Academic Session: Oral presentations
Chairs: Prof Diarmuid Smith, Mr Seamus McHugh & Helen Strapp
14:00-15:30 in Lecture Hall
Prize for Best & Runner-Up Presentations
Abstract 1
Title: The Impact of Practitioner Neuro-Divergence on Clinical Documentation Development in the Chronic Disease HUB in CHO7
Authors: SMITH Veronica, CORRY Constance, WILSON Pauline, DOYLE Christina, CREIGHTON Tara
Affiliations: Podiatry Department, Dublin South, Kildare, West Wicklow Chronic Disease Hub
Introduction: Healthcare staff includes people of varying levels of proficiency including those with common neuro-divergence issues such as dyslexia, dyspraxia and colour blindness. Excellent patient care involves maintaining good patient records. Initial patient assessment provides a baseline against which a patient's care plan can be evaluated. Standardised patient documentation needs to be adopted. Cumbersome documents can introduce excessive subjectivity, incompleteness, increase electronic health record burden and difficulty for practitioners with neuro-divergence.
Methods: Historical documentation used in the high risk and diabetic foot clinics in the Podiatry departments in CHO7 did not consider neuro-divergence during design. New versions were developed through end user feedback including those with neuro-divergence. Changes included; color-coding sections, introducing tick boxes, alerts, and improved layout, all aimed at reducing load on working memory and executive function.
Results: Results included standardisation of notes, time-saving, reduced unnecessary subjectivity and a significant increase in full documentation completion notably by those with neuro-divergence. In line with the research, qualitative feedback highlighted, tick boxes along with colour coding as having the most impact.
Conclusion: High risk and diabetic foot assessment can be very complex and a simple, standardised approach is essential to promote full document completion and interdisciplinary and multidisciplinary interpretation. It is imperative that all practitioner’s neuro-divergence and practitioner feedback is taken into account when developing patient documentation.
Abstract 2
Title: An exploration of lower extremity amputation before, during and after Covid-19
Authors: WILSON Pauline, GILLEN Corey, COLGAN Mary Paula, MARTIN Zenia, O’CALLAGHAN Adrian and PHELAN Niamh
Affiliations: St James’ Hospital, Dublin 8
Introduction: The COVID-19 pandemic has had an impact on curtailment of ambulatory care services and non-critical hospital services . In areas where multi-disciplinary diabetic foot teams (MDfTs) have been curtailed, the rate of lower extremity amputation (LEA) and poor outcomes have been noted to increase (Casciato et al 2020). In the current study location the MDfT services were not reduced or curtailed throughout the COVID-19 pandemic. Patients who preferred to use telemedicine were encouraged to do so although face-to-face appointments continued as necessary.
Methods: The rates of LEAs were collected both in total and secondary to diabetic foot disease were collated for the years 2019, 2020 and 2021 as is standard practice. These were analysed against EHR to identify those occurring subsequent to intervention of the MDfT. The rate of all-cause amputations was also analysed
Results: The rate of both major and minor amputations remained unchanged between the three years. This was true for all cause amputation (table 1) and those related to DM (table 2) Anticipated spike in rate of amputations after the pandemic did not materialise. In 2021 the rate of minor amputations actually reduced.
Discussion: The MDfT is an effective method of amputation prevention and management of DFD and should be maintained at all times. We note that throughout the pandemic as services were maintained, no increase in the rate of LEA was observed. The anticipated rise in amputations as suggested following the pandemic did not occur in this centre either for those with DM related amputation or for overall amputation rates supporting the need for continuity of service.
Abstract 3
Title: The Oral Cavity: a Potential Reservoir for Diabetic-Foot Ulcer Infections
Authors: Liam GREALY1, Eilish DUFFY1, Pauline WILSON2, Corey GILLEN, Blaithnaid DALY, Iannis POLYZOIS3, Marie Louise HEALY2, & Brenda MCMANUS1
Affiliations:
1) Microbiology Research Unit, Division of Oral Biosciences, Dublin Dental University Hospital, Trinity College, University of Dublin
2) Department of Endocrinology & Diabetes, St. James’s Hospital, James’s Street, Dublin
3) Department of Restorative Dentistry, Dublin Dental University Hospital, Trinity College, University of Dublin
Introduction: Periodontal disease, is more prevalent and severe in patients with diabetes, for whom oral health is commonly overlooked. Staphylococcal bacteria, highly prevalent in the oro-nasal cavities (ONC) of people with periodontal disease, are the predominant cause of diabetic foot ulcer (DFU) infections (DFUIs). This study compared ONC and DFU staphylococcal populations to determine if the ONC is a reservoir for DFUIs using additional members within a multidisciplinary diabetic foot team.
