Predictors of Diabetic Foot Reulceration beneath the Hallux.

AIMS: To evaluate the factors that predict reulceration beneath the hallux in people with a history of diabetic foot ulceration. METHODS: A prospective study conducted between January 2012 and December 2014 was performed in a diabetic foot unit to assess the risk factors associated with hallux reulceration. Sixty patients with diabetic neuropathy and a history of previous ulcer were consecutively included. Sociodemographic factors and comorbidities plus the biomechanical and radiographic factors were obtained. Follow-up on participants was conducted every month, and they wore offloading therapeutic footwear and custom-made insoles. Hallux reulceration during the follow-up period was assessed as the main outcome measure in the study. RESULTS: Patients were followed up during 29 (14.2-64.4) months. Twenty-nine patients (52%) developed a new ulceration: 9 patients (31%) in the hallux and 20 (69%) in other locations. Functional hallux limitus (p = 0.005, 95% CI (2.097-73.128), HR 12.384) and increased body mass index (p = 0.044, 95% CI (1.003-1.272), HR 1.129) were associated with the hallux ulceration-free survival time in the multivariate Cox model. CONCLUSIONS: Obesity and the presence of functional hallux limitus increase the probability of developing hallux reulceration in patients with diabetic neuropathy and a history of ulcers.

Effects of physical therapy and relaxation techniques on the parameters of pain in university students with tension-type headache: A randomised controlled clinical trial. / Efectos de entrenamiento físico específico y técnicas de relajación sobre los parámetros dolorosos de la cefalea tensional en estudiantes universitarios: un ensayo clínico controlado y aleatorizado.

INTRODUCTION: Non-pharmacological treatments help control tension-type headache; however, evidence about their effectiveness is still limited. This study evaluates the effectiveness of physical therapy based on cervical spine kinesiotherapy and posture correction exercises compared to a programme of relaxation techniques only (Schultz's Autogenic Training, AT). METHODS: Tension-type headache is very common among university students. We randomly selected 152 university students with a diagnosis of tension-type headache according to the criteria of the International Headache Society. Eighty-four were women (55.3%) and 68 were men (44.7%). Mean age was 20.42±2.36 years. The study design is a randomised controlled trial of a non-pharmacological intervention with a blinded evaluation of response variables. We compared the results of two independent samples: AT was used in one of the groups while the other group received AT plus cervical spine kinesiotherapy and posture correction training. Patients recorded any changes in the parameters of pain (frequency, intensity, and duration) and drug consumption in a headache diary before treatment, at 4 weeks, and at 3 months. RESULTS: Both interventions achieved a decrease in all the parameters of pain; however, decreases in frequency and intensity were more significant in the combined treatment group (P<0.01) (d=0.4). CONCLUSIONS: Such active, non-invasive therapies as AT and cervical spine kinesiotherapy, and especially the combination of both, effectively reduce tension-type headache by preventing and managing the potential psychophysical causes of this disorder. Future research should aim to assess the long-term effects of these interventions.

Neurodevelopment in preschool idiopathic toe-walkers. / Desarrollo neuromadurativo en andadores de puntillas de edad preescolar.

INTRODUCTION: Idiopathic toe walking, a differential diagnosis for neurological and orthopaedic disorders, has been associated with neurodevelopmental alterations. Neurodevelopmental assessment at early ages using specific tests may improve management and follow-up of these patients. The aim of our study is to analyse the neurodevelopmental characteristics of preschool idiopathic toe-walkers (ITW) by comparing them to a control group. METHOD: Our descriptive cross-sectional study compared possible risk factors, neurodevelopmental characteristics, and scores on the Child Neuropsychological Maturity Questionnaire (CUMANIN) between a group of 56 ITWs aged 3 to 6 and a control group including 40 children. RESULTS: The proportion of males was significantly higher in the ITW group (P=.008). The percentage of patients with a family history (P=.000) and biological risk factors during the perinatal period (P=.032) was also higher in this group. According to the parents' reports, motor coordination in ITWs was significantly poorer (59%; P=.009). ITWs scored significantly lower on CUMANIN subscales of psychomotricity (=0,001) and memory (P=.001), as well as in verbal development (P=.000), non-verbal development (P=.026), and overall development (P=.004). Foot preference was less marked in the ITW group (P=.047). CONCLUSIONS: The neurodevelopmental characteristics of our sample suggest that idiopathic toe walking is a marker of neurodevelopmental impairment. However, further studies are necessary to confirm these findings.

