Audit of skin changes present in referrals to a specialist lymphoedema service.

An audit of 100 new patients attending a specialist lymphoedema clinic revealed 52% presented with chronic oedema. More than half (58%) of the chronic oedema group presented with skin changes whereas 14% of those with lipoedema, 4% with lymphoedema of the arm, and 8% with lymphoedema of the leg developed skin changes. None of the primary lymphoedema group developed skin changes. Chronic venous disease (CVD) was significantly more prevalent in the chronic oedema group. More patients with bilateral chronic oedema suffered from cellulitis (41%) compared to unilateral (27%). Skin changes, CVD and red leg syndrome (RLS) also occur more often in bilateral leg swelling. Incidence of cellulitis is highest in the chronic oedema group (36.5%), closely followed by the primary lymphoedema group (33.3%). 85% of the patients who were weighed (n=93) were overweight, 39% obese, and 29% morbidly obese. The findings from this audit highlight the importance of skin care training for community nurses managing chronic oedema patients.

Differentiating between red legs and cellulitis and reviewing treatment options.

Red legs (RL) is a chronic inflammatory condition often misdiagnosed as cellulitis. Antibiotic therapy is not required and does not resolve the symptoms. The main causes of RL are chronic dermatological and venous disease, including chronic oedema. Raising awareness of this condition among health professionals could prevent misdiagnosis and unnecessary costly and potentially harmful antibiotic therapy. The aim of this paper is to highlight the differential diagnoses and management of red legs, and the author also includes an example through a case history.

Cultural competence among physicians treating Mexican Americans who have diabetes: a structural model.

Latinos, who constitute the fastest growing ethnically distinct US group, experience disproportionately high rates of type 2 diabetes. At the same time, linguistic and economic barriers, differing cultural expectations between patients and physicians, provider reactions based on stereotypes, and managed healthcare shortfalls limit diabetes care. Such trends highlight physicians' need to consider culture in the delivery of effective services. To address these issues we investigated predictors of culturally competent actions among a sample of 134 practicing San Diego County physicians. They provided demographic information and completed questions assessing their cultural knowledge, cultural awareness, and culturally competent actions specific to Mexican Americans with diabetes. We then developed a structural cultural competence model. Results indicated that participation in diverse medical education settings and experience in community clinics predicted cultural knowledge. Participation in diverse educational settings, Latino ethnicity, bilingual skills, and cultural knowledge predicted cultural awareness. An internal medicine specialty predicted less cultural awareness. Culturally competent actions were only predicted by cultural awareness. Goodness-of-fit statistics supported the overall model's acceptability. The number of Mexican Americans physicians see in practice did not predict any tested cultural competence dimension. Our model supports a number of conclusions. First, knowledge of cultural factors per se and simple exposure to Mexican Americans in practice do not directly facilitate culturally competent care. Rather, such care is most strongly predicted by recognition that cultural factors and awareness of personal biases are important. Results further support medical education that does not solely focus on basic information about Mexican Americans but also explores provider biases and preconceptions. Diverse educational experiences appear particularly helpful in this process. Community clinic settings also help practitioners gain cultural knowledge. While Latino ethnicity predicted cultural awareness, results also suggest that all physicians can take steps towards increasing their cultural competence.

Improvement in diabetes care of underinsured patients enrolled in project dulce: a community-based, culturally appropriate, nurse case management and peer education diabetes care model.

OBJECTIVE: To improve clinical diabetes care, patient knowledge, and treatment satisfaction and to reduce health-adverse culture-based beliefs in underserved and underinsured populations with diabetes. RESEARCH DESIGN AND METHODS: A total of 153 high-risk patients with diabetes recruited from six community clinic sites in San Diego County, California were enrolled in a nurse case management (NCM) and peer education/empowerment group. Baseline and 1-year levels of HbA(1c), lipid parameters, systolic and diastolic blood pressure, knowledge of diabetes, culture-based beliefs in ineffective remedies, and treatment satisfaction were prospectively measured. The NCM and peer education/empowerment group was compared with 76 individuals in a matched control group (CG) derived from patients referred but not enrolled in Project Dulce. RESULTS: After 1 year in Project Dulce, the NCM and peer education/empowerment group had significant improvements in HbA(1c) (12.0-8.3%, P < 0.0001), total cholesterol (5.82-4.86 mmol/l, P < 0.0001), LDL cholesterol (3.39-2.79 mmol/l, P < 0.0001), and diastolic blood pressure (80-76 mmHg, P < 0.009), which were significantly better than in the CG, in which no significant changes were noted. Accepted American Diabetes Association standards of diabetes care, knowledge of diabetes (P = 0.024), treatment satisfaction (P = 0.001), and culture-based beliefs (P = 0.001) were also improved. CONCLUSIONS: A novel, culturally appropriate, community-based, nurse case management/peer education diabetes care model leads to significant improvement in clinical diabetes care, self-awareness, and understanding of diabetes in underinsured populations.