Methods: Participants with type II diabetes with (N=76) and without (N=76) DFUs provided clinical specimens from various anatomical sites in conjunction with a comprehensive oral examination. Staphylococci were recovered on SaSelectTM chromogenic medium (BioRad, Germany). Isolates (N=2185) selected on the basis of distinct colony colours, anatomical sites and individuals were definitively identified by Pastorex latex-agglutination testing (Bio-Rad), S. aureus-/S. epidermidis-specific PCRs, 16S rRNA-sequencing and MALDI-TOF-MS. Close relatedness of S. aureus and S. epidermidis isolates, respectively, was determined using whole-genome multilocus sequence typing (wgMLST).
Results: Oro-nasal S. aureus and S. epidermidis prevalence in non-DFU patients was lower (31/76 [40.7%] and 62/76 [81.5%]), respectively, compared with DFU patients (60/76 [78.9%] and 70/76 [92.1%]), respectively. Staphylococcus aureus was significantly more prevalent across all anatomical sites of DFU patients than non-DFUs patients (P<0.05). Identical species were recovered from the ONC and DFUs of 38 DFU patients (S. aureus [28/40, 70%], S. epidermidis [10/40, 25%], S. haemolyticus [2/40, 5%], S. pettenkoferi [1/40, 2.5%], S. saprophyticus [1/40, 2.5%]). Comparative wgMLST analysis identified oro-nasal and ulcer S. aureus and S. epidermidis separated by ≤24 allelic differences (i.e. closely related) in 19/26 (73.1%) and 4/10 (40.0%) participants, respectively.
Conclusions: Oro-nasal S. aureus and S. epidermidis prevalence is higher in DFU patients than non-DFU patients. The detection of closely-related oral and ulcer S. aureus and S. epidermidis in patients with DFUs provides evidence for oro-nasal reservoirs for DFUIs.
Abstract 4
Title: The Role of the Diabetic Foot Round in Fulminant Diabetic Foot Sepsis
Authors: Cremen Sinead1, Michael Lockhart2, Ellen Young3, Gallagher David4, O’ Loughlin Aonghus2, Dineen Sean2, Tubassam Muhammad1
Affiliations:
1) Department of Vascular Surgery, Galway University Hospital, Galway, Ireland
2) Department of Endocrinology, Galway University Hospital, Galway, Ireland
3) Department of Podiatry, Galway University Hospital, Galway, Ireland
4) Department of Infectious Diseases, Galway University Hospital, Galway, Ireland
Introduction: The COVID-19 pandemic has had an impact on curtailment of ambulatory care services and non-critical hospital services . In areas where multi-disciplinary diabetic foot teams (MDfTs) have been curtailed, the rate of lower extremity amputation (LEA) and poor outcomes have been noted to increase (Casciato et al 2020). In the current study location the MDfT services were not reduced or curtailed throughout the COVID-19 pandemic. Patients who preferred to use telemedicine were encouraged to do so although face-to-face appointments continued as necessary.
Methods: The rates of LEAs were collected both in total and secondary to diabetic foot disease were collated for the years 2019, 2020 and 2021 as is standard practice. These were analysed against EHR to identify those occurring subsequent to intervention of the MDfT. The rate of all-cause amputations was also analysed
Results: The rate of both major and minor amputations remained unchanged between the three years. This was true for all cause amputation (table 1) and those related to DM (table 2) Anticipated spike in rate of amputations after the pandemic did not materialise. In 2021 the rate of minor amputations actually reduced.
Discussion: The MDfT is an effective method of amputation prevention and management of DFD and should be maintained at all times. We note that throughout the pandemic as services were maintained, no increase in the rate of LEA was observed. The anticipated rise in amputations as suggested following the pandemic did not occur in this centre either for those with DM related amputation or for overall amputation rates supporting the need for continuity of service.