Analysis of a global random stratified sample of nurse legislation.

AIM: To identify, compare and contrast the major component parts of heterogeneous stratified sample of nursing legislation. BACKGROUND: Nursing legislation varies from one jurisdiction to another. Up until now no research exists into whether the variations of such legislation are random or if variations are related to a set of key attributes. METHODS: This mixed method study used a random stratified sample of legislation to map through documentary analysis the content of 14 nursing acts and then explored, using quantitative techniques, whether the material contained relates to a number of key attributes. These attributes include: legal tradition of the jurisdiction; model of regulation; administrative approach; area of the world; and the economic status of the jurisdiction. FINDINGS: Twelve component parts of nursing legislation were identified. These were remarkably similar irrespective of attributes of interest. However, not all component parts were specified in the same level of detail and the manner by which the elements were addressed did vary. A number of potential relationships between the structure of the legislation and the key attributes of interest were identified. CONCLUSIONS AND IMPLICATIONS FOR POLICY: This study generated a comprehensive and integrated map of a global sample of nursing legislation. It provides a set of descriptors to be used to undertake further quantitative work and provides an important policy tool to facilitate dialogue between regulatory bodies. At the individual nurse level it offers insights that can help nurses pursue recognition of credentials across jurisdictions.

Defining nurse regulation and regulatory body performance: a policy Delphi study.

CONTEXT: Professional self-regulation is a privilege and needs to deliver against the underpinning social contract between the professional and citizens who are receiving care and services. AIMS: The aims of this study were to generate, international consensus on a contemporary definition of professional nurse regulation; and to articulate the key features of a highly performing regulatory body, and postulate which regulatory model and administrative arrangements are best suited to attain the key features. METHOD: A highly diverse and globally recruited random stratified sample of 75 experts was approached to participate in a classic three-round policy Delphi study. Quantitative and qualitative data were generated and subjected to thematic and statistical analysis. Both non-parametric and descriptive statistical techniques were used in relation to quantitative data. RESULTS: Consensus on a revision of the current International Council of Nurses definition of professional nurse regulation was developed and a set of 47 key features of high-performing regulatory bodies was agreed. Although a strong preference for the delegated self-regulatory model (43%) and single-board administrative approach (48%) was expressed the underlying rationale for such a preference was unclear. CONCLUSION: The research makes an important contribution to an underdeveloped field of study. The case for conducting more quantitative investigations to ascertain the best regulatory model and associated administrative approach has been made.

Nurse faculty migration: a systematic review of the literature.

BACKGROUND: To undertake a systematic review of English and Spanish literature relating to nurse faculty migration. METHODS: A systematic review of both published literature, using CINAHL, EMBASE, ERIC and MEDLINE, and grey literature, using Google and Yahoo search engines, utilizing a defined search strategy with key terms, wild card strings and logical operators, was undertaken. An initial limitation of searching for material published in the last ten years was removed due to the poor yield of relevant papers. In total, 18 research-based studies were identified, retrieved and reviewed. Finally, the retrieved material was reviewed and augmented by a group of nurse faculty and migration experts, who offered comments and proposed additional grey literature. With increased globalization, the impact of mutual recognition agreements and associated modes of supply of services as well as those factors influencing clinical nurse migration was also considered. RESULTS: Studies on clinical nurse migration and general academic faculty provided some insights, but nursing faculty differ in a number of key ways and this needs to be considered when interpreting the results. Based on this systematic review, the paper concludes that nurse faculty migration is a neglected topic and one that warrants urgent investigation if health systems redesign and the associated scale-up of nurses are to be achieved. Particular gaps in knowledge relate to nurse faculty workforce planning, and understanding the dynamics and flows of faculty both across and within countries. It is unclear as to the extent to which our knowledge of push and pull factors relating to clinical nurse migration can be used in understanding nurse faculty migration. CONCLUSION: The current policy position of organizations such as the World Health Organization and individual governments to increase nursing numbers is incomplete without due consideration of faculty migration.

Analysis of transfer lesions in patients who underwent surgery for diabetic foot ulcers located on the plantar aspect of the metatarsal heads.

