Oral care practices and hospital-acquired pneumonia prevention: A national survey of Australian nurses.

BACKGROUND: Hospital-acquired pneumonia (HAP) also known as non-ventilator associated pneumonia, is one of the most common infections acquired in hospitalised patients. Improving oral hygiene appears to reduce the incidence of HAP. This study aimed to describe current practices, barriers and facilitators, knowledge and educational preferences of registered nurses performing oral health care in the Australian hospital setting, with a focus on the prevention of HAP. We present this as a short research report. METHODS: We undertook a cross sectional online anonymous survey of Australian registered nurses. Participants were recruited via electronic distribution through existing professional networks and social media. The survey used was modified from an existing survey on oral care practice. RESULTS: The survey was completed by 179 participants. Hand hygiene was considered a very important strategy to prevent pneumonia (n = 90, 58%), while 45% (n = 71) felt that oral care was very important. The most highly reported barriers for providing oral care included: an uncooperative patient; inadequate staffing; and a lack of oral hygiene requisite. Patients' reminders, prompts and the provision of toothbrushes were common ways believed to help facilitate improvements in oral care. CONCLUSION: Findings from this survey will be used in conjunction with consumer feedback, to help inform a planned multi-centre randomised trial, the Hospital Acquired Pneumonia PrEveNtion (HAPPEN) study, aimed at reducing the incidence of HAP. Findings may also be useful for informing studies and quality improvement initiatives aimed at improving oral care to reduce the incidence of HAP.

Experiences and impact of a rural Australian high-risk foot service: A multiple-methods study.

OBJECTIVE: Most podiatry-led high-risk foot services (HRFS) in Australia are located in metropolitan areas or large regional centres. In rural areas, where there are limited specialist services, individuals with diabetes-related foot ulceration are more likely to undergo amputation. This study aimed to explore clinicians' perceptions of a recently implemented HRFS in rural New South Wales, Australia, and compare trends of amputation and hospitalisation prior to and post-implementation of the service. SETTING: Rural HRFS in Tamworth, New South Wales, Australia. PARTICIPANTS: Health professionals working within the HRFS were recruited to participate. DESIGN: This was a multiple-methods study. For the qualitative arm, semi-structured interviews were conducted, which were analysed using a reflexive thematic approach. The quantitative arm of the study utilised a retrospective analytic design which applied an interrupted time series to compare amputation and hospitalisation trends pre- and post-implementation of the HRFS utilising diagnostic and procedural ICD codes. RESULTS: The qualitative arm of the study derived three themes: (1) navigating the divide, (2) rural community and rural challenges and (3) professional identity. Results of the interrupted time series indicate that there was a downward trend in major amputations following implementation of the HRFS; however, this was not statistically significant. CONCLUSION: Clinicians were aware of the inequity in DFD outcomes between rural and metropolitan areas and were committed to improving outcomes, particularly with respect to First Nations peoples. Future research will explore service use and amputation rates in the longer term to further evaluate this specialised multidisciplinary care in a rural community.

Sensitivity and Specificity of Pulse Oximetry for Identification of Peripheral Artery Disease: A Systematic Review.

BACKGROUND: Lower limb peripheral artery disease (PAD) is associated with poor outcomes including ulceration, gangrene, amputations, and mortality. Clinicians therefore routinely perform point-of-care tests in high-risk populations to identify PAD and subsequently implement cardiovascular management and appropriate interventions. Pulse oximetry has been suggested as a useful adjunct test for identifying PAD. OBJECTIVE: The aim of this systematic review was to determine the sensitivity and specificity of pulse oximetry in the lower limb for identifying PAD. METHODS: MEDLINE, EMBASE, and CINAHL were searched up until January 10, 2023, to identify studies of sensitivity and specificity of pulse oximetry that used criterion standard diagnostic imaging as a reference standard. Two authors screened articles for inclusion and appraised quality of included studies using the Quality Appraisal for Diagnostic Accuracy Studies, version 2. RESULTS: A total of 6371 records were screened, and 4 were included. The included studies had a total of 471 participants, with an age range of 41 to 80.6 years. All studies were cross-sectional and conducted in hospital settings. Sensitivity values for pulse oximetry compared with diagnostic imaging in identifying PAD ranged from 44% to 76%, and specificity values ranged from 85% to 96%. There was no consensus regarding measurement techniques and diagnostic thresholds for pulse oximetry, which precluded meta-analysis. CONCLUSIONS: There is currently inadequate evidence to support the use of pulse oximetry for identifying PAD. Current evidence suggests that pulse oximetry has low levels of sensitivity and is therefore likely to miss PAD when it is present.

