Elizabeth Stenhouse

Effectiveness of insoles used for the prevention of ulceration in the neuropathic diabetic foot: a systematic review.

CONTEXT Ulceration can be a debilitating and costly complication of the neuropathic diabetic foot. Insoles inserted into footwear are routinely used in clinical practice to help to prevent ulceration. AIM AND SCOPE OF THE REVIEW: This review evaluated the effectiveness of insoles used for the prevention of ulcer in the neuropathic diabetic foot. METHODS Databases were searched from inception to 2008, supplemented by hand searching of references and grey literature. Data extraction and methodological quality assessment were independently conducted by two reviewers following the recommendations of the Centre for Reviews and Dissemination. RESULTS A total of five trials met the inclusion criteria: two randomised control trials (RCTs), two case control studies, and one follow-up study. The methodological quality of the majority of studies was poor. Omitted details regarding the generalisability of results made study comparison and inference to practice difficult. There is a small amount of limited evidence indicating that insoles are effective in reducing incidence of ulceration and reducing plantar peak pressures in the diabetic neuropathic foot. No study included economic analysis or patient-based outcome measures. CONCLUSIONS Insoles appear of use for the prevention of neuropathic diabetic foot ulceration, although evidence is limited. Clinical recommendation regarding type and specification of insole is not possible at this time. There is an essential need for a large well-designed RCT comparing different types of commonly used insole for the prevention of ulceration in the diabetic neuropathic foot. Outcome measures should include patient perceptions of the effectiveness and cost-effectiveness analysis.

Type 2 diabetes and cardiovascular disease in polycystic ovary syndrome: what are the risks and can they be reduced?

Diabet. Med. 27, 498–515 (2010)

Drinking water composition and childhood‐onset Type 1 diabetes mellitus in Devon and Cornwall, England

Aims  Previous studies have reported inconsistent results on the association between some compositions (e.g. nitrate) in domestic water and the risk of childhood‐onset Type 1 diabetes mellitus. This study aimed to examine the relationship between nitrate, zinc and magnesium in drinking water and the risk of childhood‐onset Type 1 diabetes mellitus.

A comparison of customised and prefabricated insoles to reduce risk factors for neuropathic diabetic foot ulceration: a participant-blinded randomised controlled trial

BackgroundNeuropathic diabetic foot ulceration may be prevented if the mechanical stress transmitted to the plantar tissues is reduced. Insole therapy is one practical method commonly used to reduce plantar loads and ulceration risk. The type of insole best suited to achieve this is unknown. This trial compared custom-made functional insoles with prefabricated insoles to reduce risk factors for ulceration of neuropathic diabetic feet.MethodA participant-blinded randomised controlled trial recruited 119 neuropathic participants with diabetes who were randomly allocated to custom-made functional or prefabricated insoles. Data were collected at issue and six month follow-up using the F-scan in-shoe pressure measurement system. Primary outcomes were: peak pressure, forefoot pressure time integral, total contact area, forefoot rate of load, duration of load as a percentage of stance. Secondary outcomes were patient perceived foot health (Bristol Foot Score), quality of life (Audit of Diabetes Dependent Quality of Life). We also assessed cost of supply and fitting. Analysis was by intention-to-treat.ResultsThere were no differences between insoles in peak pressure, or three of the other four kinetic measures. The custom-made functional insole was slightly more effective than the prefabricated insole in reducing forefoot pressure time integral at issue (27% vs. 22%), remained more effective at six month follow-up (30% vs. 24%, p=0.001), but was more expensive (UK £656 vs. £554, p<0.001). Full compliance (minimum wear 7 hours a day 7 days per week) was reported by 40% of participants and 76% of participants reported a minimum wear of 5 hours a day 5 days per week. There was no difference in patient perception between insoles.ConclusionThe custom-made insoles are more expensive than prefabricated insoles evaluated in this trial and no better in reducing peak pressure. We recommend that where clinically appropriate, the more cost effective prefabricated insole should be considered for use by patients with diabetes and neuropathy.Trial registrationClinical trials.gov (NCT00999635). Note: this trial was registered on completion.

Incidence of childhood-onset Type 1 diabetes mellitus in Devon and Cornwall, England, 1975-1996

Aims To determine the incidence of Type 1 diabetes mellitus (DM) in children aged 0–15 years in the far south‐west of England between 1975 and 1996.

Neighborhood deprivation and preterm birth in Plymouth, UK

Objective. To assess the relationship between neighborhood deprivation and the preterm birth rate in Plymouth, UK, using routinely collected data from a clinical information system. Methods. We used a clinic-based prospective case register study of all births in Plymouth UK between 1 January 1996 and 31 December 1997 combined with indices of neighborhood deprivation to assess the relationship between neighborhood deprivation and the preterm birth rate. Areas (n = 43) were classified according to the Townsend index, measuring material deprivation. Preterm births were compared with term births. Results. The incidence of singleton preterm birth was 5.3% (95% confidence interval (CI) 4.6, 6.0). The singleton preterm birth rate increased with Townsend material deprivation score. Crude rates increased by 31% (relative risk (RR) (95% CI) 1.31 (0.94, 1.84), p = 0.056) among those living in the most deprived areas compared to those living in the least deprived areas. A stepwise binary logistic regression model showed an increase in the relative risk of preterm birth of 7% for every unit increase in the Townsend material deprivation score (RR (95% CI) 1.07 (1.03, 1.11)). Conclusion. Neighborhood deprivation is related to preterm birth. Examining individual and neighborhood factors together may increase understanding of the complex causes of preterm birth.

