charles sturt universitycsusap.csu.edu.au/~hjelinek/discri documents/discri st… · web viewif...

Charles Sturt UniversityStudent Diabetes Complications

Screening Initiative

STUDENT INFORMATION

1

Academic Educators:

AProf Paul Tinley; BSc(Hons), PhDMs Harriet Farquhar; NDipPod, BSc, GradCertDr Megan Smith; BAppSc(Physiotherapy), PhD

Academic and Clinical Advisors:

Prof Patrick Ball; BSc, MSc, PhDDr Alan Luckie; MBChB, FRANZCODr Doug Oxbrow; MBBSDr Jianxiong Wang; BSc, MEd, PhDDr Lexin Wang; BMEd, MMed, PhD, ASCEPTMs Clare Wilding; BAppSc OT, MAppScDr Jenny Wilkinson; BSc(Hons), GradDipFET, PhD

Technical Support:

Ms Cherryl Kolbe; ADLT, DDIAEMs Bev deJong; BSc(Hons)

Project Coordinator:

Dr Herbert Jelinek; BSc(Hons); Grad Dip(Neurosci); GradCertTeach&Learn; PhD

2

Contents

Page

Background to Project 4

Diabetes and Cardiovascular Disease: Relationship to this Project 4Health impacts of diabetes and its complications

5Diabetic retinopathy

5Cardiovascular disease

5Foot complications

6

Quality of life and health care 7Impact of early intervention on quality of life for people with diabetes complications

7

Assessment intervention strategies in rural/regional areas 8Strategies in assessment of complications of diabetes 9

Eye Screening9

Heart assessment9

Foot assessment10

Research and student education 11References 12Standard Operating Procedures (SOP) 15

Venipuncture Technique Using the Multisample Vacutainer Sytem16

Blood Collection by Finger Prick19

Manual Blood Pressure Measurement20

Follow-up procedures when an abnormal test or emergency response occurs22

Body Mass Index (BMI)24

Ankle Brachial Index (ABPI)25

Foot Health Assessment27

Use of Tiptherm ™29

Autonomic Nervous System Function Tests (Ewing Battery)30

3-lead Electrocardiogram (ECG)32

12-lead Electrocardiogram (ECG)34

Urine testing using Combur-Test 39Retinal Photography using the Canon CR-DGi Non-Mydreatic retinal camera 40

3

Emergency Procedures 45Cedar floor plan 46Emergency response 47Hypoglycaemia emergency response 48Fainting emergency response 49

Student screening documents 50

Diabetes complications screening forms 51

Diabetes screening – Participant phone recall instructions65

Appendices 66

4

Background to the Project

Diabetes mellitus is a growing health care problem in Australia with over two million Australians expected to

be diagnosed with diabetes by 2010. This equates to roughly 10% of the population and increases the work-

load on general practitioners and allied health professionals.

Cardiovascular associated mortality accounts for 38% of all deaths. 16.4% of Australians currently have

CVD. Independent of diabetes, CVD will affect one in four Australians by 2051. CVD associated mortality

accounts for 38% of all deaths. 16.4% of Australians currently have CVD.

Of immediate concern is also the recognition that a constellation of symptoms, the metabolic syndrome

constitutes an increased risk of diabetes and cardiovascular disease.

Some relevant screening and intervention possibilities are listed below:

Identification of CV risk factors such as hypertension, obesity, smoking and alcohol as well as age, family

history and blood sugar levels

Diabetes and diabetes risk factor – increased blood sugar levels, age, ethnic background, family history,

gestational diabetes and ovarian cancer

Lifestyle counselling - Smoking abstinence, exercise, weight control, blood pressure control and diet as

well as medication review.

Medical imaging is also relevant to this as it can be used to identify asymptomatic cardiovascular disease

and confirm 12-lead or 3-lead ECG assessment.

Pharmacy medication review

Nutrition counselling

Nursing reviews

Occupational Therapy – quality of life and activities of daily living

Physiotherapy - exercise

Diabetes and Cardiovascular Disease: Relationship to this Project

Given the increased incidence of diabetes nationally and internationally over the last 2 decades, a vast

amount of literature in the area has been generated. The review below addresses the literature sets relating to

this project namely: health impacts of diabetes and its complications; assessment intervention strategies in

rural/regional areas; and, the experience of people and their families living with diabetes in rural regional

communities.

5

Health impacts of diabetes and its complications

The onset of Type 2 diabetes has been reported to occur 9 to 12 years before clinical diagnosis and thus

complications of diabetes are often severe and when identified and often the first indication of the presence of

diabetes.[1] The early detection of undiagnosed diabetes is a key intervention point in reducing the associated

personal and community burden. Both national and state governments acknowledge the disadvantage faced

by rural people in availing themselves of all aspects of diabetes management, from screening to regular

assessment, education and health care.[2]

Regular screening for complications of diabetes including vision, heart and foot complications provides an

opportunity to identify more of the people with unidentified diabetes and provide early appropriate health care

to these and people with eye, heart and foot complications. Extrapolation from data obtained from eye health

initiatives, indicates that interventions that relieve or prevent complications associated with diabetes are highly

cost effective.[3]

Diabetic retinopathy

Retinopathy is asymptomatic in the early stage. Up to 20% of people with non-insulin dependent diabetes

mellitus (NIDDM) have retinopathy at the time of diagnosis. Treatment to prevent blindness is very effective

provided the retinopathy is detected early.[4, 5] However, of people who know that they have diabetes, only

35% have regular eye checks in Victoria.[3] This figure is somewhat higher in N.S.W. at 55%. [6] Several

programs are being discussed nationally to improve the screening percentages for diabetic retinopathy with

national figures aimed at 80%.[7] Working towards an increased awareness in the community is one part of the

solution, the other is to incorporate additional models for diabetic retinopathy screening that complement

currently existing eye-care service.[3, 8] Diabetic retinopathy (DR) could be significantly reduced by simplifying

the procedure used to diagnose the condition and ensuring that early eye examinations become routine for

diabetic patients, according to an advisory group convened by JDRF.[9] Rural screening is difficult because of

health care barriers such as geographical isolation, the cost of visits to specialists and the lack of

ophthalmologists available. [10-12]

Cardiovascular disease

Cardiovascular disease, affecting the larger blood vessels is a major complication of diabetes. People with

diabetes are two to four times more likely to develop cardiovascular disease and their prognosis is not as

good. Diseases of the circulatory system such as coronary heart disease and stroke were listed as the

underlying cause of death in 55.7% of deaths in 2000 where diabetes was an associated cause. [13] In addition

some form of nervous system damage that affects the function of the heart and blood vessels, occurs in up to

60-70% of people with diabetes.[14] Regular screening and early recognition of nervous system damage

affecting cardiac function in people with diabetes allows better treatment intervention and reduces the number

of deaths associated with diabetes related cardiovascular disease.[15]

6

Foot complications

In the Western world diabetic foot problems have been reported as the most common complications of

diabetes. Diabetic foot problems are associated with nerve damage (diabetic neuropathy) and poor circulation

(peripheral vascular disease) in the lower limbs. [16] These factors increase the risk of foot ulcers, infection and

lead ultimately to lower extremity amputation. Among people with diabetes, 19.4% were found to be at risk for

foot ulcers and 2.1% reported absence of limbs. Peripheral neuropathy and peripheral vascular disease were

reported in 24.2% and 12.6% respectively. Regular monitoring of the feet for early signs of diabetic

neuropathy, peripheral vascular disease and foot deformities reduces the risk of serious foot ulcers and

amputation. An important adjunct to reducing the percentage of amputations is to have appropriate

assessment methods for recognising vascular disease.[17, 18]

7

Quality of life and health care

Few studies have assessed the influence of social environment on health, but increasing attention. [19] For

effective health care public health workers involved in diabetes prevention and control in all communities

including ethnic and Aboriginal and Torres Strait Islander communities. Health care professionals need to

listen and engage with people articulating their experiences of health and illness within the social, political,

economic, as well as biological context of their lives. [19] Communities within which public health workers are

now working are often not stable, connected and demographically as well as culturally similar populations

living within a traceable geographical location. This insight becomes especially important for communities with

increased incidence of diabetes and risk behaviour. Assessing individuals in diverse communities effectively

increases the quality of life of individuals and the overall health of the community.

Impact of early intervention on quality of life for people with diabetes complications

Quality of life is a term used in a number of disciplines, and definitions and conceptualizations vary from utility

of health states to life satisfaction and from possession of socially desirable characteristics to positive affect.

