Biofeedback for foot offloading in diabetic patients with peripheral neuropathy.

AIMS: The reduction of high plantar pressure in diabetic patients with peripheral neuropathy is mandatory for prevention of foot ulcers and amputations. We used a new biofeedback-based method to reduce the plantar pressure at an at-risk area of foot in diabetic patients with peripheral neuropathy. METHODS: Thirteen diabetic patients (age 60.8 +/- 12.3 years, body mass index 29.0 +/- 5.0 kg/m(2)) with peripheral neuropathy of the lower limbs were studied. Patients with memory impairment were excluded. The portable in-shoe foot pressure measurement system (PEDAR) was used for foot offloading training by biofeedback. The learning procedure consisted in sequences of walking (10 steps), each followed by a subjective estimation of performance and objective feedback. The goal was to achieve three consecutive walking cycles of 10 steps, with a minimum of seven steps inside the range of 40-80% of the baseline peak plantar pressure. The peak plantar pressure was assessed during the learning period and at retention tests. RESULTS: A significant difference in peak plantar pressure was recorded between the beginning and the end of the learning period (when the target for plantar pressure was achieved) (262 +/- 70 vs. 191 +/- 53 kPa; P = 0.002). The statistically significant difference between the beginning of learning and all retention tests persisted, even at the 10-day follow-up. CONCLUSIONS: Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term.

Glucagon immunoreactivities and amino acid profile in plasma of duodenopancreatectomized patients.

Glucogon immunoreactivity (IRG) was measured in plasma of duodenopancreatectomized subjects with a nonspecific (K-4023) and a specific (30-K) glucagon antiserum. After an overnight fast, plasma IRG (K-4023) was significantly (P < 0.05) higher in the subjects without pancreas, averaging 782+/-79 (SEM) pgeq/ml, than in the controls (482+/-80 pgeq/ml). IRG (30-K) of 162+/-68 pg/ml did not change during an infusion of arginine (450 mg/kg per 40 min). Insulin deprivation during 3 d in one patient did not restore the IRG response to arginine as reported in depancreatized dogs.Bio-Gel P-30 column chromatography revealed that virtually all IRG (30-K) measured in whole plasma was of different molecular weight than glucagon, and primarily of a mol wt >/= 40,000. Intravenous arginine did not significantly alter the chromatographic pattern of these plasmas. Thus, as postulated by others, duodeno-pancreatectomized humans have virtually no circulating 3,500-dalton glucagon. Hence, the presence of 3,500-dalton glucagon in plasma is not a condition for the diabetic state. It might, nevertheless, when present in normal or excessive amounts, worsen the metabolic state of diabetic patients. Among 14 amino acids measured in plasma of these patients, the concentrations of alanine, serine, ornithine, and arginine were significantly (P < 0.05) elevated to approximately twice that of normal: alanine and serine are both substrates for gluconeogenesis, whereas ornithine and arginine are involved in the formation of urea, the second product of hepatic gluconeogenesis. As the concentrations of branched chain amino acids were not grossly altered, it is hypothesized that this amino acid pattern is a consequence of glucagon deficiency rather than secondary to the diabetic state of these patients.

Plasma renin activity and blood volume in uncontrolled diabetes. Ketoacidosis, a state of secondary aldosteronism.

The renin-angiotensin-aldosterone system was evaluated in two types of uncontrolled diabetes: a) diabetic ketoacidosis, and b) nonketotic hyperglycemia. In thirteen patients with ketoacidosis, mean plasma renin activity (PRA) was 58 plus or minus 12 (S.E.M.) ng. per milliliter per hour and in four patients, plasma aldosterone was 82 plus or minus 17 ng. per 100 ml. Corresponding values for upright salt-depleted subjects were 13 plus or minus 2 and 62 plus or minus 8. In eleven diabetics with nonketotic hyperglycemia (mean glucose 318 plus or minus 19 mg. per cent), mean blood volume was 4,660 ml. and PRA 2.1 plus or minus .7. After control of the diabetes (mean glucose 129 plus or minus 13) blood volume was 4,553 ml. and PRA 3.3 plus or minus 1 (NS). The results suggest that: 1) diabetic ketoacidosis is a state of severe secondary aldosteronism, 2) no significant change in blood volume or PRA occurs during short periods of hyperglycemia, and 3) insulin is not necessary for renin release.

