. If infection spreads to deeper structures, including the underlying bone, diabetic foot osteomyelitis (DFO) develops. DFIs are the most frequent diabetes-related complication requiring hospitalisation, and DFO is present in 44–68% of cases admitted to hospital (Lipsky et al, 2016; Peters, 2016). If not managed appropriately, DFI can trigger a cascade that results in lower extremity amputation, especially in people with peripheral arterial disease (Markakis et al, 2016). DFIs account for 60% of lower extremity amputations in developed countries (Peters, 2016). Prompt identification, rapid diagnosis, timely referral for specialist review and appropriate management strategies are all vital steps in the quest to minimise the adverse outcomes associated with DFIs. Establishing the diagnosis Peters (2016) stresses the importance of an initial diagnosis of DFI based on clinical signs and symptoms, as the reliance on bloods, microbiological and radiological studies could lead to a delay in diagnosis. However, he also acknowledges the challenges faced by clinicians when using clinical judgement. It is possible that the signs and symptoms of infection are less prevalent in people with diabetes. This may be due to the presence of foot ischaemia, neuropathy and immunopathy, which could, theoretically, reduce the inflammatory response and mask the classic signs of infection (Peters, 2016). Though as Peters (2016) highlights, this theory is not proven. Citation: Rasalam R, McIntosh C, O’Loughlin A (2017) Antimicrobial management of diabetic foot infection. Diabetes & Primary Care Australia 2: 25–9 Article points 1. Diabetic foot infections (DFIs) are the most frequent diabetes-related complications requiring hospitalisation. 2. Approximately 60% of diabetic foot ulcers are infected on presentation. 3. Osteomyelitis is present in 44–68% of patients admitted into hospital with DFIs. 4. DFIs account for 60% of lower extremity amputations in developed countries. 5. Diagnosis of DFIs should be based upon the presence of local and systemic signs and symptoms. 6. The management and outcome for a DFI is superior if there is the involvement of a multidisciplinary team. Key words – Antimicrobials – Diabetic foot infections – Diagnosis – Management Authors Roy Rasalam is Head of Clinical Skills & Medical Director, College of Medicine, James Cook University, Townsville City, Qld, Australia; Caroline McIntosh is Professor of Podiatric Medicine, Discipline of Podiatric Medicine, National University of Ireland Galway, Galway, Ireland; Aonghus O’Loughlin is Consultant Physician, Diabetes Day Centre, Galway University Hospital, Galway, Ireland. Diabetes & Primary Care Australia Vol 2 No 1 2017 25
Page 1 and 2: Diabetes & Primary Care Australia V
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Page 5 and 6: Editorial Diabetes education We are
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