In order to address the quality of life issues associated with the disproportionately high rates of diabetes and

poor medical service provision in rural and remote regions of Australia, alternative models of primary health

care have to be considered.[5] There is considerable variation in diabetes management in different primary

care settings even in the same hospital.[20] The main difference was in consistent and appropriate screening

for risk factors and complications in people attending the clinics. Screening for diabetes has the potential to be

an effective intervention, especially if patients have intensive treatment of their newly diagnosed diabetes. In a

recent study the effectiveness of a home-based cardiac rehabilitation program in improving health outcomes

and rehabilitation access for special-needs patients has shown that significant positive changes for measures

of quality of life, knowledge of angina, and exercise tolerance. Additionally, higher levels of participation and

completion were also noted.[21]

Outcomes research is used increasingly for assessing the health outcome benefits of new therapeutic

programs and interventions. Therefore measures of quality of life have to consider gains in health outcomes

and programs in diabetes.[22] To achieve uniform care for all people with diabetes a on-stop assessment unit

that makes the primary health care team accessible to all, provides effective management of risks for diabetic

patients by advice, education, and therapeutic modification is the starting point to address quality of life issues

associated with diabetes.

8

Assessment intervention strategies in rural/regional areas

Complications associated with diabetes remain often undetected for quite some time especially in rural

regions, but in a twist are often health problems that alert health care providers to the presence of diabetes. [23]

Government agencies as well as specialist groups such as the Australian Diabetes Association advocate that

routine screening of persons at risk of diabetes allows earlier detection of the disease and better health

outcomes. Diabetes is a disease that is amenable to screening as the disease is common, serious, and has a

long asymptomatic phase. In addition acceptable tests exist for identification of the disease and treatment

must matter during the asymptomatic phase (World Health Organisation Guidelines). The Australian Diabetes

Association recommends screening after 45 years of age and to be repeated every 3 years. However if

hypertension, cardiovascular disease, increased lipid levels, physical inactivity, gestational diabetes and

obesity are present, earlier and more frequent screening is required. This is also the case if the person is of

pacific island or indigenous origin. At a recent primary telemedicine conference, Balsbaugh has reported that

universal screening is feasible and cost effective, it delays complications and younger patients have a longer

time to benefit from early identification.[24]

9

Strategies in assessment of complications of diabetes

Vision loss, cardiovascular disease and foot amputations are the most often occurring outcomes of diabetes.

Damage to the eye associated with diabetes (diabetic retinopathy) is the commonest cause of blindness in the

working age population in developed countries. Yet 98% of people with vision loss can be treated effectively

provided the pathology is detected early. Cardiovascular complications associated with diabetes and on it’s

own is the commonest cause of death in the population.[23] Early detection of blood vessel changes associated

with retinopathy, cardiovascular disease and foot complications is important for timely treatment to prevent or

delay the occurrence of these complications and improve the quality of life for individuals with diabetes. [11, 25]

Regular health screening that includes eye, heart and foot assessment has the potential to reduce the high

costs on the health care system and reduces the disparity in health care between rural and urban

communities by providing timely feedback to those at risk.[26]

Eye Screening

Automating the assessment changes in the retina can be carried out using mathematical techniques such as

developed by our team and others.[27-29] These mathematical techniques can be applied to the estimation of

blood vessel diameter changes and quantify the appearance of microaneurysms and haemorrhages as well

as new vessel growth in the advanced stages of diabetes. Identification of the number of microaneurysms is

positively correlated with diabetes. [30, 31] Of interest has been the correlation between blood vessel diameter

changes in the eye that is not only associated with diabetes but is also an early indicator for cardiovascular

disease and stroke.[11]

Heart assessment

Electrocardiology is still regarded as the most commonly used procedure for the assessment of cardiac

function and identification of heart disease, utilized by numerous health care practitioners including community

health nurses. We have investigated the efficacy of 3-lead ECG assessment in community health with good

outcomes suggesting a cost benefit and improvement in health care. [32] We have also developed an ECG

classification protocol for community screening using 12-lead ECG that optimizes referrals to general practice

by reducing the number incorrectly referred through community screening.[33]

ECG interpretation, although mostly automated is usually carried out by a specialist, be that a cardiac nurse,

general practitioner or cardiologist. The Charles Sturt Diabetes Complications Screening Programme has

investigated the possibility of primary health care providers assessing heart function using an automated ECG

assessment tool that differs to the traditional method by evaluating the heart rate variability obtained using a

3-lead recording. Our recording and interpretation tool adds two important features to heart assessment. 1) it

allows primary health care providers to record ECGs (placing 3-lead ECGs is less complex compared to

placing a 12-lead ECG and less invasive in community health settings) and 2) identify asymptomatic changes

in heart function associated with diabetes.[34] Our method is based on observations that many cardiac

anomalies, including diabetic autonomic neuropathy, change the heart rate variability before any overt ECG

anomalies are detectable.[35, 36] However, whereas cardiologists with current methods can not pick up

preclinical cardiac anomalies our method has the potential to do this.[37] In addition relatively short 3-lead ECG

10

recordings can be used in evidence based health care and accountability for primary health care practice with

lead II recordings showing a similar efficacy in identifying at risk individuals as 12-lead ECG recordings. [38]

Foot assessment

Regular monitoring of the feet for early signs of diabetic neuropathy, peripheral vascular disease and foot

deformities are essential.[13] Measurement of sensory impairment using monofilament tests to identify

peripheral neuropathy, ankle-brachial index to identify peripheral vascular disease and observation of skin

lesions and range of motion changes at the ankles are direct and simple yet reduce the risk of serious foot

ulcers and amputation.[39] These measures provide an indicator for further assessment if required by

specialists using more sophisticated assessment procedures.[40] Charles Sturt University has been assessing

foot health as part of its Allied Health Clinic and this knowledge can be incorporated into the mobile

assessment unit. [17]

11

Research and student educationTo address rurality and the associated health care barriers as well as experiential learning opportunities and

research, Dr Herbert Jelinek in collaboration with AProf Tinley and Mr Warner as well as other academics

has established a diabetes complications screening programme. This programme aims to provide health

information and health education to participants but also adds to our knowledge of rural health and provides

an opportunity for students for experiential learning.

12

References

13

Standard Operating Procedures (SOP)

14

Standard Operating Procedure (SOP)

Venipuncture Technique Using the Multisample Vacutainer System

SOP No:....................................Version: 1.0..................................Date: 3 April 2006

Dept/Div/School: School of Community Health

Supervisor/Manager: Cherryl Kolbe

Other Contacts: Bev deJong

RISKS/HAZARDS: Venipuncture is a procedure where there is this potential for direct contact between the skin (usually finger or thumb) of the blood collector and a sharp surgical instrument such as a needle.

It is essential that realistic assessments are made of the likelihood and severity of any injuries arising from venipuncture. Both physical and psychological risks must be assessed.

a) Ethical issues Subjects should not feel they have been abused as a result of

venipuncture. This could include excessive pain or discomfort and embarrassment or humiliation.

b) Physical Risks Patient experiencing nausea, light-headedness, dizziness,

fainting Needle stick injury

PROTECTIVE & EMERGENCY EQUIPMENT

Disposable gloves Gown & protective eyewear if appropriate There must be a First Aid / CPR trained person available in case of an

emergency. Emergency procedures must be in place – refer to Physiology

Laboratory “Guidelines for Medical Emergencies”

CONTROL MEASURES Inform the patient of the possibility of discomfort or embarrassment. Have the patient lying down with the head slightly raised on a pillow. Have available the following first aid measures:

first aid kit first aid officer emergency phone numbers near the most accessible phone

Only suitably qualified and experienced staff may perform venipuncture

Those performing venipuncture must comply with the following Physiology Laboratory Guidelines:

Venipuncture Medical Emergencies Infection Control

15

EQUIPMENT................... Clinically clean table outside laboratory area Tourniquet Appropriate vacutainer tubes (per person), labelled.

2 x 7ml EDTA tubes (purple top) 1 x 10ml tube with 100L preservative heparin 1 x 7ml plain tube (orange top)

5ml plain tubes for Hcy (one per person) 21g multiple sample needle or 21g winged infusion device Plastic sleeve to hold specimen tubes Isopropyl alcohol (70%) swabs Cotton wool balls Adhesive plaster or bandaids Disposable gloves Laboratory coat Sharps container Eye protection if deemed necessary by risk assessment

JOB STEPS Ensure all equipment is within easy reach and accessible. Select tube or tubes appropriate for samples desired. (see note at

end). Label the tubes. Tubes that contain additives should be gently tapped to dislodge any

additive, which may be trapped around the stopper. Open needle package, but do not remove needle shield. Thread

needle onto holder. Select site for venipuncture. Put on the disposable gloves Apply tourniquet. Prepare venipuncture site with an appropriate

antiseptic. (isopropyl alcohol swab) DO NOT PALPATATE VENIPUNCTURE SITE AFTER CLEANSING. Place patient's arm in a downward position. Remove needle shield. Insert the needle into the vein ensuring the bevel of the needle is

uppermost.

Push tube onto holder, puncturing the diaphragm of the stopper.

If no blood flows into tube or ceases to flow before an adequate sample is collected, the following steps are suggested to complete satisfactory collection:

Change the position of the needle. Move it forward (it may not be in the lumen)

16

or move it backward (it may have penetrated too far)

Adjust the angle (the bevel may be against the vein wall)

When first tube is full and blood flow ceases, remove it from the holder.