Asthma outpatient education by multiple implementation strategy. Outcome of a programme using a personal notebook.

More than 10 years after publication, international guidelines remain poorly implemented. To better implement them, we need to develop new strategies adapted to the expectations of patients and health professionals outside hospital settings and to ensure better outpatient follow up in the community. We developed a bilingual education programme including a brochure designed to support an interdisciplinary health care network and measured hospitalisations (H), work absenteeism (WA), emergency visits (EV), asthma medication (AM) and quality of life (QL Juniper) before and 12 months after the intervention. All QL scores improved significantly in comparison with pre-intervention values. Health service use decreased dramatically when comparing the 12 months prior to and after the intervention(H: 35-8%, WA: 39-14%, EV: 88-53%). The final cost/benefit ratio of the programme was 1.96. Interdisciplinary implementation strategy of patient education is cost-effective, improves quality of life for asthmatics, and reduces strain on health services. Such a health care network does not require an expensive infrastructure and is better adapted to the reality and competences of clinical practice.

Sulfonylureas in insulin-dependent (type I) diabetes: evidence for an extrapancreatic effect in vivo.

The effect of glibenclamide treatment on insulin-mediated glucose disposal was studied in eight C-peptide-negative type I diabetic patients. The patients were studied twice by the euglycemic insulin clamp technique. One of the two experiments was preceded by glibenclamide treatment at the dose of 5 mg, three times daily for 15 days; half of the patients had the first test before and the second test after sulfonylurea treatment, and vice versa. Insulin was infused for four periods of 2 h each sequentially at 0.5, 1.0, 2.0, and 5.0 mU kg-1 min-1; for each insulin infusion period, the steady state plasma free insulin levels were comparable with or without glibenclamide. The mean +/- SEM plasma glucose concentration was 88 +/- 2 mg/dl in both experiments. The insulin-mediated glucose disposal rate was greater with glibenclamide during the first insulin infusion period (which generated plasma free insulin levels within the physiological range) 2.68 +/- 0.32 mg kg-1 min-1 with glibenclamide vs. 1.97 +/- 0.20 mg kg-1 min-1 without glibenclamide (P less than 0.005). However, glucose disposal rates did not differ in the diabetic patients with or without glibenclamide treatment during the second, third, and fourth insulin infusion periods, which generated plasma free insulin levels in the supraphysiological range. These results provide evidence for an extrapancreatic effect of glibenclamide at low insulin concentrations during euglycemic clamping in patients with insulin-dependent diabetes mellitus. However, this effect was not reflected clinically in either an increased rate of hypoglycemic reactions or decreased insulin needs during the short term period of treatment.

The added value of therapy in diabetes: the education of patients for self-management of their disease.

The long-term success of diabetes therapy is strongly dependent on education of the patient. Considerable emphasis and effort has been directed at this dimension of treatment by healthcare providers (HCPs) in the field of diabetology. Education of patients is not aimed at making them more knowledgable about their disease, but to help them better manage their treatment and adapt the diabetes control to the constant changes in daily life. Patient education is a complex process, and many factors may interfere with the patient's understanding. There is growing awareness among HCPs that more knowledge and skill have to be acquired in the field of therapeutic education of patients.

The impact of callosities on the magnitude and duration of plantar pressure in patients with diabetes mellitus. A callus may cause 18,600 kilograms of excess plantar pressure per day.

BACKGROUND: The importance of high peak plantar pressure (PP) in the development of foot ulcer is well known. However, few studies have analyzed the real impact of callosities on plantar pressure and ulcer formation. METHODS: The plantar pressure (PP) in patients with diabetes mellitus was studied in three groups, of a total number of 33 type 2 diabetic patients, without neuropathy or peripheral vascular disease: subjects with callus (A) (n = 10), subjects without callus (B) (n = 10), and a separate group of patients with callus which was submitted to callus removal (C) (n = 13). The plantar pressure (PP) parameters were measured by FSR 174 sensors and computer analyses were performed by LabView. RESULTS: Both maximum peak PP and duration of PP are significantly higher in patients with callus (peak PP: 314 +/- 52 kPa vs 128 +/- 16 kPa, p < 0.005; duration of PP: 621 +/- 27 ms vs 505 +/- 27 ms, p < 0.05). The intervention group C before and after callus removal showed an identical trend. Callus removal has decreased the peak PP by 58% (p < 0.001) and duration of PP has been decreased by 150 milliseconds by step (p < 0.05). CONCLUSION: This study has shown the deleterious role of callus and assuming that an average person walks about 10,000 steps a day, a callus may cause 18,600 kg of excess plantar pressure per day. In addition, this study has proven the importance of early and regular removal of hyperkeratotic tissue. Even more aggressive removal could be recommended in patients with neuropathy and peripheral vascular disease.