Factors influencing diabetes-related foot ulcer healing in Australian adults: A prospective cohort study.

OBJECTIVE: Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population. RESEARCH DESIGN AND METHODS: This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation. RESULTS: A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03). CONCLUSIONS: In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal.

Perceptions of Diet Quality, Advice, and Dietary Interventions in Individuals with Diabetes-Related Foot Ulceration; A Qualitative Research Study.

BACKGROUND: Dietary intake is a recognised contributor to healing in diabetes-related foot ulceration (DFU). However, it is currently unknown how individuals with DFU perceive their diet, and what is deemed an acceptable dietary intervention. Therefore, the aims of this study were to explore perceptions of diet quality, previous dietary advice, and dietary interventions in individuals with DFU, and secondly to determine acceptable dietary interventions in individuals with DFU to assist with wound healing. METHODS: A qualitative study using reflexive thematic analysis was undertaken. Individuals with active or recent history of DFU were recruited from a high-risk foot service. Semi-structured interviews were undertaken. RESULTS: Nineteen participants were included with three themes identified: A complex relationship with food, perceptions of food, diet and dietitians, and self-management. Dietary misconceptions were common. Self-perceived diet quality varied, with most unaware of how diet could impact wound healing. Many expressed barriers relating to food agency (purchasing, preparing, and accessing food). Participants expressed a strong preference for personalised, face-to-face dietary advice and nutritional supplementation. CONCLUSIONS: There is a need for personalised dietary re-education and assistance with food agency in this cohort to overcome commonly held misconceptions of diet and improve dietary intake to facilitate wound healing.

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study.

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

Macronutrient and micronutrient intake of individuals with diabetic foot ulceration: A short report.

BACKGROUND: Adequate nutrition is essential in individuals with diabetic foot ulceration (DFU); therefore, an assessment of dietary intake is critical. A lack of nutrients including protein, zinc and vitamins C and D have all been associated with poor wound healing. However, the comprehensive dietary intake of Australian adults with DFU is poorly understood. The aim of this cross-sectional study was to describe the dietary intake of adults with DFU in an Australian setting. METHODS: Participants (n = 115) with diabetes (type 1 and 2), a mean body mass index of 36 and current foot ulceration were recruited from across New South Wales, Australia. Dietary intake was assessed using the Australian Eating Survey, a self-reported validated food frequency questionnaire. RESULTS: The mean (SD) reported energy intake was 9.57 (±SD 4.43) MJ day-1 . A mean protein intake of 104 (±SD 49) g day-1 is below recommended intake for wound healing; however, the mean protein intake contribution to energy (19%E) was within recommendations for normal populations. The mean carbohydrate intake (43%E) was within recommended ranges for healthy populations; however, the mean total fat intake (36%E) was above recommendations. Micronutrient intake was adequate, apart from folate, which was below the recommended intake, and sodium, vitamin C, vitamin A and selenium, which were above the recommended intake. CONCLUSIONS: A lack of adequate folate may have a negative impact on healing, with folate proposed to play a role in tissue repair. Wound management of individuals with DFU should include a regular assessment of dietary intake to recognise deficiencies in macro- and micronutrients, and subsequently address these inadequacies to optimise healing.

Nature and extent of outpatient podiatry service utilisation in people with diabetes undergoing minor foot amputations: a retrospective clinical audit.

BACKGROUND: People with diabetes are at high risk of foot complications that can lead to lower extremity amputations. National standards suggest that early assessment and management by a podiatry led multidisciplinary high-risk foot clinic (HRFC) helps to reduce complications. This review is a retrospective audit of the Central Coast Local Health District (CCLHD) podiatry department service utilisation in people with diabetes who had undergone a minor foot amputation. METHODS: All people with diabetes who had minor foot amputations in the calendar year 2017 in the CCLHD in New South Wales were identified. Podiatry occasions of service from all podiatry service clinics (e.g. general, orthoses, wound, HRFC) and hospital stays for 12 months prior to, and 12 months, post the minor foot amputation were extracted. RESULTS: Data on 74 people with diabetes who underwent 85 minor foot amputations were collected. In the 12-month period leading up to their minor foot amputation less than half, 42% (n=31), of the patients had attended any of the available podiatry service clinics within the CCLHD system. Post-amputation and discharge from hospital there was an overall rise of 26% in numbers attending all CCLHD podiatry- led clinics bringing the total to 68% (51). However, attendance at the HRFC rose by only 2% from 16% (n=12) to 18% n= (13). CONCLUSION: This study shows that there was underutilisation of Podiatry Services in the CCLHD in 2017 with some participants not meeting national treatment guidelines for foot health services. Revision of current referral pathways both prior to, during and following hospitalisation and expanding the multidisciplinary HRFC to accommodate the population by providing more accessible locations has since been undertaken to increase service access. Further provision of education to those highlighted to be at high risk has also been implemented.