AIMS: To analyse the risk of reulceration caused by the transfer of lesions in patients with diabetes, undergoing resection of at least one metatarsal head. METHODS: A total of 119 patients with diabetes from the Diabetic Foot Unit (Complutense University, Madrid, Spain), who underwent resection of at least one metatarsal head were analysed prospectively from November 2006 to December 2011 to assess reulceration in the other metatarsal head. RESULTS: Seven patients were excluded for being subjected to a pan-metatarsal head resection and 11 patients dropped out. During a median follow-up period of 13.1 months (interquartile range 6.1-22.8 months), 41% of patients suffered from reulcerations. Reulceration frequency in patients operated on the 1st, 2nd, 3rd, 4th, 5th and several metatarsal heads was 9 (69%), 8 (44%), 12 (52%), 2 (25%), 6 (19%) and 4 (50%) events, respectively. The Cox regression model showed hazard ratios that were significant for the location of the metatarsal resection. The first metatarsal showed the highest risk for reulceration (hazard ratio 3.307; 1.472-7.430) and the fifth metatarsal showed the lowest risk (hazard ratio 0.339; 0.138-0.832). CONCLUSIONS: Reulceration is a frequent event following resection of a metatarsal head and should be regarded as an implicit complication of the intervention. The location of the resection determines the risk of reulceration, which is highest for patients operated on the first metatarsal head and lowest for patients operated on the fifth metatarsal head.

A structured policy review of the principles of professional self-regulation.

BACKGROUND: The International Council of Nurses (ICN) has, for many years, based its work on professional self-regulation on a set of 12 principles. These principles are research based and were identified nearly three decades ago. ICN has conducted a number of reviews of the principles; however, changes have been minimal. In the past 5-10 years, a number of authors and governments, often as part of the review of regulatory systems, have started to propose principles to guide the way regulatory frameworks are designed and implemented. These principles vary in number and content. OBJECTIVES: This study examines the current policy literature on principle-based regulation and compares this with the set of principles advocated by the ICN. DESIGN AND DATA SOURCES: A systematic search of the literature on principle-based regulation is used as the basis for a qualitative thematic analysis to compare and contrast the 12 principles of self-regulation with more recently published work. RESULTS: A mapping of terms based on a detailed description of the principles used in the various research and policy documents was generated. This mapping forms the basis of a critique of the current ICN principles. A professional self-regulation advocated by the ICN were identified. CONCLUSIONS: A revised and extended set of 13 principles is needed if contemporary developments in the field of regulatory frameworks are to be accommodated. These revised principles should be considered for adoption by the ICN to underpin their advocacy work on professional self-regulation.

Spanish nurses' credentialing in the 20th century.

BACKGROUND: Nurses credentialing as healthcare professionals commenced in Western Europe and in the USA by the end of the 19th and the beginning of the 20th century, boosted by the protestant reform movement. In Spain, it started in 1915, during the kingdom of Alfonso XIII (1902-1931). This historical period was marked by great political instability and big flaws in the healthcare delivery system. AIM: To describe the regulatory pathway that gave rise to the nursing profession in Spain, through official credentialing and regulation during the first third of the 20th century. METHOD: Documental, historical and regulatory documental research describing and analysing the national legislative sources used to regulate the professional development, as well as the education, training and competencies of the nursing practice in Spain, as compared with the developments in the European and American context. CONCLUSIONS: Professional development of the nursing profession in Western Europe and in the USA is consolidated during the 20th century as resulting in educational and training enhancement and the establishment of national and international professional bodies. In Spain, the regulatory and legal recognition of the nursing profession come into being in 1915 in response to a request from a female religious congregation.

Inter-observer reproducibility of probing to bone in the diagnosis of diabetic foot osteomyelitis.

AIMS: The objectives of our study were (i) to analyse the inter-observer reproducibility or diagnostic variability of the probing-to-bone test, depending on the training of the professional involved, and (ii) to assess whether the probing-to-bone test can be extrapolated to any professional specialty that deals with these patients. METHODS: This was a cross-sectional study, involving 75 patients with diabetic foot ulcer and clinical suspicion of osteomyelitis. A registration sheet was completed for all patients involved in the research study, gathering data relative to the results of the probing-to-bone test performed by three observers. Observer 1 was a very experienced professional with several years of experience in the treatment of the diabetic foot; observer 2 was a medium-experienced professional whose experience ranges from 6 to 12 months in the treatment of the diabetic foot; observer 3 was a healthcare professional without experience in the treatment of the diabetic foot. Data were gathered confidentially by a fourth researcher. RESULTS: The results showed a kappa index of 0.593 (95% CI 0.407-0.778) between observer 1 and observer 2, 0.397 (95% CI 0.188-0.604) between observer 1 and observer 3 and 0.53 (95% CI 0.335-0.725) between observer 2 and observer 3. CONCLUSIONS: The probing-to-bone test demonstrated moderate to fair concordance with an experienced examiner, although the degree of concordance is not significant between groups.