Effect of gangliosides on diabetic peripheral neuropathy.

The effect of subcutaneously injected gangliosides on diabetic peripheral neuropathy was assessed in 26 diabetic patients with neuropathy, 20 of whom received 100 mg daily 5 days per week for 12 weeks in a randomised single-blind cross-over placebo-controlled study and six of whom, with painful neuropathy, received the same quantity of gangliosides for the same length of time but no placebo. Subjective symptoms of lower limb neuropathy improved on gangliosides but not on placebo (P = 0.01). The amplitude of the peroneal nerve muscle action potential increased on gangliosides and declined on placebo (P = 0.05), but no other significant changes were observed in nerve conduction or in any other measurable sign of lower limb somatic nerve function or of cardiovascular autonomic function.

The effect of muesli or cornflakes at breakfast on carbohydrate metabolism in type 2 diabetic patients.

Fourteen overweight insulin-treated type 2 diabetic patients ate a breakfast, consisting of either muesli (slow release starch: SRS) or cornflakes (fast release starch: FRS), in either case with milk (46 g carbohydrate), during two consecutive randomized crossover periods of two weeks. The rest of the diet remained unchanged. At the end of each period the patients underwent a glucose tolerance test after an overnight fast without their usual evening insulin injection. Both mean plasma glucose responses curves were identical after the two dietary periods, but plasma insulin was significantly lower at zero (-17%, P less than 0.05) and 2 h (-21%, P less than 0.05) at the end of the muesli (SRS) period as compared to the cornflakes (FRS) period. The mean day-long plasma glucose level (four measurements) at the end of the muesli period was 21% (P = 0.023) lower than after the cornflakes period. These results show that switching, at breakfast only, from standard cereals to slow release starch cereals improves the carbohydrate metabolism of diabetic patients. In addition, the fact that diabetic patients could reduce their insulin requirement (P less than 0.05) with concomitant reduction of their daily blood glucose level implies that sensitivity to insulin was improved by slow release starct foods consumed at breakfast.

The Thermocross: a simple tool for rapid assessment of thermal sensation thresholds.

We have developed the Thermocross, a simple device for rapid assessment of thermal sensitivity, tested it on healthy subjects and diabetic patients and evaluated its use in identifying patients whose sensation loss may expose them to the risk of neuropathic foot injury. Thermal discrimination deteriorated with age (P less than 0.001) in healthy subjects, but all the controls could detect a temperature difference less than or equal to 10 degrees C. In diabetic patients, the deficit in thermal sensation detected by the Thermocross paralleled the decline of nerve conduction. Thermocross thermal sensation was impaired in 87% of 38 ulcerated feet of 26 diabetic patients. We conclude that the Thermocross is a suitable tool for screening for sensation loss and that diabetic patients with impaired thermal sensation are vulnerable to ulceration. The Thermocross could also serve a useful educational purpose, the implications of reduced thermal sensation probably being more meaningful to patients and health care personnel than those of a reduction in the traditionally tested vibration sensation.

Cost-effectiveness of diabetes education.

The costs of long term complications of diabetes to both patients and the community are considerable. However, amputation of the lower limb is an example of a costly intervention that is often preventable in patients educated to take at least partial responsibility for the management of their condition. Aside from the obvious improvement in patients' quality of life that preventive medicine of this kind entails, reductions in the amputation rate also lead to large cost savings. Unfortunately, many patients are denied adequate education about their diabetes. This is partly due to lack of educational programmes for patients and partly the result of inadequate educational methodologies used by healthcare providers. Without major investments in patient education by healthcare policymakers and administrators, however, substantial improvements in the delivery of health education to the diabetic population are unlikely, and the opportunities for making important cost savings in this area will continue to be forgone.

