Clinical Notes: Pressure-Ulcer Data, Diabetic Foot Ulcers, IFG & HbA1c

Hospital pressure-ulcer comparison data not accurate

Performance scores for rates of hospital-acquired pressure ulcers might not be appropriate for comparing hospitals, according to a study in the Annals of Internal Medicine.

Hospital report cards for hospital-acquired pressure ulcers: How good are the grades?,” funded by the Agency for Healthcare Research and Quality, analyzed 2 million all-payer administrative records from 448 California hospitals and quarterly hospital surveillance data from 213 hospitals from the Collaborative Alliance for Nursing Outcomes.

Overall, pressure-ulcer rates were about 10 times lower when they were based on billing data compared to rates calculated from bedside exams by nurses.

“Our findings provide a strong case for removing hospital rates for pressure ulcers from the Medicare’s Hospital Compare website in order to prevent comparisons that may be misleading to patients and policymakers,” says Jennifer Meddings, MD, one of the study’s authors.

Temperature predicts diabetic foot ulcers

A systematic review and meta-analysis published in the Journal of Foot and Ankle Research has found that an increase in skin temperature in comparison to the other limb predicts foot ulcers in patients with diabetes.

Two of the authors of “Is an increase in skin temperature predictive of neuropathic foot ulceration in people with diabetes? A systematic review and meta-analysis” searched the literature from 1960 to July 2011; ultimately, nine studies were selected for analysis based on established criteria.

Two temperature-monitoring techniques were used in the studies: infrared dermal thermometry and liquid crystal thermometry. Infrared is more widely used, more user friendly, and more cost effective.

An important take-away message from the study is temperature monitoring is
an effective way to prevent diabetic foot ulcers.

IFG and HbA1c predict diabetes in older adults

A study in Diabetes Care finds that older adults with both impaired fasting glucose (IFG) and elevated HbA1c levels have “substantially increased odds” of developing diabetes over 7 years.

Elevated HbA1c and fasting plasma glucose in predicting diabetes incidence among older adults: Are two better than one?” reviewed data from the Health, Aging and Body Composition study.

An important point of the study is that combined screening with fasting plasma glucose and HbA1c might identify older adults at high risk for diabetes.

Studies on PAD interventions released

Two studies related to interventions for peripheral arterial disease (PAD) were presented at the 2013 Vascular Interventional Advances conference.

DEFINITIVE AR, a prospective, multicenter, randomized pilot study, included 102 patients with claudication who had lesions 7 to 15 cm long in femoropopliteal arteries. Patients either underwent directional atherectomy (using either the SilverHawk™ or TurboHawk™ plaque excision systems) followed by a paclitaxel-coated balloon (a combination referred to as DAART [directional atherectomy and antirestenotic therapy]) or only had the drug-coated balloon inserted.

Thirty days after the procedure, 88.6% of patients who underwent DAART and 89% of patients who only had the balloon inserted experienced improved claudication of at least one level.

The DURABILITY II study, a prospective, multicenter, nonrandomized study, included 287 patients with a Rutherford class 2-4 claudication and femoropopliteal atherosclerotic lesions up to 20 cm in length. Most patients (95%) received a single EverFlex™ self-expanding nitinol stent; the remaining received more than one stent. Three years after the procedure, 70% of patients still had patent vessels. The researchers concluded that the stent is a “reasonable, durable treatment option in this challenging patient cohort.”

CDC report: Antibiotic resistance deadly in U.S.

Antibiotic resistance threats in the United States, 2013,” published by the Centers for Disease Control and Prevention (CDC), reports that every year, more than 2 million people contract infections that are resistant to antibiotics and at least 23,000 people die as a result.

Infections classified as “urgent threats” include carbapenem-resistant Enterobacteriaceae and Clostridium difficile diarrhea.

In addition to the human costs, antibiotic resistance adds $20 billion in excess direct healthcare costs, with additional costs for lost productivity as high as $35 billion a year.
The most important factor leading to antibiotic resistance is the inappropriate use of antibiotics. Up to half of antibiotics prescribed aren’t needed or aren’t prescribed appropriately.

The CDC suggests four core actions for addressing the problem:

• Preventing infections, preventing the spread of resistance
• Tracking resistance patterns
• Improving use of today’s antibiotics (antibiotic stewardship)
• Developing new antibiotics and diagnostic tests

“If we don’t act now, our medicine cabinet will be empty and we won’t have the antibiotics we need to save lives,” said CDC director Tom Frieden, MD, MPH.

Download an infographic about the report.

Dehydrated amniotic membrane allografts improve wound healing

Adding dehydrated human amniotic membrane allografts (EpiFix®) to standard wound care improves wound healing in patients with diabetic foot ulcers, according to a study in International Wound Journal.

A prospective randomised comparative parallel study of amniotic membrane wound graft in the management of diabetic foot ulcer,” a prospective, randomized clinical trial, compared wound healing in two groups of patients: those who received standard care and those who received EpiFix.

After 6 weeks, the overall healing rate for patients who received EpiFix was 92%, compared to only 8% for patients who received standard therapy.

View: EpiFix video


Inpatient diabetes education reduces hospital readmissions

The study “Inpatient diabetes education is associated with less frequent hospital readmission among patients with poor glycemic control,” published in Diabetes Care, found patients with poorly controlled diabetes who received teaching had a readmission rate of 11% 30 days after discharge compared to 16% for those who didn’t have the instruction. Education was also associated with reduced readmissions within 180 days, although the relationship was “attenuated.”

The authors included 2,265 patients in the 30-day hospital readmission analysis and 2,069 patients in the 180-day analysis.

Patients received education from a certified diabetes educator or trainee.

High BMI risk factor for lymphedema after breast cancer surgery

Breast Cancer Research and Treatment has published a research study that finds women who have a body mass index (BMI) of 30 or higher are at increased risk for lymphedema after surgery for breast cancer. Patients whose weight fluctuated by 10 pounds after surgery were also at higher risk.

Impact of body mass index and weight fluctuation on lymphedema risk in patients treated for breast cancer” included 787 newly diagnosed breast cancer patients in the study.

The authors recommend “close monitoring or early intervention” for patients identified to be at risk.

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