Impact of diabetic foot related complications on the Health Related Quality of Life (HRQol) of patients--a regional study in Spain.

The diabetic foot reduces the health-related quality of life (HRQoL) in patients with diabetes mellitus. This study aims at ascertaining the impact of the etiological factors of the diabetic foot on the various aspects of HRQoL. This is a comparative study involving type 1 or type 2 (n = 421) diabetic patients divided into 2 groups. Group 1 (n = 258) includes diabetic patients without foot lesions and group 2 (n = 163) includes patients suffering from a diabetic foot ulcer. The HRQoL of the sample was assessed by using the SF-36 Health Questionnaire. The overall HRQoL score was 68.58 ± 18.24 in group 1 and 50.99 ± 18.98 in group 2 (P < .001). The diabetic foot-related etiological factors that significantly reduce these patients' HRQoL are neuropathy, amputation history, and poor metabolic control (P < .001). Quality of life was lower in women with diabetic foot than in men. Neuropathy--regarded as the main etiological factor in the diabetic foot--also proved to be a variable that reduces the HRQoL. Paradoxically, peripheral vascular disease did not prove to have a negative impact on the quality of life.

Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series.

AIMS: The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). METHODS: We abstracted data of a series of 185 consecutive patients with diabetes and foot osteomyelitis undergoing surgery within the first 12 h after admission at a single hospital. Bone infection was confirmed by histopathological studies. Only cases where Staphylococcus aureus was isolated from bone specimens were included in this analysis. We analysed several variables between the two groups: MRSA vs. MSSA. RESULTS: MRSA bone infection was associated with higher body temperature (P = 0.02) and white blood cell count (P = 0.02) than MSSA. Patients with MRSA infections underwent a greater number of surgical procedures (P = 0.03). Limb salvage was achieved in 93.6% of the patients, with no statistically significant difference in limb salvage rates between MRSA and MSSA-related osteomyelitis. CONCLUSIONS: From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis.

Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement.

AIMS/HYPOTHESIS: We analysed the factors that determine the outcomes of surgical treatment of osteomyelitis of the foot in diabetic patients given early surgical treatment within 12 h of admission and treated with prioritisation of foot-sparing surgery and avoidance of amputation. METHODS: A consecutive series of 185 diabetic patients with foot osteomyelitis and histopathological confirmation of bone involvement were followed until healing, amputation or death. RESULTS: Probing to bone was positive in 175 cases (94.5%) and radiological signs of osteomyelitis were found in 157 cases (84.8%). Staphylococcus aureus was the organism isolated in the majority of cultures (51.3%), and in 35 cases (36.8%) it proved to be methicillin-resistant. The surgical treatment performed included 91 conservative surgical procedures, which were defined as those where no amputation of any part of the foot was undertaken (49.1%). A total of 94 patients received some degree of amputation, consisting of 79 foot-level (minor) amputations (42.4%) and 15 major amputations (8%). Five patients died during the perioperative period (2.7%). Histopathological analysis revealed 94 cases (50.8%) of acute osteomyelitis, 43 cases (23.2%) of chronic osteomyelitis, 45 cases (24.3%) of acute exacerbation of chronic osteomyelitis and three remaining cases (1.6%) designated as 'other'. The risks of failure in the case of conservative surgery were exposed bone, the presence of ischaemia and necrotising soft tissue infection. CONCLUSIONS/INTERPRETATION: Conservative surgery without local or high-level amputation is successful in almost half of the cases of diabetic foot osteomyelitis. Prospective trials should be undertaken to determine the relative roles of conservative surgery versus other approaches.

[The effect of oxytocin on contractility of the human uterine artery]. / Effets de l'ocytocine sur la contractilité de l'artère utérine humaine.

We have studied in this work 30 human uterine arteries which were taken from hysterectomy specimens where the indication for the hysterectomy was obstetrical or gynaecological. The arteries were prepared in strips using furchgott and Bhadrakom's technique that they developed for the isolated aorta of the rabbit so that the authors could study the response to oxytocin on the isolated human uterine artery. When CIK was added to the preparation in which the arteries were, oxytocin had an antagonistic effect which was dose-dependent. The same effect was noted when Cl2Ba was added.