While each successive tube is filling, invert the previous tube containing additives 8-10 times. DO NOT SHAKE. Vigorous mixing can cause haemolysis.

Release the tourniquet after inserting the last tube. When the last tube has been removed (gold to tube), gently cover the needle tip with a cotton wool ball and remove the needle from the vein. Ask the patient to apply pressure to the puncture site until bleeding stops.

After the venipuncture, dispose of the holder and the needle into an approved sharps container.

Transfer the contents of the gold top vacutainer tube to the tube containing the preservative free heparin and invert gently to mix.

Check the patient’s arm and cover the site with a bandaid. Do not allow the patient to leave until the bleeding has stopped.

If breakage of a tube containing a collected sample should occur, avoid all contact with the exposed skin and follow proper procedures for the clean up and disposal of infectious waste.

WHEN YOU FINISH Discard gloves and wash hands.

Appendix A: Sample tubes for collection

17


Blood Collection by Finger Prick

SOP No: ...................................….Version: ………1.0……………..Date: March 2001

Laboratory Manager: Cherryl Kolbe Ext. 16995

Other Contacts: Bev deJong Technical Officer Ext. 16995

HAZARDS: Lancet stick

PROTECTIVE EQUIPMENT &

Disposable gloves Face mask and/or protective eye if required

EMERGENCY First aid kit availableEQUIPMENT

BEFORE YOU START Wash hands in warm soapy water Rinse well and dry completely

NEVER.........................

JOB STEPS If using an alcohol wipe, let the finger dry completely before testing

Warming fingers can increase blood flow Prepare the lancet device according to the manufacturers

instructions Put on disposable gloves Prick the finger to obtain the blood sample Cover the wound with a cotton ball held in place by the patient Dispose of the lancet in an approved sharps container Remove the cotton ball and apply a spot band

WHEN YOU FINISH If reading falls outside range recommended by Australian guidelines, the test is repeated the following week under overnight fasting condition

Remove gloves Wash hands in warm soapy water Rinse well and dry completely

Appendix B: Blood glucose level interpretation

18


Manual Blood Pressure Measurement

SOP No: ...................................….Version: ………1.0……………..Date: May 2006



HAZARDS: Over-inflation of the cuff may cause minor discomfort Crease in cuff may cause discomfort and slow blood flow


nil


BEFORE YOU START Wash hands in warm soapy water Rinse well and dry completely Have the participant assume a relaxed supine position for 5

minutes prior to taking a resting BP measurement. The arm should be at the level of the heart with the palm up for Brachial measurement , legs should be in a near horizontal position knees slightly flexed for Ankle measurement

Observe and question participant for contraindications for taking BP (i.e. lymphedema) and signs and symptoms of BP alterations: high (headache, flushing of face, nosebleed, fatigue in older adults) and low BP (dizziness; mental confusion; restlessness; pale, dusky or cyanotic skin; cool, mottled skin over extremities)

NEVER.........................

JOB STEPS Explain the procedure to the participant Select appropriately sized cuff Expose the extremity fully by removing any constrictive

clothing Palpate the brachial artery (arm) or posterior tibial (leg) Position the cuff 2.5cm above the site of pulsation Apply the cuff above the artery by centring the arrows

marked on cuff over the artery Wrap the fully deflated cuff evenly and snugly around the

extremity If the participant’s baseline BP is unknown, estimate the

systolic pressure by palpating the artery distal to the cuff with the fingertips of one hand while inflating the cuff rapidly to a pressure 20mmHg above the point at which pulse disappears. Slowly deflate the cuff and note the point when the pulse reappears. Deflate cuff fully and wait 30 sec.

Place the stethoscope earpieces in ears and ensure sounds are clear. Place the bell or diaphragm chest-piece of the stethoscope over the artery without touching any clothing.

19

Close the valve and rapidly inflate to 20mmHg above the systolic pressure

Slowly release pressure bulb valve and note the point when the first clear sound is heard.

Continue to deflate the cuff, noting the point at which the sound disappears

Release the remaining air quickly

WHEN YOU FINISH Record your results

If results fall outside the suggested range as specified by the Australian guidelines, the participant is requested to return the following week for a repeat test

Wash hands

20

Standard Operating Procedure(SOP)

Follow-up procedures when an abnormal test or emergency response occurs

SOP No: ...................................….Version: ………1.0……………..Date: July 2006



HAZARDS: Emotional trauma for participants receiving abnormal test results

Emotional trauma for students involved in obtaining abnormal test results for participants

Emotional trauma for students involved in accident or emergency event


nil

EMERGENCY nilEQUIPMENT

BEFORE YOU START Ensure that clinical educator is available and programme manager is informed before providing feedback to participant

Collect all relevant information such as current and past results if available for participant

For participant and student ensure appropriate environment is available and the feedback can take place in confidentiality

Ensure that relevant phone numbers for student council, ambulance and other health service providers is available

NEVER......................... Not attend to a participant and provide appropriate feedback if abnormal test result is recorded

Not attend to a student who conveyed a negative test result or involved in accident or emergency event

JOB STEPS FOR PARTICIPANTS Explain the procedure to the participant Relate the findings in the context of current health practice

and in context of participants overall clinical history Ensure that participant understands meaning of abnormal

result and the action that is advised by clinical educator Assess psychological profile of participant and use clinical

judgement to provide appropriate feedback and council Ensure that participant has support at home, if referral is

not immediate Ensure if necessary that a covering letter for the general

practitioner or hospital is provided to participant if required Determine whether participant would like to have support if

presenting alone if the participant is required to seek advise immediately from GP or hospital

FOR STUDENTS Move student to comfortable environment away from

incident Obtain necessary information of incident. This may be

recording abnormal result or accident such as a fall or emergency situation such as heart attack, hypoglycaemic

21

event or fainting Review students psychological profile Provide appropriate council and determine whether further

intervention by student counselling office is required If an emergency event occurred and most students have

experienced this , a group debriefing session is also instigated

WHEN YOU FINISH Record outcomes

Ensure that incident reports have been filled out if emergency event occurred

22


Body Mass Index (BMI)




A measure of body weight relative to height. BMI can be used to determine if people are at a healthy weight, overweight, or obese.HAZARDS: nil


nil



NEVER.........................

JOB STEPS Greet the participant & explain what you are going to do Ask the participant to remove their shoes and any heavy items

from their pockets Record weight in kg using bathroom scales Record height in meters using the stature meter Record waist circumference in cms - do not approach the

participant from the front

WHEN YOU FINISH Calculate Body Mass Index (BMI) as follows:

Weight (kg) _________

Height2 (m)

Appendix C: What is Waist Circumference?

23


Ankle Brachial Index (ABPI)

SOP No: ...................................….Version: ………1.0……………..Date: June 2006



HAZARDS: Stepping down from plinth


nil



NEVER.........................

JOB STEPS Doppler

Technique

Automated digital Blood Pressure

Measure highest systolic reading in both arms Record first Doppler sound as cuff is deflated Record at the radial pulse

Measure systolic readings in both legs Cuff applied to calf Record first Doppler sound as cuff is deflated Use Doppler ultrasound device Record dorsalis pedis (DP) pressure Record posterior tibial (PT) pressure Use PT for each leg when calculating ABPI.

Apply digital cuff of correct size and record brachial BP for each arm

Apply cuff to ankle (leg slightly flexed at knee) ensuring that the cuff lies firmly and flat against the skin, ensure tubing is not bent and that the arrow is aligned with the posterior tibial artery. Record BP for each legA cushion may be used to support the lower leg

WHEN YOU FINISH Calculations Ratio of each ankle to brachial systolic blood pressure Divide each ankle systolic pressure by corresponding systolic

brachial pressure Interpretation Ankle-Brachial ratio > 1.3: Possible calcification of blood vesselAnkle-Brachial ratio >0.95: 1.1. Normal Ankle-Brachial ratio <0.95: Peripheral Vascular Disease Ankle-Brachial ratio <0.6: Intermittent Claudication Ankle-Brachial ratio <0.5: Multi-level disease Ankle-Brachial ratio <0.26: Resting ischemic pain Ankle-Brachial ratio <0.2: Gangrenous extremity

24

http://www.fpnotebook.com/SUR3.htm


False Negative Test: Diabetes Mellitus Vessels in diabetics are poorly compressible Results in falsely elevated ankle pressure

For elevated ankle SBP indicating calcification use the ruler adjustment and measure again.Management Segmental Arterial Pressure indicated for ratio < 0.9 Consider angiography or Magnetic resonance angiography

If test result falls outside range specified by Australian guidelines the test is repeated the following week

25


http://www.fpnotebook.com/END11.htm


Foot Health Assessment

SOP No: ...................................….Version: ………1.0……………..Date: June 2006

Laboratory Manager: Cherryl Kolbe Ext. 16995Other Contacts: Bev deJong Technical Officer Ext. 16858

HAZARDS: Inadvertently being kicked with hyperactive knee reflex


Disposable gloves

EMERGENCY nilEQUIPMENT

BEFORE YOU START cleanse equipment with alcohol wipes

NEVER.........................

