Assessing peripheral arteries in South African black women with type 2 diabetes mellitus.

OBJECTIVES: To determine the value of ankle and toe blood pressure indices and pedal pulse palpation in the assessment of peripheral arterial disease in subjects with type 2 diabetes mellitus (DM). DESIGN: Cross-sectional study. SUBJECTS: A convenience sample of 85 female subjects with type 2 DM underwent a series of peripheral vascular assessments at the diabetes clinic of a community hospital. OUTCOME MEASURES: Palpation of the pedal pulses, Doppler-derived ankle brachial systolic blood pressure indices, photo plethysmographic-derived toe brachial systolic blood pressure indices and antero-posterior radiographs of both feet. RESULTS: Mean values were 1.15 (standard deviation (SD): 0.17) and 0.76 (SD: 0.17) for ankle brachial index (ABI) and toe brachial index (TBI) respectively. The differences between the two indices increased from 0.36 (95% confidence interval (CI): 0.32-0.41) to 0.58 (95% CI: 0.46-0.70) depending on whether ABI was less or greater than 1.3. The correlation coefficient for left versus right foot was 0.62 and 0.71 for ABI and TBI respectively. The relationship between ABI and TBI is non-linear with a cut point close to 1.3. Both ABI and TBI were significantly lower in subjects who had both pedal pulses absent on palpation. CONCLUSIONS: The relationship between ABI and TBI is linear below an ABI of 1.3. but with a wide 95% prediction interval. If both pedal pulses are absent the ABI is significantly diminished compared with when both pulses are present, even though not necessarily below 0.9.

Monofilament assessment of neuropathy in a community diabetes clinic.

OBJECTIVE: To compare the detection of diabetic neuropathy using monofilament, cotton wool, pinprick, vibration sense and symptom evaluation. SETTING: The diabetes clinic of a community hospital. METHODS: Two examiners evaluated 89 women with diabetes mellitus (DM) using a 10 g monofilament, cotton wool, pinprick and a 128 Hz tuning fork after completion of a University of Texas subjective peripheral neuropathy verbal questionnaire. RESULTS: Vibration sense was abnormal in either foot in 8% of subjects. Neuropathy as defined by monofilament, cotton wool and pinprick was present in 26%, 3% and 6% of patients respectively. The respective kappa values (kappa) for the comparison between monofilament neuropathy and cotton wool neuropathy, pinprick neuropathy and symptom-defined neuropathy were 0.18, 0.21 and 0.06. The kappa-value comparing monofilament and tuning fork-defined neuropathy was 0.24. There was fair agreement between 10 versus 3 sites (kappa = 0.60). CONCLUSION: More abnormalities were detected using the monofilament compared with cotton wool or pinprick. There was poor concordance between symptoms and clinically detected neuropathy. The ideal number of sites that need to be evaluated is still contentious.

Assessment of the possibility to classify patients according to cholesterol guideline screening criteria using routinely recorded electronic patient record data.

BACKGROUND: Computerised decision support systems (CDSS) can be categorised as either being inquisitive or non-inquisitive. The non-inquisitive system uses routinely entered electronic patient data, to generate patient specific feedback based on guidelines. The Dutch College of General Practitioners' (DCGP) cholesterol guideline classifies patients into risk groups, eligible for screening. The availability of sufficient routinely recorded electronic patient data to classify patients according to the DCGP cholesterol guideline is unknown. OBJECTIVE: To assess whether it is possible to classify patients according to the screening criteria of the DCGP cholesterol guideline, using data routinely recorded by general practitioners. METHODS: We analysed the DCGP cholesterol guideline to identify selection criteria for screening. These selection criteria were subsequently used to create a cohort of patient records eligible for screening in the Integrated Primary Care Information (IPCI) Database. We calculated incidence and prevalence of risk factors and selected patient records for active management according to the identified screening selection criteria. RESULTS: 145866 valid patient records were selected for classification. In the retrieved records 9741 (13.6%) males and 5756 (7.8%) females were identified for active management according to the selection criteria of the DCGP cholesterol guideline. CONCLUSION: The classification of patients into risk groups, eligible for screening, according to the criteria of the DCGP cholesterol guideline using routinely recorded electronic patient data is feasible. Care should be taken when using only diagnostic codes, as it gives higher than expected incidence and prevalence of risk factors. Based on these findings we are currently building Cholgate, a non-inquisitive decision support system for cholesterol management.