Association of peripheral artery disease and chronic limb-threatening ischemia with socioeconomic deprivation in people with diabetes: A population data-linkage and geospatial analysis.

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation.

Do toe blood pressures predict healing after minor lower limb amputation in people with diabetes? A systematic review and meta-analysis.

PURPOSE OF STUDY: To investigate toe systolic blood pressure and/or toe-brachial pressure index in predicting healing post minor diabetic foot amputations. KEY METHODS: A systematic search of EMBASE and PubMed (including Medline and The Cochrane Library) was conducted from database inception to 9 March 2020. Two authors independently reviewed and selected relevant studies. Quality was assessed with a modified Critical Appraisal Skill Programme checklist. MAIN RESULTS: Ten studies met the inclusion criteria. Nine studies investigating toe systolic blood pressure reported healing occurred at mean toe systolic blood pressure values ⩾30 mmHg, ranging between 30 and 83.6 mmHg. The meta-analysis (four studies) found toe systolic blood pressure <30 mmHg had 2.09 times the relative risk of non-healing post amputation, compared to toe systolic blood pressure ⩾30 mmHg (relative risk = 2.09, 95% confidence interval: 1.37-3.20, p = 0.001). Two studies investigating toe-brachial pressure index report successful healing where toe-brachial pressure index >0.2, with one study reporting a higher value of 0.8. MAIN CONCLUSIONS: Successful post-amputation healing outcomes were reported at mean toe systolic blood pressure ⩾30 mmHg, and the results varied considerably between the studies. Further research should identify whether variables, including amputation level, method of wound closure and length of post-operative follow-up periods, affect the values of toe systolic blood pressure and toe-brachial pressure index observed in this review.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners.

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Non-invasive assessment of vibration perception and protective sensation in people with diabetes mellitus: inter- and intra-rater reliability.

BACKGROUND: Testing of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes. METHODS: Three podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year's clinical experience. The intra- (Cohen's К) and inter-rater (Cohen's or Fleiss' К) reliability of each test was determined. RESULTS: Fifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38-0.70, p = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41-0.95, p < 0.01). The 10-site monofilament (К: 0.44-0.77) outperformed the 4-site test (К: 0.34-0.67) and the dampened tuning fork method (К: 0.41-0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52-0.57) and graduated methods (К: 0.50-0.57). CONCLUSION: We support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively.

Important features of retail shoes for women with rheumatoid arthritis: A Delphi consensus survey.

OBJECTIVES: Footwear management aims to preserve foot function, reduce the burden of foot pain and maintain joint mobility in women with rheumatoid arthritis (RA). Whilst retail footwear is commonly recommended by health professionals, there is no current consensus on recommended features of retail footwear for women with RA. This study aimed to determine consensus from health professionals about the important features of retail footwear for women with RA. METHODS: An international Delphi exercise using online survey software was conducted with 39 participants from health care backgrounds. Three iterative rounds were conducted. In the first round, participants listed features of retail footwear that would be important for women with RA. Responses of the first round, combined with results of a scoping review of patient-reported outcome measures used in assessing footwear in arthritis and a qualitative analysis of female patients' perspectives of retail footwear in RA were used to create items for the second round. Items were scored by a 9-point rating scale with consensus defined by the RAND/UCLA disagreement index. The third round consisted of items which did not reach consensus or scored >1 on the RAND/UCLA disagreement index from round two. RESULTS: Fifty-eight items (n = 58) were generated for rating and at the end of three iterative rounds, there was agreement that thirty-eight items were important, that two were not important, and there was no agreement for a further eighteen items. Item themes reaching consensus included footwear characteristics and acceptability and psychosocial aspects of footwear. Footwear characteristics related to heel height, shape, cushioning, toe box size, adjustable fastening, removable insoles, mid-foot support and soft accommodative uppers. Acceptability and psychosocial aspects included affordability, comfort, aesthetic, style, colour and impact on femininity. CONCLUSION: This consensus exercise has identified the important features of retail footwear for women with RA.

