Medical strategies to reduce amputation in patients with Type 2 diabetes

Lower extremity amputation is a common and disabling complication of Type 2 diabetes. Whilst the introduction of specialist multidisciplinary teams has led to a reduction in the incidence of lower extremity amputation in some centres, the overall prevalence of diabetes‐related amputation has actually increased in recent decades. The aetiology of diabetes‐related amputation is complex, with neuropathy, macrovascular and microvascular disease contributing significantly. Ulceration, previous amputation, increasing diabetes duration and poor long‐term control of glycaemia and lipids are important risk factors for amputation in populations with diabetes. Major randomized intervention trials of blood glucose‐lowering or anti‐hypertensive therapies in populations with diabetes have shown limited reductions in neuropathy and/or macrovascular disease, and no benefit on amputation rates. In contrast, a recent analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study showed a significantly reduced rate of minor, but not major amputations in patients with Type 2 diabetes treated with fenofibrate. Mechanistic studies are clearly needed to understand the basis of this benefit.     

Primary aldosteronism and a Texas two-step

Primary aldosteronism is unquestionably the most common secondary cause of hypertension, and effective approaches to diagnosis and targeted treatments exist. Even the most conservative estimates of the prevalence of primary aldosteronism, however, indicate that the condition is grossly underdiagnosed. Part of the reason why diagnosis and treatment lag far behind is the lack of expertise, even among endocrinologists and hypertension specialists, in the approach to the patient with possible primary aldosteronism. We will never make an impression on this important problem unless general internists and primary care physicians actively participate in the screening and referral process. A healthcare delivery team need not fear an overwhelming and fruitless battle with an intractable conundrum if a practical and staged approach to workup and treatment is taken. This review discusses the approach we have taken in Dallas, a strategy of targeted screening, referral for positive screens, and individualized management.     

Inflammatory arthritis: case review and primary care perspectives

Inflammatory arthritis (IA) has significant physical, psychosocial and economic consequences. Delays in diagnosis and initiation of treatment significantly impact on prognosis. The infrequent, variable, non-specific and, sometimes, indolent presentation make recognition of IA by primary care physicians (PCPs) challenging. To undertake an in-depth case review assessing the diagnostic trajectory of patients diagnosed with IA to inform development of practical recommendations to facilitate timely recognition and referral of suspected IA to specialist services, a case review was undertaken in one UK general practice using a proforma to collect information on patient demographics, diagnostic activities (presentation to PCP, specialist referral and final diagnosis) and documentation of disease-specific features for all patients diagnosed with IA between January 2000 and February 2011. Cases were excluded if consultation notes, a definitive diagnosis or evidence of specialist assessment were absent. Twenty-four cases were included in the final analysis. Duration from first primary care presentation to specialist rheumatological referral ranged from 4 to 2,165 days. Undertaking radiographs significantly lengthened delays from presentation to referral. Patients with IA attended between 2 and 41 primary care appointments before being referred. None of the cases identified had a comprehensive record of symptoms documented in the medical record. Once patients present to primary care, specialist referral is not always in accordance with the urgency necessitated in current guidelines. Improving PCPs’ knowledge and awareness of IA, development of screening tools and improvement in record keeping are proposed to facilitate early recognition and referral of IA and subsequently reduce the disease burden of IA.     

Managing type 2 diabetes in Soweto—The South African Chronic Disease Outreach Program experience

Diabetes (DM) and its resultant complications are a problem worldwide, and especially in developing countries like South Africa (SA). Risk factors associated with DM are potentially modifiable, but DM control is poor. Problems in SA include high prevalence of morbidity from DM and hypertension (HTN), lack of recognition of the importance of chronic kidney disease (CKD), late presentation to health care services, lack of education of health providers and patients, and poor quality of care in primary health care settings (PHC). In response, there has been growing advocacy for prevention strategies and improved support and education for primary health care nurses (PHCNs). A Chronic Disease Outreach Program (CDOP), based on the chronic care model was used to follow patients with DM and HTN, support PHCN, and improve health systems for management in Soweto. A group of 257 DM patients and 186 PHCN were followed over 2 years, with the study including the evaluation of ‘functional’ and clinical outcomes, diary recordings outlining program challenges, and a questionnaire assessing PHCNs’ knowledge and education support, and the value of CDOP. CDOP was successful in supporting PHCNs, detecting patients with advanced disease, and ensuring early referral to a specialist center. It improved early detection and referral of high risk, poorly controlled patients and had an impact on PHCNs’ knowledge. Its weaknesses include poor follow up due to poor existing health systems and the programs’ inability to integrate into existing chronic disease services. The study also revealed an overworked, poorly supported, poorly educated and frustrated primary health care team.     