JOB STEPS

Monofilament

Vibration sensation

Seat client comfortably in reclining plinth with leg in horizontal position

Explain procedure to client Using the palm of the hand demonstrate the monofilament

instrument Ask the client to close their eyes and indicate when they feel

monofilament pressure on their feet –indicating yes/no and approximate positionPerform the test at random intervals randomly changing between feet and areaRecord results on sheet supplied

Demonstrate vibration tuning fork on the styloid process of the radius just proximal to the thumb

Start vibration and place instrument on base of first metatarsal of foot and ask client to indicate when vibration ceases. Note level of indicator triangle. >6 is regarded as normal

If abnormal vibration sensation is experienced repeat test upon the medial malleolus of the tibia; then again at the medial epicondyle of the femur.

Repeat tests on other limb Record results

Ask client to hang legs over side of plinthKnee Reflex.

Palpate patella tendon Test knee reflex by gentle but firm hit to patella tendon. Be

sure to position yourself so as to avoid being kicked.

26

Reflexes

Muscle strength

If no response reflex can be enhanced by asking client to perform a Jendrassik’s manoeuvre ( hook the flexed fingers of the two hands together and forcibly try to pull them apart) observe level of vigour of knee extension.

Ankle Reflex. Ask client to stand with one knee resting on a chair Test ankle reflex by gentle but firm hit to the Achilles tendon,

observe level of plantar (downward) movement.

Muscle Testing. Test muscle strength by feeling resistance as client presses

against your hands Place hands on lateral surface of lower legs and ask client to

press out. Place hands on dorsal surface of lower legs and ask client to

lift legs up. Place hands on medial surface of lower legs and ask client to

adduct legs Place hands on ventral surface of feet and ask client to extend

feet down Record results

WHEN YOU FINISH Wash hands, cleanse lower region of plinth

27


Use of Tiptherm ™

SOP No: ...................................….Version: ……………………..Date: 28 June 2006…………..

Laboratory Manager: C. Kolbe Ext. 16995

Other Contacts: B. de Jong Technical Officer 16885

HAZARDS: No known hazards


Nil



NEVER.........................

JOB STEPS

Hold the tip therm device against the skin on each foot in 5

different places

Ask the participant to indicate whether it is hot or cold.

Record the results

WHEN YOU FINISH Wash hands in warm soapy water Rinse well and dry completely

28

(SOP)

Autonomic Nervous System Function Tests (Ewing Battery)




HAZARDS Over-inflation of the cuff may cause minor discomfort Irritation from electrodes when ECG recording

Contraindications: Patients with proliferative retinopathy should not perform the

Valsalva manoeuvre because of the risk of retinal haemorrhage. Atrial fibrillation (tests uninterpretable, except postural hypotension

and handgrip tests).


BEFORE YOU START Wash hands in warm soapy water

Rinse well and dry completely

EQUIPMENT NEEDED Use a standard sphygmomanometer and cuff of appropriate size Dynamometer Macintosh computer, electrode leads, etc Disposable mouthpieces Balloons Nose clip

JOB STEPS

1. Blood pressure response to standing

2. Blood pressure response to sustained handgrip

Have the participant lying down for 3-5 minutes Position the cuff and place stethoscope over brachial artery Measure the blood pressure (BP) twice Ask the participant to stand up Palpate radial artery Take systolic BP immediately upon standing Measure systole/diastole using stethoscope 1 minute post standing Measure again at 3 minutes post standing

Explain the dynamometer and determine maximum hand grip of the dominant arm

Position the BP cuff on the non-dominant arm Measure BP at rest Ask the participant to squeeze the dynamometer (30% maximum

voluntary contraction) Record time and BP at 1 minute intervals up to 5 minutes Note: If the participant cannot hold for the full 5 minutes allow them

to release their grip and record this on the sheet. Measure of response: This is the difference between the resting

diastolic BP and maximal diastolic BP

29

3. Heart rate deep breathing

4. Heart rate response to standing up

5. Heart rate response to lying

6. Valsalva manoeuvre

Attach electrode leads as per 3 lead ECG SOP Allow the participant to rest seated quietly for 3 minutes Start ECG at beginning of first cycle and continue throughout test

insert marker (double clicking start button) to indicate phases Record heart rate whilst performing 5 deep breathing cycles 5

sec deep inspiration and 5 second deep expiration.

Note: All participants are to have a practice session before recording commences. The maximum and minium heart rate for each breathing cycle is measured and the mean of three successive breathing cycles is taken to give the maximum-minimum heart rate.

Measure heart rate as standing from lying position. Take 30:15 interval.

Measure heart rate as lying from standing position. Take 30:15 interval.

Attach Pulse oximeter and check O2 saturation Attach electrode leads as per 3 lead ECG SOP # If O2 saturation < 95%. HR<60 and/or patient has a CVD or

respiratory condition advise clinical supervisor before continuing with this test.

Participant sits quietly wearing nose clip for 2-3mins Start ECG at beginning of first cycle and continue throughout test

insert marker (double clicking start button) to indicate phases With mouth closed blow hard and deeply towards the pelvis (as for

pushing out a baby or straining) for 15sec. Rest 30 sec and then repeat 2 times for a total of 3 cycles

Note: Heart rate increases normally followed by rebound bradycardia after release. The ratio of the longest RR interval shortly after the manoeuvre to the shortest RR interval during the manoeuvre is measured. The Valsalva ratio is the mean of three successive manoeuvres.

WHEN YOU FINISH Remove the leads from the participant Calculate results

Appendix D: Ewing battery: autonomic nervous system function tests interpretation

30

Standard Operating Procedure

(SOP)

3-lead Electrocardiogram (ECG)

SOP No: .........................................….Version: ………1.0……………..Date: May 2006



HAZARDS: There are no known risks associated with an ECG.


nil


BEFORE YOU START

Wash hands in warm soapy water Rinse well and dry completely Welcome the participant and introduce the staff/student members present

Software Setup

Electrode Attachment

1. Turn on the Macintosh computer2. Double click on the desktop icon ‘Diabetes 3 lead ECG’ to open Chart V3.63. Click on Setup > Channel Settings4. Reduce the number of channels to 15. Click on Bioamp and enter the following settings

Range 1MVNotch ONHigh Pass 0.3 HzLow Pass 50 Hz

6. Click on OK7. Click on OK to close the channel settings window

1. Ask the participant if they have any allergies to bandaids or alcohol wipes.2. To ensure a stable artefact free ECG the skin should be properly prepared. Remove any

hair at the electrode site and clean the area with an alcohol wipe. Allow to dry.3. Attach the electrode leads to the disposable electrodes prior to placement on the

participant.4. The ECG leads should be positioned as shown in the following diagram. Peel the

electrodes off the card and attach to the participant.(R) clavicle neg electrode(L) hip pos electrode(R) hip ground

5. Make stress loops with the leads and attach firmly to the skin with micropore tape. You will be shown how to do this.

31

Recording the ECG

First SegmentStanding to Lying

Second SegmentLying

Third SegmentLying to Standing

New Recording

1. Ask the participant to stand relaxed in front of the bed with their arms to the side and explain to them the series of recordings and what they are expected to do. ie. Remain still and quiet.

2. Click on start and ensure the trace is free of noise. It is essential to have a noise-free recording – if there is noise in the recording check the electrode attachments. This is usually the reason.

3. When satisfied with the trace click on Stop.

1. Click on File > New > Don’t Save. This will open a new recording.2. Click on Start3. Record for 30 secs & then insert a marker by double clicking on Stop (this also restarts

the timer)4. Ask the participant to lie down and continue the recording for another 40 secs.5. Click on Stop.6. Click on File > Save As > and then enter the file name: SL_code name_date eg

SL_KOLC220253_300506

7. Select Format:Chart(win)data which adds the code adichtNote: saves in windows format8. Click on Save9. Click on File > Save As > and then enter the file name: SL_code name_date eg

SL_KOLC220253_30050610. Click on SaveNote: saves in macintosh format

1. Click on File > New 2. Click on Start3. Record for 20 mins. Don’t forget to set your timer.4. Click on Stop5. Click on File > Save As and then enter the file name: 20min_code name_date eg

20min_KOLC220253_300506

6. Select Format:Chart(win)data which adds the code adichtNote: saves in windows format7. Click on Save8. Click on File > Save As and then enter the file name: 20min_code name_date eg

20min_KOLC220253_3005069. Click on SaveNote: saves in macintosh format

1. Click on File > New2. Click on Start3. Record for 30 secs, then insert a marker as before4. Ask the participant to stand (ensure they aren’t light headed on standing)5. Continue the recording for another 40 secs6. Click on Stop.7. Click on File > Save As > and then enter the file name: LS_code name_date eg

LS_KOLC220253_300506

8. Click on Save9. Select Format:Chart(win)data which adds the code adichtNote: saves in windows format10. Click on Save11. Click on File > Save As > and then enter the file name: LS_code name_date eg

LS_KOLC220253_30050612. Click on SaveNote: saves in macintosh format

1. Click on File > New2. Now you are ready for the next participant3. Remove the electrode leads and disposable electrodes from the participant and check

that all the adhesive is removed

32

WHEN YOU FINISH

Wash hands

Now you are ready for the next participant

33


12-lead Electrocardiogram (ECG)

SOP No: .........................................….Version: ………1.0……………..Date: May 2006



HAZARDS: nil


nil


BEFORE YOU START

Wash hands in warm soapy water Rinse well and dry completely Welcome the participant and introduce the staff/student members present

JOB STEPS Give the participant a brief outline of the procedure 12 lead ECG to test the heart describing the electrode placement to them Explain that ECG measures “the electrical wiring” (most people will relate to

pacemaker) of the heart, emphasise that the process does not apply any electrical stimulation.

