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      Valoración enfermera de la neuropatía periférica diabética en Atención Primaria en Canarias: Fase inicial del estudio “NEUDIACAN” Translated title: Nursing assessment of diabetic peripheal neuropathy in primary health care in the Canary Islands: Initial phase of the “NEUDIACAN” study

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          Abstract

          RESUMEN La neuropatía periférica diabética (NPD) es una de las complicaciones más comunes y problemáticas de la diabetes mellitus puesto que supone la principal causa de úlceras y amputaciones en miembros inferiores. El objetivo del presente estudio es conocer cómo se lleva a cabo la valoración para la detección precoz de la NPD en Atención Primaria de Canarias. Tras llevar a cabo una búsqueda bibliográfica en las principales bases de datos no se recuperó documento alguno respecto a la valoración de la NPD por enfermeras. Con el fin de recabar información sobre la realización de estas exploraciones en Atención Primaria de Canarias, se diseñaron dos cuadernos de registro de datos: uno para enfermeras y otro para médicos que se distribuyeron entre profesionales sanitarios de centros de salud de las diferentes islas. La valoración de la NPD del paciente diabético en los centros de salud de Atención Primaria en Canarias puede mejorarse. Existe una relación directa entre la formación en neuropatía diabética y la realización de esta valoración con la asiduidad necesaria y los métodos y técnicas válidos para ello. Se requiere establecer estrategias para la formación continuada del personal sanitario de Atención Primaria en éste campo.

          Translated abstract

          ABSTRACT Diabetic peripheral neuropathy (DPN) is one of the most common and problematic complications of diabetes mellitus since it is the leading cause of ulcers and amputations in the lower limbs. The objective of the present study is to know how the assessment for DPN early detection is carried out in the Canary Islands’ primary health care setting. After accomplishing a bibliographic search in the main databases, no document was retrieved regarding the DPN evaluation by nurses. In order to obtain information about the accomplishment of these explorations in the Canaries primary health care setting, two data logbooks were designed: one for nurses and the other for physicians. They were distributed among health professionals of the different islands. The assessment of the DPN for needs to be improved. There is a direct relationship between training in diabetic neuropathy and the completion of this evaluation with the needed assiduity and valid methods and techniques. It is required to establish strategies for the primary health care personnel training in this field.

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          Most cited references11

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          The global burden of diabetic foot disease.

          Diabetic foot problems are common throughout the world, resulting in major economic consequences for the patients, their families, and society. Foot ulcers are more likely to be of neuropathic origin, and therefore eminently preventable, in developing countries, which will experience the greatest rise in the prevalence of type 2 diabetes in the next 20 years. People at greatest risk of ulceration can easily be identified by careful clinical examination of the feet: education and frequent follow-up is indicated for these patients. When assessing the economic effects of diabetic foot disease, it is important to remember that rates of recurrence of foot ulcers are very high, being greater than 50% after 3 years. Costing should therefore include not only the immediate ulcer episode, but also social services, home care, and subsequent ulcer episodes. A broader view of total resource use should include some estimate of quality of life and the final outcome. An integrated care approach with regular screening and education of patients at risk requires low expenditure and has the potential to reduce the cost of health care.
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            Validation of Michigan neuropathy screening instrument for diabetic peripheral neuropathy.

            The reliability and accuracy of the Michigan neuropathy screening instrument (MNSI) have been discussed recently. As a result of the difficulties of performing and analyzing nerve biopsy as a standard diagnostic test, electromyography and neuronography is used as the best alternative diagnostic procedure. The objective of this study was to determine the diagnostic performance of the test characteristics and cut-off point of MNSI scoring for the diagnosis of diabetic peripheral neuropathy. Over a 2-year period, a cross-sectional study was conducted on 176 type 2 diabetic patients. An internist carried out the MNSI and the sum of scores varying from 0 to 1 for each abnormality as revealed in foot appearance, ulceration, ankle reflexes and vibratory perception has been recorded. A neurologist, who was blind to the MNSI scores, performed all neurophysiological studies. The test performance characteristics of the MNSI procedure were measured for different cut-off values. MNSI scores of 1.5, 2.0, 2.5 and 3.0 were assessed as cut-off values. Sensitivities were 79%, 65%, 50% and 35% and specificities were 65%, 83%, 91% and 94%, respectively. Positive predictive values increased and negative predictive values decreased for each score. Accuracies, likelihood ratios and post-test probabilities were measured. The accuracy of MNSI scoring makes it a useful screening test for diabetic neuropathy in taking a decision regarding which patients should be referred to a neurologist for electrophysiological studies. High specificity, likelihood ratios over 5 and a moderate to good post-test probability give a high diagnostic impact for MNSI scoring. We suggest a cut-off point of 2 for the MNSI procedure. However, electrophysiological studies should be considered when the patient has signs and symptoms other than those rated by the MNSI, suggesting peripheral nerve involvement, and also because the MNSI is still just a screening test.
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              Longitudinal assessment of diabetic polyneuropathy using a composite score in the Rochester Diabetic Neuropathy Study cohort.