The Physical Characteristics of Materials Used in the Manufacture of Orthoses for Patients with Diabetes

Background: Neuropathic diabetic foot ulceration may be prevented if the mechanical stress transmitted to the plantar tissues can be modified. Orthotic therapy is one practical method commonly used to maintain tissue integrity. Orthotic design must consider the materials chosen for use in fabrication and profile of the device because both aspects influence the performance and durability of the device. Published research evaluating the physical properties of materials commonly used in the manufacture of orthoses for patients with diabetes is limited. This study investigated the physical properties of materials used to fabricate orthoses designed for the prevention of neuropathic diabetic foot ulcers. Methods: Fifteen commonly used orthotic materials were selected for testing: four specifications of 6.4-mm Poron® (Rogers Corp., Gent, Belgium), 3.2-mm Poron®, three densities of 12-mm Ethylene Vinyl Acetate (EVA), 12-mm low-density plastazote, two depths (6.4-mm, 3.2-mm) of Cleron™ (Algeo Ltd., Liverpool, UK), Professional Protective Technology (PPT), and MaxaCane (Algeo Ltd, Liverpool, UK). The density, resilience, stiffness, static coefficient of friction, durability, and compression set of each material were tested, ranked, and allocated a performance indicator score. Results: The most clinically desirable dampening materials tested were Poron® 96 (6-mm) and Poron® 4000 (6-mm). High density EVA (Algeo Ltd., Liverpool, UK) and Lunacell Nora® EVA (Freudenberg, Weinhein, Germany) possessed the properties most suitable to achieve motion control. The data present a simple and useful comparison and classification of the selected materials. Conclusions: Although this information should not be used as a single indicator for assessing the suitability of an orthotic material, the results provide clinically relevant information relating to the physical properties of orthotic materials commonly used in the prevention of neuropathic diabetic foot ulcers.

Space–time clustering of childhood Type 1 diabetes in Devon and Cornwall, England

Aims Several studies on space–time clustering have been reported in childhood diabetes, but the findings are conflicting. The present study was undertaken to examine whether such clustering could be detected at either birth or the time of diagnosis in the far South‐west of England.

Women with pre-existing diabetes and their experiences of maternity care services

AIMS AND OBJECTIVES the aims of the study were to explore the experience of maternity care services used by women whose pregnancy is complicated by pre-existing diabetes, to gain a deeper understanding of service use and to identify aspects of services that women with pre-existing diabetes would like improved. BACKGROUND for women with pre-existing diabetes; pregnancy, birth and the transition to motherhood can be complex and even chaotic. The aim of specialist diabetes care given during pregnancy and delivered by a specialist team of health-care professionals is to optimise pregnancy outcome. However, how health-care professionals within maternity services provide care and support women with pre-existing diabetes during pregnancy and early motherhood has received limited attention. DESIGN an exploratory study utilising a grounded theory approach was conducted. Data were collected via in-depth interviews with 20 respondents; one-to-one, dyad and group interviews were undertaken to fully explore issues. Analysis was undertaken by sub-groups of the research team with at least two members working on each of them. FINDINGS three themes were identified from interviews: empathic care with care more focused on diabetes not pregnancy; feeling judged by health-care professionals (with nearly all respondents reporting negative encounters of consultation with the specialist team); and the notion of expertise (with respondents reporting feeling frustrated when it seemed health-care professionals did not value their expertise). CONCLUSIONS the study emphasised the importance of the health-care relationship for pregnant women with pre-existing diabetes. For outcomes to be optimised women need to be able to form open and trusting relationships with the health-care team. RELEVANCE TO CLINICAL PRACTICE this study highlights the need for the health-care team not only to provide physical care to optimise outcome but also supportive care to assist women with pregnancies complicated by diabetes to achieve the best possible physical and emotional health and well-being.

Measuring the Contribution and Complexity of Nurse and Physiotherapy Consultants: A Feasibility Study

Advanced practice roles in nursing and other health professions have become integral to a range of healthcare services world-wide providing experienced practitioners with the opportunity to extend their roles and influence decision making whilst maintaining patient contact. However, there has been limited research to evaluate the impact on health services of these advanced practice roles. The aim of this feasibility study was to analyse Nurse and Allied Health Professionals (AHP) Consultant activity in the four functions of the role (education, expert practice, leadership, research). A structured diary assessed the activity of five Consultant Nurses and one Consultant Physiotherapist over a one week period. Detailed analysis of a clinic carried out by one of the Consultants was undertaken using a mapping procedure. Results suggest that the activity diary, combined with mapping of activities, illustrate the complexity and variety of the role and facilitate meaningful reflection on what advanced practitioners do.