Enquire if the participant has previously undergone a 12 lead ECG recording Ask the participant if they have a sensitivity to bandaids or adhesive plaster – record on

sheet Ask the participant to remove their undergarments and replace their outer shirt leaving it

untucked and unbuttoned at the front. They may then lie down. Ensure that the area is enclosed for privacy

Note: Students should leave the room while the participant is undressing.

To ensure a stable artefact free ECG the skin should be properly prepared. Using a disposable razor remove any hair at the electrode site and clean the area with an alcohol wipe. Allow to dry.

Ask permission to feel along the ribs prior to electrode placement

Electrode Placement: Apply the precordial electrodes as outlined below:

V1: In the fourth intercostal space at the right sternal border. V2: in the fourth intercostal space at the left sternal border. V3: mid-way between V2 and V4. V4: in the fifth Intercostal space in the mid-clavicular line. V5: in the left anterior axillary line at the level of V4. V6: In the left mid-axillary line at the level of V4.(Directly under the midpoint of the armpit)

34

Note: It is essential to be discrete whilst placing precordial electrodes on women. If practical, leave the breasts covered. Attach the limb leads appropriately to the ankles and wrists. Ask the participant if they are in a comfortable position and require a blanket or a pillow

under their knees if they experience back pain.

Recording ECG

Double click on the CardioPerfect desktop icon to open the program

Enter the word ”admin” as the password and click on

10 Second Recording Click on File > New> Patient The PatientCard window will appear Enter information as shown in the figure below (eg patient code_length of

recording_date) Click OK

Click on > ECG

The New ECG window should appear

35

Click OK The recording window will appear

When the trace has stabilised, click on Turn off the recording device when prompted The recording will automatically be saved

5 Minute Recording Click on File > New> Patient The PatientCard window will appear Enter information as shown in the figure below (eg patient code_length of

recording_date) Click OK

Click on > ECG

36

The New ECG window should appear

Click OK The recording window will appear

When the trace has stabilised, click on Turn off the recording device when prompted The recording will automatically be saved

Remove the electrode leads and disposable electrodes from the participant and check that all the adhesive is removed

WHEN YOU FINISH

Wash hands

Now you are ready for the next participant

Appendix E: CSU 12-lead ECG classification table

37


Urine Testing using Combur-Test D

SOP No: ...................................….Version: ………1.0……………..Date: July 2006

Laboratory Manager: Cherryl Kolbe Ext. 16995Other Contacts: Bev deJong Technical Officer Ext. 16995HAZARDS: Nil


Disposable gloves Face mask and/or protective eye if required


BEFORE YOU START Wash hands in warm soapy water Rinse well and dry completely put on glove/s

NEVER......................... Treat urine samples without glove on

JOB STEPSSample collection

Testing procedure

Advise the patient they are required to provide a urine sample. Supply the participant with an appropriately labelled yellow top

urine container and paper bag/towel. Direct the participant to the toilet & ask them to bring back the

urine container inside the paper bag/towel and place it in the esky provided.

Perform the urine test as soon as possible or within 2 hours of sample collection. If immediate testing is not possible, store the urine at 40C.

Urine samples must have reached room temperature at testing time

Mix the urine sample thoroughly before testing Do not touch the test zones on the strip with fingers

Put on a pair of disposable gloves Take a test strip out of the container. Close the container immediately after removal of the strip. Briefly (not more than 1 second) dip the test strip into the urine

making sure that all test areas are moistened. Do not bend test strips during dipping.

Wipe the edge of the strip against the rim of the vessel to remove excess urine.

Briefly (not more than 1 second) dab the long edge and then the back of the test strip on an absorbent surface (e.g. paper towel).

To visually read the test strip, wait one minute and then compare the reaction colors with the colors on the bottle.

Note: Compare the blood test area with both colour scales as separate colour scales are given for erythrocytes and haemoglobin.

Any color changes appearing only along the edges of the test areas, or developing after more than 1 minute, do not have any diagnostic significance.

WHEN YOU FINISH Urine should be discarded into the toilet and the empty containers discarded into a biohazard bag and placed in the biohazard bin.

Remove disposable gloves and discard into biohazard container

Wash hands in warm soapy water Rinse well and dry completely

38

SOP No: ................................... Version: .................................. Date: 27 March 2007

Written by: C. Kolbe

Dept/Div/School: School of Community Health

Supervisor/Manager:

Other Contacts: Bev deJong

Contraindications: Epilepsy Lens transplant

Protective / emergency equipment:

First aid kit available

Before you start: Check the objective lens before taking an image as any stains or scratches on it will appear as white spots.

Sudden heating of the room in cold area will cause condensation to form on the lenses. In this case wait until condensation disappears before performing photography.

Always ....................... Ask the participant if they have: Epilepsy Had a lens transplant

Job steps: Non-mydreatic retinal camera set-up

Power-up

DHClient Software Entering Participant Details

This step will be completed by staff Dioptic compensator - =/- 10 refractive error - if can’t focus Small pupil – on or off – leave on Infra red filter – stays IN! Lamp - only adjusts contrast of monitor Flashing light – participant focal point:

o anterior view – orangeo posterior view – green

This step will be completed by staff Unlock non mydriatic camera (rear LHS) Turn on the laptop (username and password = localuser) Turn on the Canon digital camera (switch below the LCD on the rea of

the camera) Turn on the Fundus camera (switch at the RHS next to the power inlet)

39

TASK: Retinal Photography using the Canon CR-DGi Non-Mydreatic retinal camera

STANDARDOPERATINGPROCEDURE

Double click on the HDClient desktop icon In the Identify a Patient window enter the following:

o Patient numbero Family nameo Given nameo Gender

Click Next>> If you are entering a new participant then the New Patient, NOT in

Database window will appear.

Click on Next>> to open the Patient Details window. Check the details in the first 3 fields and click on Next>>. Type the participant code as before and click on OK.

40

Photography1. Positioning and

Focusing

Your screen should now look like the image below

Note: If the word “SLEEP” blinks on the monitor press the shutter release button.

Note: You will be taking two photographs of each eye.

Photo 1 = optic disc is located centrally Photo 2 = optic disc is located in a lateral position approx 1cm from the field perimeter

Ask the participant to remove any spectacles or contact lenses and have them sit down and place their face against the chin rest and forehead rests.

Adjust the height of the chin rest by turning the chin rest height adjustment ring so that the eye is aligned with the height adjustment mark on the face rest pole.

Slide the operation lever to the side of the eye to be photographed.

To position the pupil turn the height adjustment ring and incline the operation lever [R] or [L] so that the eye front is displayed almost at the center of the monitor.

Adjust the height of the chin rest by turning the chin rest height adjustment ring as required.

Note: Hold the operation lever and slide the stage if you need to move the unit more.

41

Ask the participant to stare at the internal eye fixation target. Incline the operation lever back and forth until the split images of the

pupil are aligned.

Note: If the pupil is smaller that the inner alignment ring either darken the room or use the small pupil function.

To display the retinal image press the alignment button. The eye fixation target will blink for 3 seconds.

Note: If the stage slides in either direction the display will change to eye front image again.

Align the split bars by turning the focus knob.

Focusing is correct when the split bars are aligned.

42

2. Taking the image

To precisely adjust the position of the retinal image incline the operation lever forward and backward so that both working distance dots are displayed the smallest and are equally positioned from top to bottom and right to left.

Note: Unless the retinal image is positioned properly flare will appear in the periphery of the retinal image after the image is taken.

Press the shutter release button. After the image is taken, eye front image will be displayed.

Both eyes will be contracted after the image is taken. Wait until the eye is sufficiently dilated, then take the second image.

Repeat all the above steps for the other eye Click on End on the small Photo window and the Quit Visits/study

window will appear.

Select Start a New Patient or Search which will return you to the Identify a Patient window.

When you finish: Wipe the chin and forehead rests with an ISOWIPE bacterial wipe. Turn OFF the power of the instrument. Place the lens cap over the objective and place the dust cover over the

instrument. Dust will appear on the image when the objective lens is dusty.

Be sure to attach the dust caps on the mounts of retinal camera and digital camera when the digital camera is detached from the retinal camera.