Guía de práctica clínica sobre el manejo del paciente con dispepsia. Actualización 2012

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made.     

Chronic ulcerative colitis: incidence and prevalence in a community.

Utilising the population based data resources of the Rochester Epidemiology Project, we determined the incidence and prevalence of chronic ulcerative colitis among Rochester, Minnesota, residents over the 20 year period, 1960-79. One hundred and thirty eight cases met diagnostic and residency criteria, for an overall age, and sex adjusted chronic ulcerative colitis incidence rate of 15.0 per 100,000 person years. The male:female ratio of age adjusted rates was 1.5:1. Age specific incidence was roughly bimodal in appearance but was not consistent in different patient subgroups. On 1-1-80, there were 120 Rochester residents with a history of chronic ulcerative colitis, corresponding to a prevalence rate of 225.2 per 100,000 population. Fifty three per cent of chronic ulcerative colitis incidence cases were 'definite' and 47% were 'probable', the former requiring consistent observations for at least six months. The definite group had proportionately more men and disease of greater extent and severity. Pancolitis comprised about one-third of all cases (4.6 per 100,000 person years). Proctitis and distal disease (7.1 and 2.0 per 100,000 person years) made up most of the rest. One-fourth of all patients had 'severe' or 'moderate' disease (3.8 per 100,000 person years), while the remainder had either 'mild' or 'transient' chronic ulcerative colitis (11.2 per 100,000 person years). In residents of Rochester, Minnesota, chronic ulcerative colitis is most often a mild disease. The over-representation of severe or complicated examples that results from selected referral to major centres probably distorts the natural clinical spectrum of the disease.     

Public health aspects of breast cancer gene testing in Canada. Part 3: A model of potential need and demand.

Centres offering expert counselling and genetic testing are already experiencing high levels of demand, and yet the potential demand is much greater. There have been few attempts to estimate the potential demand created by particular guidelines for referral or testing. A model of need and demand for genetic services is presented, and research questions are identified that should assist in better prediction of future requirements for genetic counselling and testing. The value of integrated routine data on referral criteria, demand and clinical service load is considerable. Attention needs to be paid to referral at primary care and general specialist levels as well as to expert centres.     

Delivery of care for adult patients with congenital heart disease in Europe: results from the Euro Heart Survey.

AIMS: The increasing number of adults with congenital heart disease (CHD) has prompted the development of recommendations for the management of these patients and for the organization of their healthcare. The aim of this report is to describe the delivery of care in Europe for adults with congenital cardiac anomalies. METHODS AND RESULTS: As part of the Euro Heart Survey on Adult Congenital Heart Disease, we obtained data from 71 voluntarily participating centres that detailed their care practices for these patients. Forty-eight of these centres were specialist centres and 23 were non-specialist centres. We found that only 19% of the specialist centres complied with defined standards for optimal care structure. The criteria that appeared to be most difficult for all centres to achieve were performing 50 congenital heart operations or more per year and involving nurse specialists in the care of these patients. CONCLUSION: This survey indicated that the provision of care in Europe for adults with congenital heart defects is suboptimal. To fully realize the benefits of cardiac surgery performed in infants and children, continuous effort must be applied by healthcare professionals in order to implement the recommendations on the organization of care for these patients.     

Analysis of hospital mortality of patients with congenital heart defects in the 1st year of life

Causes of mortality were analysed in a group of 122 patients with congenital heart disease in their first year of life following conservative management, closed surgery and operations under assisted circulation. Fatal outcomes were predetermined by a severe congenital defect in 18.2% of the patients, while in the remaining cases they could basically have been prevented by means of a timely primary diagnosis and referral to a specialized clinical institution, accurate topical diagnosis, correct assessment of the severity of the patients' condition and improved post-operative intensive care.     

