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Post by robertisaacs on Jul 13, 2009 14:27:39 GMT
Carried over from "shy" Certainly the presence of neuropathy to the diagnostic side of such a lesion. However I would offer that some tests we do have little application to how we actually treat. I can see the use of informing the patient of the need for extra care if they are ischeamic / neuropathic. But then, one can never rule out neuropathy anyway can we? So should we not be advising care as a universal precaution? As when it comes to the meeting of blade and flesh what difference then. We debride to the height of our ability in terms of care and detail for every patient. We're not "extra careful" (as they so often ask us to be) because they are diabetic. And lets face it, with a bit of experiance you can tell the vascularly comprimised patients at a glance. The doppler and pulses just confirm what you think. If you see a patient with dusky, red or white, cold and puffy skin i presume ischaemia even if the doppler sings like a bird! Bring out the EBM, We'll have a look. There is a case study in pod now, Reference is at works so i'll have to put it up later, which shows a huge neuropathic heel ulcer with a damn great set of artery clamps pushed into it to demonstrate the extend of undermining. That Ulcer is neuropathic to the point that this caused the patient had no Pain. The patient had intact 10g monofilament sensation So a negative (ie the patient can feel it) monofilament test does not mean the patient is not neuropathic. A positive (IE the patient CAN'T feel it) test, of course, indicates neuropathy. Yet I've seen patients who can't detect 10 g who end up clinging to the ceiling tiles when you debride their ulcer! So if we can have neuropathy in a patient with intact 10g sensation, and NO neuropathy (from a practical viewpoint) in a patient without, what use the test? Look forward to a debate on this one. I'd love to be wrong! Regards Robert
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seekerofwisdom
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Post by seekerofwisdom on Jul 13, 2009 15:16:38 GMT
robert
I agree that we take care with all patients when using a scalpel, but I would say that maybe my treatment would be a little more conservative when dealing with a diabetic with known long term complications .
I always work on the principle that a test is useless unless you follow it up- and because my patients are already under the remit of the diabetic team/ practise nurse I am not the first port of call for these patients although obviously my input is valuable should I notice anything that has changed or developed since their last diabetic check. It seems pointless for me to repeat what has already been done by the nurse who can actually do something with the results if necessary. For that reason I rarely use a doppler, and never use monofilaments.
I am a pod in PP by the way, and have good referral paths to the central diabetic clinic should I need to use them.
VP
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Post by Rie on Jul 15, 2009 7:46:08 GMT
I think the case study Robert is referring to is: McConville D O, The development of extensive painless heel ulceration with preserved monofilament sensation ina newly diagnosed diabetic. Podiatry Now 2006; 9(1): 16.There are many other studies which show the monofilament to be unreliable as a predictor of neuropathy- Kaestenbauer et al, JAPMA 2001; 91(7): 343-350 McGill et al, Diabetes Care 1999; 22(4): 598 -602and many many more.... The monofilament should not be used as a stand alone test for neuropathy. It is well known that it is not the most reliable test (yes Robert I am agreeing with you!). It is also known that there are patients out there who have normal responses to monofilamet and even biothesiometer, but who have small fibre neuropathy which can't easily be diagnosed clinically. (I can't think of any references off the top of my head but I think there might be mention in Managing The Diabetic Foot by Mike Edmonds & Ali Foster). These patients will present as normal sensation but are equally at risk of ulceration. Any tests carried out should always be accompanied by observation, history taking and a sufficient level of knowledge and expertise on the part of the clinician, and any test results should always be viewed as part of the bigger picture and not individually as absolute gospel. I have to disagree with this! This particular test may not be overly useful but unless you are 100% confident in the ability of the nurse (or other trained person) to carry out all of the screening tests fully and accurately, then I would always reapeat them. It doesn't take long. I have previously had a patient referred to me as completely neuropathic. After assessing the patient I could find absloutely nothing wrong with their neuro-vascular status. It was only after the patient expressed her amazement that I had asked her to remove her socks that we discovered the probelm. The practice nurse had carried out the monofilament & vibration perception testing and done dopplers through a fairly substantial pair of socks!! It is therefore worth assuming that you might be the first 'competent' clinician to assess their feet, and as such your assessment and input may make all the difference to the care they receive elsewhere. Having said that it is also worth remembering that a patient with Diabetes does not have to have any vascular or neurological impairment to ulcerate, so IMO all should be treated and educated as though they are at risk of immediate problems. Rie
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Post by johnmccall on Jul 15, 2009 14:41:50 GMT