Relationship between lower limb vascular characteristics, peripheral arterial disease and gait in rheumatoid arthritis.

OBJECTIVES: Rheumatoid arthritis (RA) is associated with higher risk of atherosclerotic vascular disease, including peripheral arterial disease (PAD). The aim of this study was to measure lower limb vascular characteristics (indicative of PAD), using non-invasive chairside testing methods, in people with RA compared to matched controls, and to determine the association between vascular characteristics and gait velocity as a measure of functional capacity in people with RA. METHODS: This was a cross-sectional pilot study which measured lower limb vascular characteristics (bilateral continuous wave Doppler, toe brachial index [TBI] and ankle brachial index [ABI]) and gait velocity (6-m walk test) in people with RA and controls. Differences in vascular characteristics between groups were determined using linear regression models, and associations between vascular characteristics and gait were determined using logistic regression models. RESULTS: Seventy-two participants were included: 34 participants with RA mean disease duration 26.2 (SD 12.1) and 38 age- and sex-matched controls. The control group contained 30 females (79%), and the RA group had 28 females (82%). There were no significant differences between the RA and control groups for lower limb vascular characteristics. People with RA walked significantly slower compared to controls (1.10 m/s vs 0.91 m/s, P < .001). People with RA who had abnormal TBI, or abnormal qualitative Doppler walked significantly slower compared to those with normal TBI (0.86 m/s vs 0.95 m/s, P = .043 and 0.81 m/s, vs 0.93 m/s, P = .028). There was no significant association between ABI and gait velocity. CONCLUSION: This study did not identify different lower limb vascular characteristics in people with RA compared to matched controls. However, in people with RA, abnormal Doppler and TBI results are associated with slower walking velocity.

Lower limb vascular assessment techniques of podiatrists in the United Kingdom: a national survey.

BACKGROUND: Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments. METHODS: A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used. RESULTS: Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient's general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed. CONCLUSION: The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors.

"Come and live with my feet and you'll understand" - a qualitative study exploring the experiences of retail footwear in women with rheumatoid arthritis.

BACKGROUND: Foot pain and deformity are common in people with rheumatoid arthritis (RA). Previous research has identified that women with RA seek retail footwear to alleviate their foot problems. The specific footwear features that women with RA require, and what would help them to find shoes that meet these requirements, are unknown. This study aimed to determine the factors that influence the choice of appropriate retail footwear by women with RA. METHOD: An overarching qualitative approach was taken, using reflexive thematic analysis of conversational style interviews. The interviews explored experiences and use of retail footwear in 20 women with RA. The interviews were digitally recorded transcribed verbatim and analysed using a reflexive thematic framework. RESULTS: Women with RA sought retail footwear which had adequate cushioning, width, a flexible sole, lightweight, were made from breathable materials and were easy to put on and take off. However, this choice was driven by the need for comfort, cost and usability, with aesthetics being less of a priority. Despite having opinions on what criteria they felt that they needed, these women did not feel empowered to make good choices about purchasing retail footwear for symptomatic relief. Furthermore, they did not receive the necessary support from podiatrists and shoe shop staff. CONCLUSION: Women with RA have clear ideas about what features a retail shoe should have to achieve comfort. There is a constant compromise between achieving comfort and their feelings about their appearance and how they feel others perceive them. Women with RA describe negative experiences with shoe shop assistants and podiatrists leading to poor footwear choices. Both retail staff and podiatrists need increased understanding about the particular problems that women with RA experience.

How does a short period of exercise effect toe pressures and toe-brachial indices? A cross-sectional exploratory study.

