Patients Risk Stratification in the Management of Osteoporosis: the Latest International Guidelines

@#Assessment of risk of a fragility fracture is a vital step a physician needs to undertake in every patient suspected of osteoporosis, as this will influence the decisions on whether to treat with a pharmacological agent, with which drug, and for how long. After risk stratification, patients deemed Very High-Risk should be considered for an anabolic agent, or if this is not feasible, a parenteral anti-resorptive. High- Risk or Moderate-Risk patients may be considered for oral bisphosphonates.

Effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers

<p><b>INTRODUCTION</b>This is the fi rst prospective study done locally to determine the effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers.</p><p><b>MATERIALS AND METHODS</b>An electronic vacuum pump was used to apply controlled negative pressure evenly across the wound surface. Changes in wound dimension, presence of wound granulation and infection status of diabetic foot ulcers in 11 consecutive patients with diabetes were followed over the course of VAC therapy.</p><p><b>RESULTS</b>Healing was achieved in all wounds. Nine wounds were closed by split-skin grafting and 2 by secondary closure. The average length of treatment with VAC therapy was 23.3 days. Ten wounds showed reduction in wound size. All wounds were satisfactorily granulated and cleared of bacterial infection at the end of VAC therapy.</p><p><b>CONCLUSIONS</b>VAC therapy was useful in the treatment of diabetic foot infection and ulcers, which after debridement, may present with exposed tendon, fascia and/or bone. These included ray amputation wounds, wounds post-debridement for necrotising fasciitis, wounds post-drainage for abscess, a heel ulcer and a sole ulcer. It was able to prepare ulcers well for closure via split-skin grafting or secondary closure in good time. This reduced cost of VAC therapy, as therapy was not prolonged to attain greater reduction in wound area. VAC therapy also provides a sterile, more controlled resting environment to large, exudating wound surfaces. Large diabetic foot ulcers were thus made more manageable.</p>

Foot screening for diabetics

<p><b>INTRODUCTION</b>This study aims to evaluate the results of foot screening performed in a study population of 2137 diabetics (3926 feet) screened from 2006 to 2008 by the National University Hospital (NUH) multi-disciplinary team for diabetic foot problems.</p><p><b>MATERIALS AND METHODS</b>A standardised protocol was designed. Foot screening consisted of detailed history taking and clinical examination including assessment for sensory neuropathy by Semmes Weinstein monofilament (SWMF) and neurothesiometer and assessment of vasculopathy by ankle-brachial index (ABI) and total body irradiation (TBI). The foot screening was performed by a trained staff nurse. All patients were classified according to King's College Classification.</p><p><b>RESULTS</b>Majority of the patients were in the fifth (27.9%) and sixth (30.0%) decades of life. Two thousand sixty-four had type II diabetes, and only 73 had type I diabetes. Neuropathy was found in 1307 (33.3%) feet based on 5.07 SWMF. Vasculopathy was recorded in 510 (13.0%) and 546 (13.9%) feet based on ABI <0.8 and TBI <0.7. According to King's Classification, 1069 (50.0%) were Stage 1: Normal and 615 (28.8%) were Stage 2: At-Risk.</p><p><b>CONCLUSION</b>Foot screening should be performed as early as possible to detect "At-Risk" feet and prevent the development of diabetic foot complications, thereby further reducing the risk of major amputations.</p>

Measuring the quality of care of diabetic patients at the specialist outpatient clinics in public hospitals in Singapore

<p><b>INTRODUCTION</b>This study aims to measure the quality of care for patients with diabetes mellitus at selected Specialist Outpatient Clinics (SOCs) in the National Healthcare Group.</p><p><b>MATERIALS AND METHODS</b>The cross-sectional study reviewed case-records of patients from 6 medical specialties who were on continuous care for a minimum of 15 months from October 2003 to April 2005. Disproportionate sampling of 60 patients from each specialty, excluding those co-managed by Diabetes Centres or primary care clinics for diabetes, was carried out. Information on demographic characteristics, process indicators and intermediate outcomes were collected and the adherence rate for each process indicator compared across specialties. Data analysis was carried out using SPSS version 13.0.</p><p><b>RESULTS</b>A total of 575 cases were studied. The average rate for 9 process indicators by specialty ranged from 47.8% to 70.0%, with blood pressure measurement consistently high across all specialties (98.4%). There was significant variation (P <0.001) in rates across the specialties for 8 process indicators; HbA1c, serum creatinine and lipid profile tests were over 75%, while the rest were below 50%. The mean HbA1c was 7.3% +/- 1.5%. "Optimal" control of HbA1c was achieved in 51.2% of patients, while 50.6% of the patients achieved "optimal" low-density lipoprotein (LDL)-cholesterol control. However, 47.3% of patients had "poor" blood pressure control. Adherence to process indicators was not associated with good intermediate outcomes.</p><p><b>CONCLUSIONS</b>There was large variance in the adherence rate of process and clinical outcome indicators across specialties, which could be improved further.</p>