Older Adults and Chronic Kidney Disease Decision Making by Primary Care Physicians: A Scholarly Review and Research Agenda

Background Chronic kidney disease (CKD) is a growing public health concern that overwhelmingly affects older adults. National guidelines have called for earlier referral of CKD patients, but it is unclear how these should apply to older adults. Objective This scholarly review aims to explore the current literature about upstream referral decisions for CKD within the context of decisions about initiation of dialysis and general referral decisions. The authors propose a model for understanding the referral process and discuss future directions for research to guide decision making for older patients with CKD. Results While age has been shown to be influential in decisions to refer patients for dialysis and other medical therapies, the role of other patient factors such as competing medical co-morbidities, functional loss, or cognitive impairment in the decision making of physicians has been less well elucidated, particularly for CKD. Conclusions More information is needed on the decision-making behavior of physicians for upstream referral decisions like those being advocated for CKD. Exploring the role of geriatric factors like cognitive and functional status may help facilitate more appropriate use of resources and improve patient outcomes.     

Smoking: can we really make a difference?

The enormous health benefits of stopping smoking are now well established. Doctors have a vital role in motivating smokers and initiating quit attempts. The mainstay of National Health Service smoking cessation strategy should be the routine provision of brief opportunistic intervention in primary care, backed up by referral to a specialist smoking cessation service. There is an urgent need to increase substantially the numbers of smokers referred by general practitioners, other members of the primary care team, and those working in acute hospital trusts, to specialist smoking cessation services and for better channels of communication between the various agencies. Use of pharmacotherapy (nicotine replacement therapy or bupropion) in combination with behavioural support achieves higher cessation rates than either component alone and is the most effective way of helping smokers to stop. Smokers who quit often relapse and hence will need repeated help.     

Non-invasive diagnosis and follow-up of non-alcoholic fatty liver disease

NAFLD is a frequent disease that affects 25% of the worldwide population. There is no specific diagnostic test for NAFLD, and the diagnosis mainly relies on the elimination of the other causes of chronic liver diseases with liver biopsy kept for unsure diagnoses. Non-invasive tests are now available to assess NAFLD severity and therefore to help physicians decide on the patient management and follow-up. These non-invasive tests can also be used to define pathways that organize referrals from primary care and diabetology clinics to the liver specialist, with the ambition to improve the screening of asymptomatic patients with NAFLD and advanced liver disease. NAFLD being the liver expression of the metabolic syndrome, physicians need also take care to screen for diabetes and to evaluate the cardiovascular risk in those patients. These recommendations from the French Association for the Study of the Liver (AFEF) aim at providing guidance on the following questions: how to diagnose NAFLD; how non-invasive tests should be used to assess NAFLD severity; how to follow patients with NAFLD; when to perform liver biopsy in NAFLD; and how to decide referral to the liver specialist for a patient with NAFLD.     

Prevalence of Hypertension in Patients with Type II Diabetes in Referral versus Primary Care Clinics

We compared the prevalence of hypertension in patients with non–insulin-dependent diabetes mellitus (NIDDM) in referral and primary care practices using definitions of The Fifth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC-V), while controlling for other risk factors such as hypertension, obesity, smoking, and age. Patients (n = 1443) were enrolled consecutively from a large referral practice at the Jackson Diabetes Center and four primary care clinics in the vicinity. Blood pressures were measured at three clinic visits after a 5-min rest in a sitting position using a standard clinical sphygmomanometer. Charts were reviewed to determine diabetes duration, insulin usage, height, weight, smoking history, use of antihypertensive and oral hypoglycemic medications, socioeconomic status, and race. Patients were classified as hypertensive based on JNC-V definitions or if they were on antihypertensive medication. Hypertension was termed uncontrolled if blood pressure was JNC-V Stage 2 or higher while on antihypertensive medication.

Seventy-eight percent of referral clinic and 55% of primary care clinic patients had either JNC-V State 1 or higher hypertension or were on antihypertensive medication. Actual blood pressures indicated that more patients had JNC-V Stage 1 (mild) or higher hypertension in referral compared to primary care clinics (62% versus 48% p = 0.01) but fewer had JNC-V Stage 2 or higher (moderate-severe) hypertension (12% versus 19% p = 0.002). Patients seen in the referral clinic were significantly more likely to have greater age, greater duration of diabetes, higher insulin dosage, longer smoking history, antihypertensive medication, and live outside the metropolitan area. By logistic regression, the odds of hypertension were significantly increased with age (OR 1.51/decade), BMI greater than 27 (OR 2.17), diabetes duration (OR 1.04/year), and insulin dosage (OR 1.74/U/kg). Current smoking and attending a referral clinic were not significantly related. The odds of moderate-severe hypertension were significantly increased with age (OR 1.23/decade), decreased by attending a referral clinic (OR 0.45), and not significantly related to other confounders in the model.