Hi Folks, The Monofilament test is not intended as a tool for diagnosing neuropathy. It was developed as a screening tool to predict the risk of ulceration, not to diagnose neuropathy. There is no one single good test for that but a clinical history of the patient dropping a tin of beans on a bare foot and feeling no pain does away with the need for any clever tests. Monofilament testing can't predict neuropathy- it can only give a fairly accurate prediction of the likelyhood of ulceration (7 times more likely to develop an ulcer if you fail the test. (Booth,Young blah blah) It doesn't mean that if you pass the monofilament test you won't ulcerate. It just means your are much less likely to. Currently the NICE guidelines, the SIGN guidelines, the World Health Organisation, the International Diabetes federation, Foot in Diabtes UK and most of the folks I know who try to know something about the diabetic foot use the monofilament for screening. Doesn't make it perfect and no- one is forced to use it but the overwhelming evidence is that despite its failings its the best simple (maybe!!) method we've got until something better comes along. Education: There's plenty of guidance on this on the web but not a lot of really good evidence. Basically most 'experts' agree: People without diabetic foot problems need good general footcare habits. People who are more at risk need specific advice that may help prevent ulceration or amputation. BUT if you have diabetes and are lucky enough/ able enough to keep your blood glucose levels reasonably normal then you're unlikely to get complications and won't need very much education in foot care at all. I think screening seems like a good idea because at least it lets us target the education to the risk and individuality of the patient. HOWEVER there is no evidence in the Scottish Diabetes Survey (or anywhere else that I can find) to suggest that a national foot screening programme actually reduces the number of ulcers/amputations. Good grief Foot ulcers can be healed. Amputations can be avoided or postponed for a few years but we should target education and behavioural change early so that people with diabetes get the opportunity to take steps to avoid getting complications in the first place. We could argue all day about evidence and if I wasn't too busy to provide pages of references I could provide 'evidence' for many sides of all sorts of arguments around diabetic foot care however the reality is that the evidence around the prevention and management of diabetic foot disease is actually not all that good. So we have to go on what evidence we have and on the collective opinion, such as it is, of the folks who deal with the problem. Ramble ....ramble... OK my next patient has arrived Cheers John
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Post by dtt on Jul 15, 2009 15:38:00 GMT
Hi John / Rie But does screening increase the amount of undiagnosed DM's being found early because of the sensory loss being picked up and the patient referred on for further testing , bloods ect?? I find it works well and pick up around 10 per annum that are confirmed after the further testing. Cheers Derek
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seekerofwisdom
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Post by seekerofwisdom on Jul 15, 2009 19:12:00 GMT
Del
Forgive me if I have read this wrong but John seems to be saying that screening is not diagnostic?
It's good that you pick up 10 undiagnosed diabetics per annum, but how many referrals do you make and what is your 'success rate' ?
It also seems to me that every other over 80 year old that goes to the GP is now diagnosed as diabetic.
I know the criteria for diabetes, but does that criteria correlate with the complication rate, and if diagnosed as diabetic after 85 are you more or less likly to suffer the disastrous consequences of 'untreated' diabetes and subsequent death than dementia.?
Are we scaringthe sh** out of our oldies and condeming them to a food joyless old age and expensive end of life 'care'.
Shy
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Post by seekerofwisdom on Jul 15, 2009 22:11:49 GMT
Del
I must congratulate you on those 10 diabetic pickups per annum- I dont have anything like that where I practise, but that may be because the GPs and nurses are particularly on the ball!
I am surprised that sensory loss is the presenting symptom, I thought there would have been other more usual presentations such as weight loss or thirst, or maybe eye problems which could have been diagnostic at an earlier stage. Perhaps there is a diabetic specialist amongst us who could point us in the direction of some studies which would clarify this.
sunseeker
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Post by johnmccall on Jul 16, 2009 0:05:57 GMT
Hi folks, Sorry - by screening I meant screening for risk of developng diabetic foot ulcerartion. But generally screening for diabetes is worth discussion. People with type II diabetes are often symptomless, or get fairly mild symptoms that they may attribute to being 'a bit under the weather' or believe that its simply part of getting older. Weight loss, relentless thirst, polyurea and the more obvious (to the patient) symptoms usually occur in people with type 1 DM. So should we screen everyone? What else should we screen for? I got a nice little letter the other day asking if I want screening for bowel cancer. Lovely I'll probably get the screening but where do you stop with screening?? I've assessed 'new' diabetics and discovered symptoms of fairly advanced neuropathy in a fair number of them. At a rough guess fond neuropathy in about 10% of the couple of thousand newly diagnosed that I've foot screened over the last 18 years. It is not unusual for pods in my area to have been the first to suggest to the patient that diabetes should be suspected (and turned out to be right) I had one case recently: Male, 59yrs, foot ulcer, sensory loss. Not diabetic (??) Got blood glucose test - no diabetes, fasting blood glucose - no diabetes, did GTT (glucose tolerance test) - you've guessed it - no diabetes. OK; treated the ulcer (pressure relief, infection control, wound care, no vascular probs, healthy eating) which healed. Six months later he was gettting symptoms of diabetes, got above testss done again and got a definite diagnosis. Its a funny old world Nearly forgot: Passed monofilament test but still got ulcer / fails monofilament but still feels pain - of course there are exeptions to the rule. No test is perfect. Some people survived Hiroshima but I wouldn't use that evidence to say it was safe to be there Cheers John
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davidh
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Post by davidh on Jul 16, 2009 6:30:57 GMT
Perhaps there is a diabetic specialist amongst us who could point us in the direction of some studies which would clarify this. sunseeker Johnmccall = Diabetes Specialist.