Patient education and diabetes research: a failure! Going beyond the empirical approaches.

A literature review of 37 papers cited by MEDLINE between 1986 and April 1996 under the terms "diabetes", "patient education" and "randomized" was carried out. The articles were analysed on the basis of a check list (Educational Procedure Check List), which contains 27 items grouped into 8 areas: study objectives, educational objectives, population, educational strategy, content, evaluation, outcome, final results. The results of our study show that authors do not describe the educational interventions that they have used; thus, we suggest that editors request randomized trial studies containing information on identification of patients' needs, elaboration of learning objectives, and planning and running of the program and the evaluation system used.

Bronchial asthma and self-management education: implementation of Guidelines by an interdisciplinary programme in health network.

UNLABELLED: Asthma is a chronic disease generating very high costs even for Switzerland. Self-management education (SME) is effective and recommended as an integral part of management in the most recent guidelines on asthma treatment. Its aim is to reduce morbidity [hospitalisations (H), lost workdays (LW), emergency consultations (EC)] and improve quality of life (QOL) in these patients. METHOD: Integrated programme with educational platforms (two-language booklet), SME in 66 patients (30 m, 36 f) with interdisciplinary quality team (pneumologists, primary care physicians, pharmacists, specialised nursing staff), QOL questionnaire. Measurement of morbidity parameters 12 months before and after SME. Measurement of QOL before and 12 months after SME. RESULTS: Hospitalisations fell from 35 to 8%*, EC from 88 to 53%*. and LW from 39 to 14%* (*p <0.001). Overall, SME resulted in a health cost saving of CHF 202,510 in terms of LW and CHF 131,200 in terms of days in hospital, i.e. a total of CHF 333,710. Costs saved per patient were CHF 5,056 per year. QOL improved with the following scores: overall QOL 4.5 +/- 0.9 to 5.2 +/- 0.9*; activities 4.5 +/- 0.9 to 5.2 +/- 0.9*; symptoms 4.2 +/- 1.1 to 5.2 +/- 1.1*; emotions 4.9 +/- 1.1 to 5.6 +/- 1*; environment 4.5 +/- 1.4 to 4.9 +/- 1.3* (*p <0.001). CONCLUSION: SME by interdisciplinary health network is effective. It brings a steep fall in costs for asthma treatment by cutting back hospitalisations and lost workdays and by improving the asthmatics' quality of life. It should be recognised and better supported by the health system.

Bridges, why and from where to where?

Therapeutic intervention for chronic diseases does not rely only on drugs but is also strictly dependent on how the patient has been informed about his disease and how he is able to master the various skills required by his treatment. Education therefore plays a fundamental role in the efficacy of control of those diseases. But what is education? Among the various possible definitions, one could be metaphorically illustrated by bridges. How to get the message across from the medical world to that of the patient, or, inside the medical professions from one group of providers to another. Different bridges may have different functions or roles. One is for commuting in the current daily life. Another one is to ensure vital needs. Bridges help also to discover new territories, but any new visitor may not always be welcomed in these new regions. Bridges need to be solidly constructed with a structure which can be methodologically described. This may help repair in case of problems. Patient education is a kind of bridge submitted to all sorts of forces and barriers which may interfere with the passage of knowledge and skills from the health care providers to the patient and his family.

Revisiting the approach to treatment of long-term illness: from the acute to the chronic state. A need for educational and managerial skills for long-term follow-up.

The initial training of physicians and nurses is in the acute medical system, whether dealing with diagnosis or treatment of crises. This professional activity has gradually shaped the professional identity and is based on direct control, on avoiding risks and using therapeutic algorithms. When healthcare providers have to face chronic diseases and long-term follow-up strategies, this initial identity may often be counter-producing. This article describes the differences between the acute and chronic dimensions of diseases and treatments. Chronicity imposes on the healthcare provider a totally different way of functioning where he treats indirectly and should help the patient to manage the disease. Medical training has not put sufficient emphasis on the difference between those two approaches to disease. There is an urgent need for specific training in the strategies of management of long-term diseases.

