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CPD module 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. According to Boekholdt et al (2012), which combination of LDL cholesterol and non- HDL cholesterol has the HIGHEST hazard ratio for major cardiovascular events? Select ONE option only. LDL cholesterol (mmol/L) Non-HDL cholesterol (mmol/L) A. 4 3 B. 2 4 C. 2 3 D. 3 2 2. When considering the primary prevention of CVD, for which ONE of the following people with diabetes is Australian CVD risk tool appropriate? Select ONE option only. A. A 30-year-old man with type 1 diabetes B. A 45-year-old woman with type 2 diabetes and familial hypercholesterolaemia C. A 62-year-old man with type 2 diabetes and diabetic nephropathy D. A 57-year-old woman with type 2 diabetes and hypertension E. A 91-year-old man with type 2 diabetes and Parkinson’s disease 3. Which ONE of the following features is found in the JBS3 risk calculator but NOT in the Australian CVD risk assessment tool? Select ONE option only. A. Ability to include diabetes as a risk factor B. Ability to include rheumatoid arthritis as a risk factor C. 5-year risk D. Life years gained E. 10-year risk 4. A 47-year-old man with type 2 diabetes has a 5-year Australian CVD risk score of 16%. Which is the MOST appropriate INITIAL medication, if any, to reduce his cardiovascular risk? Select ONE option only. A. Atorvastatin 20 mg B. Atorvastatin 80 mg C. Simvastatin 40 mg D. Simvastatin 80 mg E. Lifestyle changes alone recommended 5. For which ONE of the following people with type 1 diabetes is a statin as primary prevention of CVD the MOST appropriate? Select ONE option only. A. A 17-year-old male smoker B. A 26-year-old female with a total cholesterol of 6.4 mmol/L C. A 35-year-old male with poor glycaemic control D. A 39-year-old male diagnosed 5 years ago E. A 46-year-old female with CKD stage 3 6. A 59-year-old woman with type 2 diabetes agrees to start high-intensity statin medication today for primary CVD prevention. When is the MOST appropriate time-interval (in months), if any, before remeasuring her lipid profile? Select ONE option only. A. 1 B. 3 C. 6 D. 12 E. No repeat lipid profile required 7. What is the MINIMUM target REDUCTION in non-HDL cholesterol recommended for people with diabetes starting a high-intensity statin? Select ONE option only. A. 10% B. 20% C. 30% D. 40% E. 50% 8. A 61-year-old man with type 2 diabetes is at high risk of CVD. He is intolerant of both atorvastatin and simvastatin due to myalgia. His creatine kinase (CK) was normal at the time of reporting symptoms. Which is the SINGLE MOST appropriate monotherapy to now recommend? Select ONE option only. A. Fenofibrate B. Ezetimibe C. Nicotinic acid D. Omega-3-acid ethyl esters E. Rosuvastatin 9. A 49-year-old man with type 2 diabetes has a 10-year CVD risk score of 32%. Despite good lifestyle modification and concordance with maximal statin dosages, his total and LDL cholesterol remain poorly controlled. Which is the SINGLE MOST appropriate add-on therapy, if any, to recommend as primary prevention? Select ONE option only. A. Fenofibrate B. Bile acid sequestrant C. Co-enzyme Q10 D. Ezetimibe E. No add-on therapy recommended 10. A 65-year-old woman developed muscle pain after starting simvastatin 40 mg. Her CK was elevated at twice the upper limit of normal. According to European Atherosclerosis Society guidance (Stroes et al, 2015), what is the MINIMUM time-interval (in weeks) before a statin re-challenge is recommended? Select ONE option only. A. 1 B. 2 C. 4 D. 8 E. 12 110 Diabetes & Primary Care Australia Vol 2 No 3 2017
Article Primary care practitioner guide to the International Working Group on the Diabetic Foot: Recommendations for the Australian context Rajna Ogrin, Jane Tennant Diabetes-related foot complications negatively impact on the lives of people with diabetes and increase healthcare costs. Practical, evidence-based guidance has been developed by the International Working Group on the Diabetic Foot (IWGDF), focusing on five main topics: prevention, footwear and offloading, peripheral arterial disease, infection and wound management. This article will discuss the prevention of diabetes-related foot ulcers and apply the IWGDF recommendations to the Australian context for primary care providers. By applying the evidence to the local context, the authors anticipate that these guidelines will be more easily implemented into practice. Currently, more than 1.2 million Australians are estimated to be living with diabetes (National Diabetes Strategy Advisory Group, 2015) with approximately 2–3 million Australians projected to develop diabetes by 2025 (Magliano et al, 2009). Up to 25% of people with diabetes will develop foot ulcers in their lifetime (Singh et al, 2005) and, in 2012–13, 4402 Australians required an amputation related to diabetes (Australian Commission on Safety and Quality in Health Care, 2015). The negative effect of diabetes on quality of life is high; people with diabetes who have foot ulcers have significantly lower quality of life and higher rates of depression compared to the people without diabetes and to those who do not have foot complications (Ribu et al, 2007). Further, people with diabetes who have a foot ulcer or undergo a lower-extremity amputation have double the risk of death at 5 years, compared to those without diabetes (Faglia et al, 2001). Prevention of foot ulceration in people with diabetes is the most effective way to prevent the individual and economic burden associated with foot complications, and primary care providers have an important role to play in doing this (Harris, 2009). In September 2016, Diabetes & Primary Care Australia published an article about foot screening of people with diabetes to identify the risk of amputation in people with diabetes (Ogrin and Forgione, 2016). The current article builds on this, by outlining the recommendations for prevention of diabetes-related foot ulcers, developed by the International Working Group on the Diabetic Foot (IWGDF). The IWGDF have developed guidance in five main areas: prevention, footwear and offloading, peripheral arterial disease, infection and wound management. This article covers the prevention of foot ulcers in people with diabetes at risk of serious foot complications, and includes how the IWGDF recommendations can be applied in the Australian context. We anticipate that this will make it easier for primary care providers to access and use the recommendations. IWGDF guidance The IWGDF was founded in 1996 and in 2000 became a Consultative Section of the International Diabetes Federation (IDF). The aim of the IWGDF is to create awareness and improve Citation: Ogrin R, Tennant J (2018) Primary care practitioner guide to the International Working Group on the Diabetic Foot: Recommendations for the Australian context. Diabetes & Primary Care Australia 2: 111–18 Article points 1. Primary care health professionals have an important role to play in the prevention of foot ulceration. 2. If you are unsure of how to complete a procedure or do not have the relevant equipment, seek a podiatry clinic or specialist that does. Key words – Diabetic foot – International guidelines – Prevention Authors Rajna Ogrin is Senior Research Fellow, RDNS Institute, St Kilda, Vic, Australia; Adjunct Research Fellow, University of Melbourne, Austin Health Clinical School, Vic; Adjunct Assistant Professor, University of Western Ontario, London, Canada. Jane Tennant is an Advanced Practising Podiatrist, East Melbourne Podiatry, Melbourne, Vic; Austin Health, High Risk Foot Clinic, Melbourne, Vic, Monash University, Melbourne, Vic. Diabetes & Primary Care Australia Vol 2 No 3 2017 111
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