              Because there are little satisfactory data on change in severity of diabetic polyneuropathy (DP) over time from study of population-based cohorts of diabetic patients in epidemiologic surveys of DP, it is difficult to predict outcome or morbidity or to identify risk factors; it is also difficult to estimate statistical power for use in controlled clinical trials. In this longitudinal study of almost 200 patients from the Rochester Diabetic Neuropathy Study (RDNS) cohort, we assess which symptoms, clinical examinations, tests, or combinations of examinations and tests (composite scores) are best used as minimal criteria for the diagnosis of DP and as a quantitative measure of severity of DP. An abnormality (> or = 97.5th percentile) of a composite score that included the Neuropathy Impairment Score of the lower limbs plus seven tests (NIS(LL)+7 tests), was a better minimal criteria for DP than clinical judgment alone or previously published minimal criteria. First, it provided a more comprehensive assessment of neuropathic impairment. Second, it avoided the overestimated frequency of DP when the minimal criteria for DP was any one or two abnormalities from multiple measurements. Minimal criteria using nerve conduction and reduced heart beat response to deep breathing identified approximately twice as many patients with DP than did clinical examination and vibration detection threshold using CASE IV. This difference could be used to subclassify state 1 DP. Although various individual measures of DP, for example, vibration detection threshold (as evaluated by CASE IV and the 4, 2, and 1 stepping algorithm [see text]), were good measures of worsening, the composite score NIS(LL)+7 tests (assessing neuropathic impairment) was much better at showing monotone worsening. Using this composite score, the average diabetic patient in the RDNS worsened by 0.34 points per year, whereas patients with diabetic polyneuropathy worsened by 0.85 points per year. On the assumption that a therapeutic agent may prevent worsening of DP but not cause improvement, controlled clinical trials of patients with DP would need to be conducted for a period of 3 years to achieve a meaningful change of 2 NIS points (the level of abnormality considered by a Peripheral Nerve Society consensus group to be clinically meaningful).
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                Author and article information

                Journal
                ene
                Ene
                Ene.
                Martín Rodríguez Álvaro (Santa Cruz de La Palma, La Palma, Spain )
                1988-348X
                2017
                : 11
                : 3
                : 717
                Affiliations
                [5] orgnameCentro de Salud de Candelaria
                [8] orgnameColegio Oficial de Enfermeros de la provincia de S/C de Tenerife
                [6] orgnameUnidad Docente de Atención Familiar y Comunitaria Tenerife Sur
                [7] orgnameCentro de Salud Ofra Miramar
                [2] orgnameNEUDIACAN orgdiv1Programa de Formación en Valoración del Pie Diabético
                [4] orgnameServicio Canario de la salud orgdiv1Gerencia de Atención Primaria de Tenerife orgdiv2Unidad de Formación e Investigación en Cuidados
                [3] orgnameServicio Canario de la salud orgdiv1Gerencia de Atención Primaria de Tenerife
                [1] orgnameUnidad Docente de Atención Familiar y Comunitaria Tenerife Sur orgdiv1Subcomisión de enfermería familiar y comunitaria
                Article
                S1988-348X2017000300010 S1988-348X(17)01100300010
                50f69696-7fb6-4a21-952f-2456afb01548

                This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

                History
                : 07 September 2017
                : 21 September 2017
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 11, Pages: 0
                Product

                SciELO Spain

                Categories
                Operativa del Cuidado

                medición,cribado,Neuropatías Diabéticas,nursing,diabetic foot,peripheral neuropathy,Diabetic Neuropathies,measurement,enfermería,pie diabético,neuropatía periférica,screening

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