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Post by robertisaacs on Jul 16, 2009 11:20:21 GMT
That makes a lot more sense!
Nice! A reason to send them for a blood test I guess. Somebody said on another thread (I think it was the one on levels of training) about how the full training is useful as many a more sinister complication has been picked up by a vigilant podiatrist. I'm not sure if thats our job but its nice when it happens.
Here's fun. You can get a blood glucose test in the chemist these days. Would it be worth keeping a blood glucose monitor (lets face it, they're dirt cheap) in the clinic for such patients? I know its a flawed test cos they might be 6.5 on the way between 2 and 14 but if a neuropathy test has value for finding undiagnosed diabetics would this not do it better?
THATS an assessment test I can really see picking up those millions of undiagnosed DMs walking around. And I bet high blood sugar is a risk factor for ulceration!
Regards Robert
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Post by dtt on Jul 16, 2009 11:38:13 GMT
John All my patients get in the primary assessment testing for sensory loss in their feet. 10g monofillament ,128Hz tuning fork for vibration and neuroitip for pain. If they fail, they get referred to their GP for further testing along with a report ( which we built in to the practice management system) outlining the reasons for the referral. The age group is usually around 50 /60 and yes around 10 a year is about right that go on to be diagnosed as DM2. I find it is the vibration test that is the decider as it seems to be the main test they fail on rather than the monofillament but that could just be my recollection of events ? The Gp's and practice nurses appreciate that I have done the first line testing and usually take over from there. Robert, I think it is a worthwhile practice to screen all new patients for diabetes not sure about blood testing ( the set may be cheap but have you seen the price of the test strips and Lancet barrels )all "only to be used by the individual patient" The cost would be prohibitive I fear. Just my take on it Cheers Derek
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Post by seekerofwisdom on Jul 16, 2009 18:19:52 GMT
Del
would that be 10 out of your 700 or so new patients per year?
Does that make it about 1.4%/
sunseekr
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jbb
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Post by jbb on Jul 16, 2009 18:27:37 GMT
Hi Robert
in response to your suggestion about having a glucometer in the clinic, it might be worth tellling you about a recent experience of mine on my Uni's ethics committee.
Someone (an opthalmologist) was going to screen for undiagnosed diabetic patients who attended for eye examination at a number of local high street optician shops. One of the things she was planning to do was to do a finger prick BM test, using a glucometer. In addition she was going to ask them all to bring a urine sample so she could do a dip stick test as well.
So, what do you think we on the ethics committee said - quite simply, a resounding 'absolutely not'.
Why do you think we gave this decision ?
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Post by seekerofwisdom on Jul 16, 2009 18:33:38 GMT
jbb
interesting question!
I have never attempted to do these tests because I consider them outside of my scope of practise and would have to refer on anyway and thus the tests would have to be repeated.
ss
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10feet
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Post by 10feet on Jul 17, 2009 6:50:18 GMT
Jbb
I agree with SOW regarding competencies in regulated professions and the probability of diabetic screening being outside the scope of practice of an opthalmologist. I consider the diagnosis of diabetes to be outside my scope of practice so like SOW, I advise what to do if a patient suspects or I suspect a patient my have the symptoms of diabetes.
I would also go one stage further and say potentially that this opthamologist runs the risk of unethical selling. Customer goes in for a glucose test and comes out with a new pair of glasses - the potential is there for a complaint?
I would also urge caution with both DTT and Robert's approach. Foot screening is not the first line testing for diabetes and I would not encourage blood glucose testing a selling point in any Podiatric practice for picking up undiagnosed diabetics.
Indeed we have a duty of care to refer on any patient we suspect as having diabetes but to test and refer on every patient who fails a vibration sensation or monofilament test may be a little excessive. Surely we have the skills to assess if sensory loss has occured for another reason? This of course is another subject.
For many patients the diagnosis of diabetes is a traumatic experience and the post diagnosis period can leave patients with a feeling of vulnerability. This is where our area of expertise comes in, as a part of the diabetic team but not in the primary diagnosis.
I am sure though jbb will soon put us right on why the ethics committee said no.
Pete the prat
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