The prevalence of hypertension among patients with NIDDM was higher in referral than primary care clinics. The higher prevalence in the referral practice can be accounted for by the greater severity of associated risk factors in the referral practice patients; however, most patients will be diagnosed and treated for hypertension prior to referral. More patients in the referral practice were on hypertensive medication, which lowered the stage or severity of hypertension but still not to the normal range. The results suggest that the primary detection of hypertension in patients with type II diabetes resides with the primary care physician. Management of hypertension will require both a delineation and acceptance of responsibilities between the primary care physician and diabetes specialists.     

Incidence and prevalence of inflammatory bowel diseases in gastroenterology primary care setting

BackgroundThe incidence of inflammatory bowel diseases (IBDs) has markedly increased over the last years, but no epidemiological study has been performed in gastroenterology primary care setting. We describe the epidemiology of IBD in a gastroenterology primary care unit using its records as the primary data source.MethodsCase finding used predefined read codes to systematically search computer diagnostic and prescribing records from January 2009 to December 2012. A specialist diagnosis of Ulcerative colitis (UC), Crohn's disease (CD), inflammatory bowel disease unclassified (IBDU) or segmental colitis associated with diverticulosis (SCAD), based on clinical, histological or radiological findings, was a prerequisite for the inclusion in the study. Secondary, infective and apparent acute self-limiting colitis were excluded.ResultsWe identified 176 patients with IBD in a population of 94,000 with a prevalence 187.2/100,000 (95% CI: 160.6–217.0). Between 2009 and 2012 there were 61 new cases. In particular, there were 23 new cases of UC, 19 new cases of CD, 15 new cases of SCAD, and 4 new cases of IBDU. The incidence of IBD was 16.2/100,000 (95% CI 12.5–20.7) per year. The incidence per year was 6/100,000 (95% CI 3.8 to 8.9) for UC, 5/100,000 (95% CI 3.0–7.7) for CD, 4/100,000 (95% CI 2.3–6.5) for SCAD, and 1/100,000 (95% CI 0.3–2.6) for IBDU.ConclusionsWe assessed for the first time which is the prevalence and incidence of IBD in a gastroenterology primary care unit. This confirms that specialist primary care unit is a key factor in providing early diagnosis of chronic diseases.     

Management of dyspepsia across the primary-secondary healthcare interface.

Primary care remains at the frontline of care for most patients and the need to contain healthcare costs has led to a re-evaluation of the divide between primary and secondary care. Dyspepsia has a community prevalence of 25-50%, and forms 5% of the primary care physician's workload, 10% of whom are referred to a specialist. Problems presenting in primary care tend to be undifferentiated; those who do not have alarm symptoms and are under the age of 55 years are unlikely to have serious pathology. Management is largely symptom driven, on an empirical basis rather than on a diagnostic model as in secondary care where investigation rates are higher. The predictive value of symptoms for a specific diagnosis is small; primary care physicians include gastro-oesophageal reflux disease as part of the dyspepsia complex and the overall expenditure on acid suppression therapy is relatively large. The availability of open-access investigations such as endoscopy has influenced specialist referral rates and the ability to diagnose and treat patients with Helicobacter pylori-related problems has opened further opportunities. However, variations in the availability of the recommended diagnostic tests and the implications to primary care clinical practice of some of the new management recommendations (Maastricht II) in some national settings illustrate the divide with secondary care. The gap between primary and secondary care is narrowing in gastroenterology and the two groups need to continue collaboration to attain effective and cost-effective management for their patients.     

Primary care diabetes in the Republic of Ireland

The Republic of Ireland has a mixed public and private healthcare system. Individuals with diabetes have traditionally been managed in specialist settings, particularly in urban centres. This is changing rapidly with more and more type 2 diabetes being managed in primary care. As yet there is no structured national diabetes care programme though there is currently an Expert Advisory Group on Diabetes meeting to make recommendations to government regarding setting up such a service which will integrate diabetes care between primary and specialty sectors.     