Abstract 5
Title: Retrospective analysis of diabetes foot osteomyelitis management and outcomes in a specialised outpatient multi-disciplinary diabetes foot clinic
Authors: Conor CAHILL1,2, Jill CUNDELL2, David GALLAGHER1 & Stephen KEARNS1
Affiliations:
1) Galway University Hospitals, Galway, Ireland
2) Ulster University, Antrim, Northern Ireland
Introduction: Incidence of Diabetes Mellitus (DM) is increasing and Diabetes Foot Disease (DFD) will increase in tandem. Osteomyelitis (OM) is a problematic complication of DFD that increases the risk of Lower Extremity Amputation (LEA). This study retrospectively analysed cases of OM managed in a Multi-Disciplinary Complex Foot Clinic (CFC).
Methods: A retrospective case analysis was conducted between November 2018- May 2020. Subjects were identified via the Diamond (Hicom™) database and were included/excluded based on the study criteria.
Results: Forty-nine cases of OM were deemed appropriate for inclusion. Forty subjects (85.1%) were male, mean age at diagnosis was 70 years and mean HbA1c was 64.47mmol/mol. Most cases of OM involved subjects with T2DM (89.8%). Mean DM duration was 13.8 years. Most OM cases seen in this clinic were managed medically without surgical intervention (n=38; 76%). Mean ulcer duration was 240 days. The majority of patients diagnosed with OM were managed on PO antibiotics as outpatients (55.1%). Thirty-nine cases (79.6%) achieved full wound closure. Twenty-three cases (46.9%) required admission with an average length of stay of 14.2 days. An IV to PO antibiotic switch was used in 40.8% of cases. Eight cases (16.3%) required amputation. Single digit amputation was the most common surgical intervention in this cohort (10.3%). Thirty-eight cases (77.6%) receive ongoing podiatric care as of May 2022.
Conclusion: This study retrospectively analysed OM cases in a medically led diabetic foot clinic. Most cases were managed as outpatients with targeted antibiotic therapy. This is supported by a growing body of research advocating the use of antibiotic therapy in cases of OM. Minor amputations represented the majority of surgical interventions in this cohort. Further research should analyse microbiological sample culture and sensitivities and gather data from multiple sites. Further efforts should be made to integrate the wider MDT in order to enhance patient outcomes.
Abstract 6
Title: Corynebacterium sp. in Diabetic Foot Ulcers – A Retrospective, Single-Centre, Observational Descriptive Study from a Tertiary Hospital
Authors: Michael LOCKHART1,2, Laura O’DOHERTY3, David GALLAGHER2,3
Affiliations:
1) Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals
2) School of Medicine, University of Galway, Galway, Ireland
3) Department of Infectious Diseases, Galway University Hospitals, Galway, Ireland
Introduction: Corynebacterium sp. has long been understood to be a colonising bacteria in diabetic foot infections. We present a retrospective study to describe the experience of Corynebacterium sp. in a cohort of inpatients with active diabetic foot disease (DFD) in a tertiary referral centre.
Methods: We included all inpatients attending our tertiary referral centre who were admitted with a DFD-related presenting complaint and who were seen on the multidisciplinary diabetic foot round (DFR) between September 2023 and March 2024. The primary outcome of the study was the presence of Corynebacterium sp. growth in superficial or deep tissue cultures. The secondary outcome was correlation of Corynebacterium sp. growth on bone/tissue samples with superficial swab samples.
Results: In total, 62 new patients were reviewed on the DFR in this 6-month period. 2 of these patients had a second admission for a DFD-related presenting complaint within the study period, and so 64 patient episodes were included in the study. Of these patient episodes, 56 had samples sent for culture. 30 (54%) had superficial swabs, 5 (9%) had deep tissue samples and 21 (37%) had bone samples sent as their highest-quality sample. Corynebacterium sp. were cultured on 9 of 56 patient episodes with culture samples sent in the study period (16%). Of these, 8 were detected on bone culture (7 intra-operative samples, 1 bedside sample) and 1 on deep tissue culture; no superficial wound swabs grew Corynebacterium sp. during the study period. None of these positive culture results was consistent with growth from a superficial swab within 3 months of the positive sample.
Conclusions: In this cohort, Corynebacterium sp. were present only in bone or deep tissue samples with no superficial sample correlation. This study adds to the growing understanding of this microorganism's importance in diabetic foot infections. If we wish to adequately target potentially pathogenic microorganisms like Corynebacterium sp., we must push for deep tissue samples to be sent in all of our patients with diabetic foot infections.