Appendix F: Diabetic retinopathy chart

43

Emergency Procedures

44

Cedar Floor Plan

45


Diabetes Complications Screening Emergency Response




Rationale: Given the number of participants enrolled in the screening program and their co-morbidities including diabetes, cardiovascular disease including hypertension and diseases associated with aging the emergency response below has been developed in the event of a medical emergency.

EMERGENCY EQUIPMENT

Telephone First aid kit Resuscitation Equipment List of First Aid Officerso Bev De Jong Physiology Lab (Back Wilcara) 16858o Tim Rowston Photography 16914o Karen Scheetz Library 16877o Steve Knox Services Officer (Secutity) 16888o Corey Fisher Services Officer (Security) 16888

These staff all have current Intermediate First Aid and Cardio-Pulmonary Resuscitation certificates.

JOB STEPS Conscious patient with chest pain and or difficulty of breathing

Unconscious Patient Breathing

Unconscious not breathing

Put patient on a bed or chair, whichever is closer, should not be walked, wheel chair needed.

Call for Help Apply Oxygen at 6L via a Hudson mask Call RN or First Aid Officer (Bev deJong) to assess the patient Phone ambulance 000 as appropriate

Turn patient on the left lateral side Call for help Maintain airway and apply Oxygen 8L Hudson to assess the patient Call ambulance DRABC (Check for Danger, Response, Airways, Breathing and

Circulation) Call ambulance 000 Call RN or First Aid Officer (Bev deJong) Perform CPR as appropriate

Note: In service will be provided by Paul Warner to communicate this procedure to staff and students involved in the Diabetes Complications Screening program.

WHEN YOU FINISH Make sure an accident/Incident report is completed

46


Hypoglycaemia Emergency Response

SOP No: ...................................….Version: ………1.0……………..Date: 2004



SIGNS & SYMPTOMS: Excessive sweating Shanking and/or trembling Feeling faint Headache Blurred vision Irritability Extreme hunger Racing / pounding heart Personality change eg aggression Lethargy and/or drowsiness Coma / fitting

EMERGENCY EQUIPMENT

First aid kit available Resuscitation equipment

JOB STEPS for theCONSCIOUS PATIENT

Perform a blood glucose test If < 5mmol/L administer quick acting sugar in the form of:

o 5-7 jelly beanso warm sugary drink (eg tea or coffee)o ½ can of regular soft drinko fruit juice

After several minutes redo the blood glucose and administer long acting carbohydrate in the form of:

o 2 sweet biscuitso breado fruit

After 30 minutes redo the blood glucose which should be > 5mmol/L

JOB STEPS for theUNCONSCIOUS PATIENT

Call 000 and remain with the patient Do not administer anything by mouth Position patient on the side Clear the airway Tilt the head slightly and support the jaw Check vital signs

47


Fainting Emergency Response

SOP No: ...................................….Version: ………1.0……………..Date: 2004



Fainting may be caused by nervous excitement (venipuncture). The victim looks shocked, feels faint and giddy and may collapse.

EMERGENCY EQUIPMENT

First aid kit available Resuscitation equipment

JOB STEPS Lay the patient down if not already on the floor Raise both legs Loosen any tight clothing at the neck and waist Apply a cool towel to the head Apply Oxygen if available – Hudson mask @ 6-8L/min Check for pupillary response Ventilate room Reassure the patient if awake Do not give food or drink until the patient has recovered fully Assist the patient to a seated position when they feel ready Assist the patient to a standing position when they feel ready

48

Student screening documents

49

Diabetes Complications Screening Forms

50

Charles Sturt UniversitySchool of Community Health

PO Box 789Albury NSW 2640

Tel (02) 6051 6000

Diabetes Screening Complications Research Initiative (DiSCRi)Participant Information sheet

Chief Investigator Clinical Educator Clinical Educator Clinical Educator

Dr Herbert Jelinek Dr Paul Tinley Megan Smith Harriet Farquhar

02 6051 6946 02 6051 6934 02 6051 6738 02 6051 6933

[email protected] [email protected] [email protected] [email protected]

You are invited to participate in a research project on complications associated with diabetes (such as heart disease, eye and foot disease) that also provides clinical experience for undergraduate students. The main purpose of this research is to determine whether regular screening is of benefit to the rural community. In particular we aim to establish the value of specific screening procedures in the early detection of complications that may be associated with diabetes. An additional goal of this research project is to give students valuable experience in the implementation of standardised tests in a screening program

As this research project includes both research and educational components it is coordinated by a team of academics with specific skills in these areas. Students from the School of Community Health, under the supervision of academics, will be involved as part of their course work requirements. Postgraduate students may also be involved if this research project relates to their higher degree research and they have ethics permission to do so.

What does your participation involve?If you agree to participate in this research you will be asked to undertake a series of screening tests that will take approximately 2½ hours to complete. These tests are often used in the screening of people with diabetes and include: questionnaires; echocardiograms (ECGs); blood pressure; blood oxygen levels; blood tests; urine samples; foot health test; and autonomic nervous system function tests. Each test is detailed below.1. Questionnaires: involve questions about your general medical history and medications,

use of alternative medication and foot health as well as quality of life. 2. Echocardiograms (ECGs) and Blood pressure:

a. Blood pressure will be recorded whilst lying and standing. b. A 12-lead ECG recording will be taken whilst you lie still for 5 minutes. c. A 20 minute 3-lead recording – this will start with you in standing and continue

during the movement from standing to lying, and for 20 minutes lying still. The test will finish by recording whilst you move from lying to standing again. ECG recording involves attaching sensors to your skin. It may be necessary to clean a small area of skin, with an alcohol swab and/or shaving, to ensure the sensors are attached properly.

The main risk with the ECG recording is temporary dizziness when you move from lying to standing, similar to getting out of bed too quickly. In order to prevent any problems you will be monitored and assisted throughout and following the recording.

3. Blood oxygen levels: Whilst undergoing ECG recording we will also record your oxygen saturation in the blood. This involves putting your finger in a sleeve that senses the level of oxygen in your blood.

4. Blood tests: a. 20 ml of blood will be collected via venipuncture to test for: markers of oxidative

stress; markers of glucose; and markers of inflammation( d-dimer . homocysteyne)b. a finger prick test for Blood Glucose Levels (BGL)c. We ask that you give your consent for us to access blood test results relevant to

diabetes from your doctor and the pathology laboratory. 5. Urine sample: you will be asked to provide a urine sample which will be tested using a dip

stick.

51

mailto:[email protected]



6. foot health test: a. your ability to detect touch on your feet will be assessed

b. Ankle brachial index – is a test similar to having your blood pressure taken, but in this case the cuff is placed around your calf.

c. Pulse pressure test - involves placement of a small Velcro band around the index finger and big toe whilst we record the changes in blood flow. The band does not exert any pressure on your finger or toe.

NB: these will not be undertaken if you have foot ulcers or other signs of peripheral vascular disease.

7. Autonomic Nervous System Function Tests: a. blood pressure response to a sustained handgrip (30% maximal), b. heart rate monitoring (by ECG) whilst deep breathing and whilst breathing out

forcefully five times (the Valsalva manoeuvre). NB: you will be asked not to participate in this test if you have a known heart or respiratory problem.

8. Weight and height measurements: to calculate your body mass index9. Girth measurement

If you have reported that you are diabetic or that you have a family history of diabetes and that you have additional risks associated with diabetes (such as high blood pressure or are overweight) we will ask you to participate in an eye test. This test involves taking a photo of the retina of each eye. The flash may momentarily blind you and you may see a blue halo. This disappears within 10 minutes from the photo being taken. The photograph is then assessed by an ophthalmologist at the Albury Eye Clinic and you will be informed if there is any abnormality detected. There is no recorded risk associated with this procedure however if you have a cataract or other eye disease please inform the technician taking photographs.

Tests will not be done if they have recently been carried out and the result is available.

Test resultsTest results will be explained to you at the end of your session. It is important to note that some deviations from standard results do not indicate that there is a problem. However, you will be advised to seek the advice of your doctor if any result deviates from normal. We will give you a copy of your results and a letter to take with you to your consultation with your doctor.

What will we do with your test results?Confidentiality of your results is important to us. Therefore, all test results will be stored such that your identity is protected, i.e., data will not have identifying information included and a code will be used to identify your data.

The data from this research project will be used by research students and researchers involved in this research project to evaluate how useful these tests are in the screening of people with and without diabetes. Any publications that arise from this research project will maintain your confidentiality. Whilst a small section of an ECG or pulse wave recording may be published we will ensure that you cannot be identified from this section of ECG. The data collected in this research project may be used in future research with other researchers. Future researchers will only have access to material that has had all identifying material removed.

It is important to note that these screening tests are conducted as part of a research project and should not be considered in any way to constitute provision of health care. Feedback provided to you consists of data collected as part of the research project and is not a clinical diagnosis. Whilst you will be informed of your test results and given information regarding deviation of these results from normal levels, no health advice can be given to you by the researchers. Whenever test results deviate from normal participants will be asked to seek health advice from their doctor.