Associations with Retinopathy in Type 2 Diabetes: a Population-based Study in a Swedish Rural Area

This population-based study was carried out in a rural area in Sweden. The impact of duration of diabetes, metabolic control, albuminuria, and mode of detection (screening or presence of overt symptoms at the time of diagnosis) on retinopathy in patients with type 2 diabetes aged under 70 years was investigated at a primary health care centre. Ninety-nine percent of all known persons with Type 2 diabetes were under care at the centre. The fundi were examined in all but one of those under 70 years, and a 100% attendance rate was noted with regard to other variables such as albuminuria, glycated haemoglobin, and blood lipids. A team approach (general practitioner, nurse specialist, dietitian, and chiropodist) with patient education as an integral part of the treatment has been practised for the past 15 years. Retinopathy was associated with duration of disease, glycaemic control, systolic blood pressure, detection by overt symptoms, and albuminuria. The risk of retinopathy was not associated with smoking or treatment category. The prevalence of retinopathy was 26.5% in the whole population, and 18.8% among the patients who had been treated for their diabetes at the centre from the time of diagnosis. The importance of an appropriate organization in primary health care for early case finding, near-normal glycaemia, team approach, and structured collaboration with a department of ophthalmology is emphasized in order to realize the aims of the St Vincent declaration to reduce eye complications due to Type 2 diabetes.     

Resource Use Study In COPD (RUSIC): A prospective study to quantify the effects of COPD exacerbations on health care resource use among COPD patients

BACKGROUND:

There is increasing interest in health care resource use (HRU) in Canada, particularly in resources associated with acute exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE:

To identify HRU due to exacerbations of COPD.

METHODS:

A 52-week, multicentre, prospective, observational study of HRU due to exacerbations in patients with moderate to severe COPD was performed. Patients were recruited from primary care physicians and respirologists in urban and rural centres in Canada.

RESULTS:

In total, 524 subjects (59% men) completed the study. Their mean age was 68.2±9.4 years, with a forced expiratory volume in 1 s of 1.01±0.4 L. Patients had significant comorbidities. There were 691 acute exacerbations of COPD, which occurred in 53% of patients: 119 patients (23%) experienced one acute exacerbation, 70 patients (13%) had two acute exacerbations and 89 patients (17%) had three or more acute exacerbations. Seventy-five patients were admitted to hospital, with an average length of stay of 13.2 days. Fourteen of the patients spent time in an intensive care unit (average length of stay 5.6 days). Factors associated with acute exacerbations of COPD included lower forced expiratory volume in 1 s (P<0.001), high number of respiratory medications prescribed (P=0.037), regular use of oral corticosteroids (OCSs) (P=0.008) and presence of depression (P<0.001). Of the 75 patients hospitalized, only 53 received OCSs, four received referral for rehabilitation and 15 were referred for home care.

CONCLUSIONS:

The present study showed a high prevalence of COPD exacerbations, which likely impacted on HRU. There was evidence of a lack of appropriate management of exacerbations, especially with respect to use of OCSs, and referral for pulmonary rehabilitation and home care.     

Management of thyroid dysfunction by primary care physicians of the Province of Quebec: a transversal study

OBJECTIVES: This study aims to evaluate clinical practice of primary care physicians regarding common thyroid disorders. MATERIALS AND METHODS: A sample of 210 primary care physicians was randomly selected in three Quebec's administrative regions. Four clinical vignettes (V1 to V4) were presented by mail: two cases of subclinical hypothyroidism (women of 25 years - V1 - and 70 - V2 - years of age) for which physicians had to choose to either treat or not with thyroid replacement and two cases of hyperthyroidism (women of 30 - V3 - and 66 - V4- years of age) for which they had to choose a course of action (observation, treatment or referral to a specialist). V1 and V2 where followed by four sub-questions presenting supportive elements that could influence the decision to treat (presence of antithyroid antibodies, accumulation of symptoms, LDL cholesterol and thyreostimulin levels). RESULTS: The overall response rate was 22%. Forty-two percent of respondents would have treated V1 outright and 49% would have treated V2. The therapeutic approach in the face of these two vignettes, independently of the presence or absence of supportive clinical or biochemical elements, did not vary according to geographic practice area. However, one region was significantly more conservative for V4. The number of years in practice or assistance to continuous medical education activities did not affect management of vignettes. CONCLUSION: This study outlines the importance of clinical practice guidelines and tools to facilitate their application in clinical management of thyroid disorders.