Abstract 7
Title: A Real-World, Single-Centre Experience of Vascular Specialist Input on the Multidisciplinary Diabetic Foot Round in a Tertiary Hospital – an Observational Study
Authors: LOCKHART Michael1,6, YOUNG Ellen2, KELLY Colm2, CAHILL Conor2, O’SHEA Katie3, REDDINGTON Lisa1, PANDIAN Arunabai4, JOYCE Doireann5, CREMEN Sinead5, TUBASSAM Muhammad5,6, O’LOUGHLIN Aonghus1,6, GALLAGHER David4,6, DINNEEN Seán1,6
Affiliations:
1) Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
2) Clinical Podiatry Department, Galway University Hospitals, Galway, Ireland
3) Tissue Viability Nurse Specialist, Galway University Hospitals, Galway, Ireland
4) Department of Infectious Diseases, Galway University Hospitals, Galway, Ireland
5) Department of Vascular Surgery, Galway University Hospitals, Galway
6) School of Medicine, University of Galway, Galway, Ireland
Introduction: Diabetic Foot Disease (DFD) is a common complication of diabetes associated with significant morbidity and mortality. Multidisciplinary Foot Team (MDFT) input is a cornerstone of national and international best-practice guidelines for the management of active DFD. This study describes the experience of an inpatient DFD ward round (DFR) in a tertiary hospital over two three-month periods, one year apart. One cohort had direct input from vascular surgical specialists at the time of the DFR, and one cohort did not.
Methods: We prospectively captured data from the DFR in our hospital over two three-month periods: September to December 2022 and September to December 2023. This weekly ward round reviews inpatients with active DFD on a consults basis and is attended by Endocrinology, Infectious Diseases and Vascular Surgery specialists, podiatrists, tissue viability, infectious diseases and diabetes nurse specialists. During the 2022 time period, no vascular surgical specialists were available to be in attendance at the time of the round. The primary outcome measure was rate of amputation. Secondary measures included length of stay, microbiology and imaging investigations, vascular studies, HbA1c, diabetes classification and prior history of amputation and ulceration. Categorical data were compared using Chi-squared test. Numerical data were compared using Mann-Whitney U test.
Results: Over the study period, 24 individual patients who were admitted with a primary diabetic foot-related presenting complaint were reviewed on the DFR between September and December 2022. Between September and December 2023, there were 23 such reviews. There was a statistically significant increase in amputation rates between 2022 and 2023 [X2 (1, N = 47) = 4.04, p = 0.044]. There were 3 minor and 2 major amputations in the 2022 period (1 patient underwent both a minor and major amputation during the admission). There were 10 minor and 0 major amputations in the 2023 period. Average length of stay was not significantly different between the two groups (30 days vs 29 days, p = 0.889).
Conclusions: The presence of vascular surgical input on the DFR was associated with a significantly higher rate of minor amputations. We believe this change reflects prompt vascular input leading to timely definitive management. It is possible that patients in the 2022 cohort left the hospital prior to MDFT discussion with vascular surgery input, which could potentially have led to a delay in definitive treatment. This study highlights the powerful role that a comprehensive MDFT assessment plays in altering patient outcomes.
Abstract 8
Title: A Decade of OPAT for Diabetic foot infection in a large urban teaching hospital
Authors: Pauline WILSON, Maura REYNOLDS, Corey GILLEN, Elaine MORRISON, Susan CLARKE & Ceppi MERRY
Affiliations: St. James’s Hospital Diabetic Foot Team
Introduction: The use of intravenous antibiotics is recommended for the management of moderate to severe DFI. In the absence of surgical resection extended courses of intravenous antibiotics are often used thus increasing patients length of hospital stay. Outpatient antibiotic therapy (OPAT) allows for such services to be delivered to stable patients at home thus reducing the burden on inpatient services.
Methods: Data was collected between 2013 and 2023 and retrospectively reviewed for length of treatments; number of patients with DFI; bed days saved and overall cost savings.
Results: The results show that using OPAT in conjunction with other standards of care was useful in admission avoidance for DFI during the period. The number of bed days saved and costs are presented in the table below. The average cost saving is € 21362 per patient. No complications were observed in any of the participants related to the OPAT treatment.
Conclusion: The use of OPAT for stable moderate and severe infections is an effective admission avoidance strategy in those with DFI and yields significant cost savings.