Your participation in this research project is entirely voluntary. You are free to withdraw your consent and withdraw from the research project at any time you wish.

52

NOTE: Charles Sturt University’s Ethics in Human Research Committee has approved this project. If you have any complaints or reservations about the ethical conduct of this project, you may contact the Committee through the Executive Officer:

The Executive OfficerEthics in Human Research CommitteeAcademic SecretariatCharles Sturt UniversityPrivate Mail Bag 29Bathurst NSW 2795

Tel: (02) 6338 4628Fax: (02) 6338 4194

Any issues you raise will be treated in confidence and investigated fully and you will be informed of the outcome.

53

Charles Sturt University School of Community HealthPO Box 789Albury NSW 2640

Participant Consent Form

Chief Investigator Clinical Educator Clinical Educator Clinical Educator

Dr Herbert Jelinek Dr Paul Tinley Megan Smith Harriet Farquhar

02 6051 6946 02 6051 6934 02 6051 6738 02 6051 6933

[email protected] [email protected] [email protected] [email protected]

1. I, ……………………….……………………consent to my participation in the research project titled Diabetes Complications Screening Research.

2. I understand that I am free to withdraw my participation in the research at any time3. The purpose of the research has been explained to me and I have read and understood the information

sheet.4. I understand that students will be involved in the data collection.5. I understand that any information or personal details gathered in the course of this research about me are

confidential and that neither my name nor any other identifying information will be used or published without my written permission.

6. I understand that any data gathered in the course of this research may be published and/or used in subsequent research projects.

7. I understand that the feedback provided to me consist of data collected as part of the research project and is not a clinical diagnosis.

Name of Participant: ……………………………………… Name of Witness:

Signature of Participant: ………………………………………. Signature of witness:

………………………….

Date: ……………………………………....... Date:

…………………………

Contact address: …………………………………………

…………………………………………

Home Phone: …………………………………………

Work Phone: …………………………………………

Mobile: …………………………………………

Email: …………………………………………

I consent to the researchers requesting from my general practitioner or pathology laboratory, pathology results relevant to diabetes.

General Practitioner: Name…………………………………….

Address…………………………………

…………………………………

Phone no………………………………..

54




Charles Sturt University School of Community HealthPO Box 789Albury NSW 2640

Diabetes Complications Screening Research Clinical History

Male Female Age ……………….(yrs) DOB…………………………….

Have you been diagnosed with diabetes? Yes No

Type I Type 2

Length of time since diagnosis …………… (yrs) Do you take insulin? Yes No

Type of insulin:………………………………………dosage: …………………………………………………………..

Type of insulin:………………………………………dosage: …………………………………………………………..

Have you been diagnosed with the following?Cardiovascular disease no. of yrs………………… High Blood Pressure no. of yrs…………………

Have you been diagnosed with or experienced any of the following? angina kidney problems ulcers on the legs/feet

heart failure bladder problems general pain in feet

atrial fibrillation epilepsy numbness in feet

heart attack reflux loss of sensation in feet

stroke increased sweating tingling sensation in feet

chest pain glaucoma (eyes) cold sensation in feet

pain in (L) arm retinopathy (eyes) burning sensation in feet

dizzinessAfter having eaten a meal do you suffer from any of the following? nausea vomiting bloating abdominal pain palpitations

other cardiac symptoms

please specify: ………………………………………………………………………………………………………..

Other medical information:……………………………………………………………………………………

What are your current medications? (Please include all diabetic and other medications including dosage)

………………………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………………………

Have you had any changes to your medication or commenced any Yes No

new medication in the last month?

Changes: ………………………………………………………………………………………………………………….

Have you been admitted to hospital since your last screening? Yes No

Reason: …………………………………………………………………………………………………………………....

Lifestyle Questions:

Do you smoke more than 5 cigarettes per day Yes No

Do you consume more than 2-3 glasses of alcohol per day Yes No

Are you currently taking medication for High Blood Pressure? Yes No

Do you have a family history of diabetes Yes No

Do you have a family history of cardiovascular disease? Yes No

Are you currently following a weight loss diet? Yes No

How many hours of exercise would you do in a typical week?

Duration (hrs): none 1 2 3 4 5 6 7 8 9 10 10+

Intensity: low moderate high

55

Clinician Enquiries

1. Have you been involved in our screening before? Yes No

2. If yes, were you advised to follow up any results with Yes Noyour GP or other health care professional?

What were you advised to follow up?..............................................................................................

How did you follow this up?.............................................................................................................

What was the outcome?……………………………………………………………………………………

3. How long ago did you last visit your:

a. General Practitioner …………………(months)

b. Physician (Cardiologist, Endocrinologist, Neurologist) …………………(months)

c. Ophthalmologist …………………(months)

d. Podiatrist …………………(months)

e. Diabetes Educator or Community Health Centre …………………(months)

4. If you have diabetes or cardiovascular disease, how often did you see the following clinicians regarding these

conditions?

a. General Practitioner …………………

b. Physician (Cardiologist, Endocrinologist, Neurologist) …………………

c. Ophthalmologist …………………

d. Podiatrist …………………

e. Diabetes Educator/Community Health Centre …………………

5. If you have diabetes, does your GP test for the following during a:

Diabetes related consultation? Regardless of the nature of your visit?

Eye Yes No Yes No

Listen to the heart sounds Yes No Yes No

Foot Yes No Yes No

Blood Pressure Yes No Yes No

6. If you have cardiovascular disease (CVD), does your GP test for the following during a:

CVD related consultation? Regardless of the nature of your visit?

Eye Yes No Yes No

Listen to the heart sounds Yes No Yes No

Foot Yes No Yes No

Blood Pressure Yes No Yes No

7. If you DO NOT have diabetes or cardiovascular disease, does your GP test for the following during your visit?

Eye Yes No

Listen to the heart sounds Yes No

Foot Yes No

Blood Pressure Yes No

If after completing this part of the questionnaire you have any concerns please let the researcher know and you will be provided with options for seeking further information. 56

Urinalysis

Observation Test

Test Result Normal

Colour (eg pale, medium or dark) Straw yellow

Transparency (eg clear or cloudy) Clear

Odour (describe – note if pungent)

Dip StickNote: Each dipstick must remain in contact with the urine for ONE minute

Test Result Normal Range

pH 5 - 9

Protein Negative

Glucose Normal

Ketones Negative

Blood Negative

Haemoglobin Negative

57

Monofilament [L] Foot

Could you feel if the skin on your [L] foot was being damaged?

Yes No Don’t know

58

Carville Score [L] Foot = _______ out of 10

Note: Neuropathy if get 4 or more incorrect.[L] Foot table

1 2 3 4 5 6 7 8 9 10

Monofilament [R] Foot

Could you feel if the skin on your [R] foot was being damaged?

Yes No Don’t know

Carville Score [R] Foot = _______ out of 10

Note: Neuropathy if get 4 or more incorrect.

[R] Foot table

1 2 3 4 5 6 7 8 9 10

59

Diabetes Complications Screening Research Autonomic nervous system (ANS) function tests

Score: Normal = 0 Borderline = ½ Abnormal = 1 no CAN 0 - 0.5 / early CAN (1.0 - 2.5) / definitive and severe (3.0 - 5.0)

Deep Breathing (DB)Test

Deep breath in for 5secs out for 5 secs, repeat 6 times

Take average of first three cycles

Signed…………………………………

Measurements for DB

Shortest inspire Longest expire MAX-MINCycle 1 ……………… ……………... …………..

Cycle 2 ……………… …………… …………..

Cycle 3 ……………… ……………… ……………

Average (MAX-MIN)………..

Classification ……………………………………….. Normal : ≥ 15 Border: 11 to 14 Abnormal: ≤10 (HR)

Valsalva Test

Hold Breath and push down into abdomen for 15 secs, rest 30 sec repeat three times.tick or n/a [ ] NO HEART, BLOOD PRESSURE OR

RESPIRATORY PROBLEMS[ ] HEART RATE (> 60 bpm)[ ] OXYGEN SATURATION TEST OK (must be >95%)

Signed…………………………………

Measurement for Valsalva

Longest after shortest during ratio L/SCycle 1 …………… ………………. ……….

Cycle 2 ……………. ………………. ……….

Cycle 3 ……………. ………………. ……….

Average ratio…………

Classification:………………………………………..

Normal : ≥1.21 Border: 1.11 - 1.20 Abnormal: ≤1.10

Hand Grip (HG)Test

AUTOMATED BP MONITOR

pO2 %………….. MAX HG ……………

30% MAX HG ……………

Signed…………………………………

Result: Highest DBP – baseline DBP ……………..

Classification ……………………………………….