Patient education in Switzerland: from diabetes to chronic diseases.

The Division of Therapeutic Education for Chronic Diseases at the University Hospital of Geneva has been playing an important role in the field of therapeutic patient education for more than 25 years. More than 16,000 patients have been hospitalised and an excess of 75,000 h have been spent with a rather novel interdisciplinary approach involving doctors, nurses, dieticians, psychologists, podiatrists and pedagogues. For the past 12 years, our division has held over 50 seminars of 1-week postgraduate training attended by over 3000 participants coming from more than 60 countries worldwide. In 1998, the faculty of medicine at the University of Geneva implemented a 3-year curriculum on therapeutic patient education leading to a postgraduate university diploma. In 1983, the WHO designated the Swiss teaching division as a WHO Collaborating Center for reference and research in diabetes education. In 1998, a WHO-Euro Working Group Report entitled "Therapeutic Patient Education. Continuing education programmes for health care providers in the field of prevention of chronic diseases" was published.

Patients' experiences with their disease: learning from the differences and sharing the common problems.

Experiences and views of patients are presented concerning psychological, professional, family life, cognitive and financial aspects of the costs of several chronic diseases: arterial hypertension, autonomous dialysis, back pain, bronchial asthma, chronic obstructive pulmonary disease, colostomy, diabetes mellitus, epilepsy, laryngectomy, Parkinson's disease. The posters expressed what patients would really like to tell their doctors.

The patients' voice: testimonies from patients suffering from chronic disease.

A medical congress brings together those doctors who are interested in the proposed theme of that particular congress. Within the congress 'Patient Education 2000' an unusual aspect was the presentation, in the form of posters, of the requirements of patients suffering from one of the diseases or conditions covered by the congress. On the one hand, these posters showed the impact of the illness; on the psychological aspect, within the family, within the professional and social lives as well as the financial aspect. On the other hand, the posters showed what the patients really wanted to say to the health care team. In this paper we present a synthesis illustrating certain significant examples.

Qualitative evaluation of courses intended for patients suffering from chronic diseases. New observation method for the continuous training of the healthcare team.

Experience has shown that when teaching patients, healthcare providers concentrate more on information concerning the illness rather than on the handling of treatment. Therapeutic education of patients imposes a precise structure on the pedagogic method and teaching aids. It is essential that, during their clinical practice, care-providers develop teaching methods which encourage a maximum of interaction to help patients learn to manage their own treatment. In this perspective, the authors propose 'analytical observation' as a method of training evaluation for healthcare providers. Three observation charts, as well as an analytical method for evaluation, have been devised. They have been tried and validated during a study whose principal objective was to measure quantitatively the impact of supervision of care-providers in the domain of therapeutic education of patients. The authors conclude that this method has a definite impact on the pedagogic progress of the care-providers. It makes it possible to record and to give a structure to the pedagogic follow-up (inspection, examination, testing) of care-providers. Since patient education plays a key role in therapeutic success, this type of methodology for training and evaluation conforms to the rigorousness essential to any therapeutic undertaking.

A comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings.

OBJECTIVE: To compare patients with diabetes and new onset foot ulcers treated in Veterans Health Administration (VHA) and non-VHA settings. METHODS: The treatment of patients with new onset diabetic foot ulcers was prospectively monitored in three VHA and three non-VHA hospitals and outpatient settings until ulcer healing, amputation, or death. RESULTS: Of the 302 individuals enrolled in this study, 47% were veterans receiving VHA care. There were no significant differences between veterans and nonveterans in baseline wound classification, diabetes severity, or comorbid conditions. Veterans received significantly fewer sharp debridements, total contact casts, and custom inserts than their nonveteran counterparts, and they had significantly more x-rays, local saline irrigations, IV antibiotics, and prescriptions for bed rest. The percentage of amputations was higher in veterans but did not achieve statistical significance. CONCLUSIONS: Many commonly held stereotypes of veteran men were not found. Veterans and nonveterans with foot ulcers were similar in terms of health and foot history, diabetes severity, and comorbid conditions. There was considerable variation in treatment of diabetic foot ulcers between VHA and non-VHA care. Yet this variation did not result in statistically significant differences in ulcer outcomes.