Abstract 9
Title: What is the clinical utility of SEM measurement in the discernment of DFU
Authors: Pauline WILSON1,2, Declan PATTON2, Aglecia BUDRI2, Tom O’CONNOR2, Fiona BOLAND, Niamh PHELAN1 And Zena MOORE2
Affiliations:
1) St. James’s Hospital Dublin
2) School of Nursing and Midwifery RCSI
Introduction: Previous research has shown that the measurement of sub-epidermal moisture (SEM) identifies increased risk of PU by early identification of cellular oedema. This study aimed to assess the effectiveness of SEM in the early identification of DFU.
Methods: In this prospective observational study SEM measurements using the SEM ScannerTM were taken from 216 individuals attending outpatient diabetes clinics in a large urban teaching hospital in Ireland. Measurements were taken at foot sites associated with ulceration-plantar hallux, first metatarsophalangeal joint, fifth metatarsophalangeal joint and the heel. Those participants identified at increased risk at baseline had an additional 2 assessments within the next 7 days.
Results: Of the 216 participants, 22% (n=47) were identified as high risk using standard assessment, 70% (n=152) had suboptimal diabetes control, 23% (n=49) had loss of protective sensation and 2% (n=5) had non-palpable pulses. Elevated SEM was identified in 32% (n=69). There was agreement between SEM and standard risk assessment tools in 62% (n=42) of these cases. Of the 13% (n=9) of the high risk participants who developed a visual DFU during the 7 day period, 88% (n= 8) had an elevated SEM prior to ulceration. Abnormal SEM was correlated with DFU and this correlation was statistically significant. SEM readings had a high sensitivity and specificity.
Conclusion: Whilst tentative, initial analysis from this study shows that similar to early stage PU identification, that SEM measurement can also result in the earlier detection of DFU through identifying cellular oedema and local inflammation.
Abstract 10
Title: Multidisciplinary diabetic foot clinic initiative in a high-volume Irish tertiary referral centre, A Quality improvement project
Authors: ELKADY R.1, DAVENPORT K.2, GALLAGHER T.3, O’DONOGHUE A3, KELLEGHER E3, CORNALLY D.1, HETMANAU D.1, WARD P.4, CALLANAN I.5 , HURLEY H.1, CANAVAN R.6, WALSH S.7, DOWDALL J.1, FEENEY E.2, BARRY M.1.
Affiliations:
1) Vascular surgery department, St. Vincent’s University Hospital, Dublin, Ireland.
2) Infectious disease department, St. Vincent’s University Hospital, Dublin, Ireland.
3) Podiatry department, St. Vincent’s University Hospital, Dublin, Ireland.
4) Ability Maters, Orthotics, Dublin, Ireland.
5) Clinical Audit department, St. Vincent’s University Hospital, Dublin, Ireland
6) Endocrinology department, St. Vincent’s Hospital Group, Dublin, Ireland.
7) Lambe Institute for Translational Research, Discipline of Surgery, University of Galway, Galway, Ireland.
Introduction: Diabetic foot disease is a complex multifactorial pathology that constitutes a large burden for both patients and physicians. It’s complications also places a substantial burden on the patient’s family. (1) The current set up in SVUH is very encouraging to set the foundation for a multidisciplinary team (MDT) input for this challenging cohort of patients.
Methods: We aimed to set up an MDT diabetic foot clinic (DFC) utilizing the variety of disciplines available in our center. A formal email that invited the potential teams and a meeting to discuss the options available was convened. The project was met with great interest from the different team representatives. The Outpatient Antimicrobial Therapy (OPAT) clinic was chosen to incorporate the MDT DFC. This clinic is already set up for wound review and has some members from the teams needed to set up the clinic, so that with some minor adjustments it can encompass the full MDT foot care service.
Results: From January 2023 to July 2023, 26 clinic sessions were held. 31 patients were reviewed in the MDT DFC. 9 patients achieved complete wound healing (29%). Sixteen patients were changed to a chronic wound without a surgical intervention (52%). Three patients required minor amputation (10%). Nine patients had significant peripheral arterial disease (29%) (Mean absolute toe pressure of 36 mmHg) out of which, 6 had reconstructible options and underwent balloon angioplasty. New endocrinology referrals were sent for 6 patients (19%). Referrals were made to treating endocrinologists if the patients were found to have a poor glycemic control. Twelve new referrals were made for custom made footwear (39%).
Conclusion: We believe that as an initiative, the MDT DFC is a project that is showing great potential in a large volume centre as SVUH. This would encourage to expand and formalize the project.