[Cost of training a diabetes mellitus patient. Effects on the prevention of amputation]. / Coût de la formation du patient atteint d'un diabète sucré. Effets sur la prévention des amputations.

Cost of disease is a complex notion: financial cost, psychological cost for those who have cope with a chronic disease. But there is also another cost which has not yet sufficiently been taken into account: the cost of resistance to change. It has largely been shown that patient education could result in major cost-saving as well as improvement of quality of life. Why is there such a resistance from health care providers, health policy planners for implementation of patients education programs? These resistances may well be part of the real cost of efficient control of a disease and like in the case of diabetes, prevention of acute and chronic complications. Education and training of patients has enabled us to decrease markedly lower extremities amputations: 12 times less above knee amputations, reduction by half of below knee amputations and a four fold decrease of toe amputations at the University Hospital of Geneva, Switzerland.

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.

The tuning fork revisited.

The performance of the Rydel-Seiffer graduated tuning fork was examined in healthy subjects and in various groups of diabetic patients in order to evaluate its efficacy for identifying patients whose loss of vibration sensation may expose them to the risk of foot injury. Vibration perception score measured with the tuning fork declined with age (p less than 0.001) in the control subjects. It correlated well (r = -0.90, p less than 0.001) with the thresholds obtained with an electromagnetic instrument (Vibrameter) in diabetic patients, in whom vibration perception score was impaired compared with control subjects (4.0 +/- 1.8 (+/- SD) vs 5.4 +/- 1.4, p less than 0.001). Age-related Rydel-Seiffer tuning fork vibration sensation was impaired in 79% of 38 ulcerated feet of 26 patients. The tuning fork score was less than or equal to 4.0 in 95% of the ulcerated feet. We conclude that the Rydel-Seiffer graduated tuning fork is a suitable tool for screening for sensation loss and that diabetic patients with a tuning-fork score of less than or equal to 4.0 are vulnerable to ulceration.

Additional factors associated with plantar ulcers in diabetic neuropathy.

Patients can only examine and handle their own feet if they have adequate visual acuity and joint mobility. We therefore studied the physical capacity of patients with neuropathy to perform the preventive footcare measures previously taught. The study included three groups of diabetic outpatients, comparable for age and duration of diabetes: (1) 38 patients with neuropathic ulcers; (2) 21 patients with neuropathy, but no ulcers; (3) 30 patients without neuropathy. Visual acuity and joint mobility, expressed as minimum eye-metatarsum and heel-buttock distances, did not differ between uncomplicated neuropathic and non-neuropathic patients: visual acuity was sufficient in 95% of neuropathic patients without ulceration and in 87% of non-neuropathic patients; joint mobility was in the normal range in both groups. However, 71% of complicated neuropathic patients had insufficient visual acuity for correct foot examination, and their joint mobility was reduced compared with uncomplicated neuropathic and non-neuropathic patients.