BACKGROUND: Whilst post exercise ankle-brachial indices (ABI) are commonly used to help identify peripheral arterial disease (PAD), the role of post exercise toe pressures (TP) or toe-brachial indices (TBI) is unclear. The aim of this study was to determine, in a population without clinical signs of PAD, the effect that 30 s of weight-bearing heel raises has on TP and TBI values. Additionally, the ability of resting TP and TBI values to predict change in post-exercise values using the heel raise method was investigated. METHODS: Participants over the age of 18 with a resting TBI of ≥0.60 and ABI between 0.90 and 1.40, without diabetes, history of cardiovascular disease and not currently smoking were included. Following ten minutes of supine rest, right TP and bilateral brachial pressures were performed in a randomized order using automated devices. Participants then performed 30 s of weight-bearing heel raises, immediately after which supine vascular measures were repeated. Data were assessed for normality using the Shapiro-Wilk test. For change in TP and TBI values the Wilcoxon Signed-Rank Test was performed. For correlations between resting and change in post exercise values, the Spearman Rank Order Correlations were performed, and where significant correlation identified, a linear regression undertaken. RESULTS: Forty-eight participants were included. A statistically significant decrease was seen in the median TP from resting 103.00 mmHg (IQR: 89.00 to 124.75) to post exercise 98.50 mmHg (IQR: 82.00 to 119.50), z = - 2.03, p = 0.04. This difference of 4.50 mmHg represents a 4.37% change and is considered a small effect size (r = 0.21). The median TBI also demonstrated a statistically significant decrease from resting 0.79 (IQR: 0.68 to 0.94) to post exercise 0.72 (IQR: 0.60 to 0.87), z = - 2.86, p = < 0.01. This difference of 0.07 represents an 8.86% change and is considered a small effect size (r = 0.29). Linear regression demonstrated that resting TBI predicted 22.4% of the variance in post exercise TBI, p = < 0.01, coefficients beta - 0.49. CONCLUSIONS: Thirty seconds of weight-bearing heel raises resulted in a similar decrease in TBI values seen in longer periods of exercise. TP values also showed a decrease post exercise; however this was contrary to previous studies.

How sensitive and specific is continuous-wave Doppler for detecting peripheral arterial disease in people with and without diabetes? A cross-sectional study.

BACKGROUND: Continuous-wave Doppler is frequently used for detecting peripheral arterial disease in patients with diabetes; however, there is limited evidence investigating diagnostic accuracy. This study aimed to determine sensitivity and specificity of continuous-wave Doppler for detecting peripheral arterial disease in populations with, and without, diabetes and to investigate the influence of disease severity on sensitivity of continuous-wave Doppler for detecting peripheral arterial disease. RESULTS: Data from 396 participants were included. Using colour Duplex ultrasound as reference standard (N=66), printed continuous-wave Doppler waveform analysis sensitivity was 81.75% (95% confidence interval: 76.75 to 85.88) and specificity 89.34% (95% confidence interval: 82.62 to 93.67). Printed continuous-wave Doppler waveform analysis sensitivity for peripheral arterial disease was comparable to sensitivity calculated using angiography as the reference standard (81.67%; 95% confidence interval: 69.56 to 90.48). Sensitivity and specificity were unaffected by diabetes diagnosis (n = 176), sensitivity 82.76% (95% confidence interval: 74.86 to 88.55), and specificity 88.33% (95% confidence interval: 77.82 to 94.23). CONCLUSION: Continuous-wave Doppler is a fair assessment tool for peripheral arterial disease in a community-based sample with suspected peripheral arterial disease. Diagnostic accuracy of continuous-wave Doppler for peripheral arterial disease is unaffected by the presence of diabetes.

Diagnostic accuracy of the postexercise ankle-brachial index for detecting peripheral artery disease in suspected claudicants with and without diabetes.

The postexercise ankle-brachial index (ABI) is recommended in patients with normal resting ABI when peripheral artery disease (PAD) is suspected. The aims of this study were to determine the comparative diagnostic accuracy of the resting and postexercise ABI for detecting PAD, and, the effect of the presence of diabetes on these. Three methods of interpretation currently in use were also investigated: a reduction in postexercise ABI by >20% compared to resting ABI, an ABI value of ≤0.90 postexercise, or a reduction in systolic ankle pressure of >30 mmHg postexercise. This retrospective study used colour duplex ultrasound (CDU) as the reference standard. In 278 limbs (whole group), the resting ABI had an overall area under the curve (AUC) of 0.71, with the postexercise ABI yielding a similar diagnostic accuracy of AUC 0.72. In the non-diabetes group ( n=171), the resting ABI had an overall AUC of 0.74 and the postexercise ABI had a similar AUC of 0.76. In the diabetes group ( n=107), overall accuracy was reduced compared to the non-diabetes group, with the resting ABI having an overall AUC of 0.65 and the postexercise ABI yielding a similar accuracy with an AUC of 0.64. The overall diagnostic accuracy of the postexercise ABI for diagnosing PAD was not greatly improved compared to resting ABI. Given the lower overall diagnostic accuracy in the diabetes group, both the resting and the postexercise ABI results in diabetes populations should be interpreted with caution. There is a risk of undiagnosed disease if relying on these results alone to determine lower limb vascular status.