Normal: ≥ 16 Border: 11 to 15 Abnormal: ≤10

Measurements for HG

Time (mins) BP

0 (resting)

1

2

3

4

5

BP change on standing)

Resting BP (av lying) ………………Palpated SBP ………………1 min post standing ………………3 min post standing ………………Resting minus 1min standing SBP ………………

Classification…………………………………………

Normal : ≤ 10 Border: 11 to 29 Abnormal: ≥ 30

HRV change on lying and standing

HR interval at 15th and 30th beat post lyingRatio 30:15 ……………

Classification……………………………………………

HR interval at 15th and 30th beat post standingRatio 30:15 ……………

Classification……………………………………………

Normal : ≥ 1.04 Border: 1.01 to 1.03 Abnormal: ≤1.00

Outcome: Normal: no anomalies Early: one of HRV abnormal or 2 borderline Definite: 2 or more abnormal Severe: 2 or more HRV abnormal plus 1 or both BP abnormal or both borderline.

60

Charles Sturt University School of Community HealthPO Box 789Albury NSW 2640Tel (02) 6051 6000

Participants research results

To: General Practitioner Re: CSU diabetes complications screening research resultsParticipant Name: Participant Code:

The Diabetes Complications Screening Research Project at Charles Sturt University involves the public in a research project that aims to determine how best to implement alternative health care models in community health and identify novel risk indicators for early identification of disease and disease prevention. Tests are carried out by CSU investigators and students. All results are obtained with optimum care, however the results are not intended to take the place of a regular review by your general practitioner and do not constitute a clinical assessment/diagnosis, which the research participant may be seeking from their general practitioner.

Body Mass Index (BMI) and waist circumference measurementsThe body mass index (BMI) is a risk factor for cardiovascular disease and diabetes. It is considered normal if the score is below 25. Overweight is associated with a value between 25 and 29.9, whereas obese is a value greater than 30. Waist circumference measurements regarded as normal are less than 80/94cm female/male whilst measurements above 90/102cm female/male are regarded as indicative of substantially increased risk to health.

BMI Result: …….….……..kg/m2

Waist circumference …….….……..cm

Comments:

Blood Glucose

Normal values for fasting are levels below 7 mmol/l and for non-fasting (having something to eat within two hours) below 11 mmol/l. A pre-diabetes condition is associated if fasting Blood Glucose levels are greater than 5.5mmol/L but below 7mmol/L.

Early morning fasting glucose reading (if applicable) ……….……

Screening reading …….….……..mmol/L

Time since last meal ………………hr

Comments:

Ankle-Brachial-Index (ABPI)The ABPI is a measure that compares the blood pressure in the arm with that in the leg. As such it is an indicator of how well blood moves down into the feet.

Result of ABPI:

Right side:

Left side:

The normal range for ABPI is between 0.9 and 1.3.

Comments:

61

Peripheral NeuropathyWe also tested for how well the sensory nervous system functions in the foot. Clinical significance is considered when bilateral changes are evident or 2 or more of the tests show changes indicative of decreased function.

Monofilament:

Vibration:

Reflexes:

Muscle tone:

Comments:

Autonomic Nervous System Assessment:

Heart rate variability lying to standing: (Normal : ≥1.04 Border: 1.01 to 1.03 Abnormal: ≤1.00)

Valsalva (ratio): (Normal : ≥1.21 Border: 1.11 - 1.20 Abnormal: ≤1.10)Deep breathing (HR): (Normal : ≥15 Border: 11 to 14 Abnormal: ≤1)BP Lying to Standing (systolic mmHg): (Normal : ≤10 Border: 11 to 29 Abnormal: ≥ 30)Handgrip test (mmHg): (Normal: ≥16 Border: 11 to 15 Abnormal: ≤10)

The measures are based on those recommend by Ewing and known as the Ewing battery. Comments:

Cardiovascular Assessment Assessment of your ECG has indicated: see interpretation on ECG trace

…………………………………………………………………………………………………...

………………………………………………………………………………………………… Blood Pressure: …………………mmHg

Note: It is not uncommon for healthy people to show some anomaly to normal sinus rhythm on their ECG trace due to aging or because they are sports active, slim or large.

If any of your results are abnormal with respect to Australian guidelines, we recommend that you visit your general practitioner for a check up.

We would also appreciate if you could write us a letter letting us know of what you thought of the diabetes screening research you attended and any further outcomes from follow-up with your general practitioner.

If you have any further questions or comments you can contact Herbert Jelinek on 02 60516946 With thanks from the Diabetes Complications Screening Research..

Herbert Jelinek. PhD Clinical EducatorCoordinator Name:Diabetes Complications Screening & Research Signature:

Participant interviewed by:

Name:

Signature:

62

Screening Stations

Station 1 Consent form completed

SWPS Pathology Dorevitch Pathology

Urine sample collected

Waist circumference……………………………….…cm

Height ……………….. (cm) Weight ………………..(kg)

BMI (kg/m2) = ………………………………………….

Signed:

Station 2: Blood collection

Non diabetes Type 1 Type 2

Early morning glucose:………………..….……..mmol/L

Time since last meal:……………………….…..(hrs)

Screening glucose test:……………………..….mmol/L

Blood taken for biochemistry: Yes No

Signed:

Station 3: Neuropathy(please circle)

Left Right

Monofilament P A R P A R

Muscle P A R P A R

Vibration P A R P A R

Reflex – ankle P A R P A R

Reflex – knee P A R P A R P=present A=absent R=reduced

Signed:

Station 4: ABPI

Automated BP Doppler

SBP DBP

(L) Arm(L) ABPI

Average ABPI

(L) Leg

(R) ABPI(R) Arm

(R) Leg Signed:

Station 5: ANS / 3 Lead ECGSkin sensitivity: Yes No

Dizziness on rising: Yes No

ANS test completed:

LS/SL Yes No

DB Yes No

VA Yes No

Hand grip Yes No

Signed:

Station 6: Eye Photography

Contraindications - epilepsy: Yes No

Date of last eye test:…………………………………………

Eye conditions: Yes No

Please specify:………………………………………………..

………………………………………………………………….

………………………………………………………………….

Signed:

Station 7: 12 Lead ECGSkin sensitivity: Yes No

Dizziness on rising: Yes No

Previous heart problem: Yes No

Chest Pain: Yes No

10 sec recording completed

5 min recording completed

Signed:

Station 8: Lying to Standing Blood PressureDizziness on rising: Yes No

SBP DBPLying 1 ………………/…….……..….

Lying 2 ………………/………...…….

Standing palpated systolic ………...……/………...…….

Standing 1 (1 min) ………………/………...…….

Standing 2 (3 mins) ………………/………...…….

Signed

For GP consideration: Not Required Recommended ImmediateECG Blood Pressure Podiatry Diabetes EYE BMI

63

Diabetes screening – Participant phone recall instructions

1. Introduce yourself.eg your name and what course you’re studying

2. Explain the nature of the phone call.eg Ringing with regard to the Diabetes Screening programme which you’ve been participating in.

3. Ask if they would like to continue in the screening.

If they are, offer them a choice of booking times. If none of the times are suitable then place them on a waiting list for next time.

If they don’t wish to continue with the screenings, thank them for their participation in the past and tell them their name will be taken off the list.

4. Give a brief outline if required (For participants continuing with the screening and wish to know tests to be carried out)

Bloods: ~15ml for biochemistry and a finger prick for a blood glucoseECG: 12-lead heart check like they do in hospitals – electrodes on the chestAutonomic nervous system: (automatic part of nervous system)

3-lead ECG where we record segments lying down and standing up -electrodes on collar bone and hipsHand grip test while we take blood pressures every minute for 5 minutesTests in which we ask you to breath deeply while we run a 3-lead ECG to measure your heart rate

Foot health tests – sensation, reflex, vibration and muscle strengthBlood pressures in arms and legsRetinal Eye Photographs: of the back of the eyes to check for small haemorrhagesQuestionnaires

5. Ask if the participant has diabetes and note this on the booking sheet.

6. Check their date of birth and participant code Note: the participant code consists of the first 3 letters of their second name followed by the initial of the first

name and DOB eg Cherryl Kolbe DOB 220253 = KOLC220253

Instructions for attending participants

If non-diabetes: Fast for 2 hours prior to appointment time Drink lots of water Wear a front opening cotton shirt (for the ECG’s) Bring a written list of medications and the name / address of GP

Diabetes: DO NOT fast Bring your early morning fasting glucose reading Drink lots of water Wear a front opening cotton shirt (for the ECG’s) Bring a written list of medications and the name / address of GP

The tests will be run in the Cedars Building at 601 Olive Street (next to the child care centre, 3 buildings up from Wilson Street)

Come in front doors and down the hallway to the desk

You may like to bring a snack with you as the tests will take about 2 to 3 hours.

Phone number - cancellation or queries: Bev 60516858 or Cherryl 60516995

64

Appendices

65

Appendix A: Sample tubes for collection

Tube Test Volume of whole blood Requirement Storage

EDTA Homocysteine 8ml Plasma -800C

EDTA MetHb, viscosity 8ml Whole blood Room temp

Preservative free Heparin

GSH, MDA4ml

RBC hemolysate -40CD-dimer, cholesterol profile Plasma -200C

2 x 7ml EDTA tubes (purple top)

1 x 7ml plain tube (orange top)

1 x 10ml tube with 100L preservative free heparin

Collect the two EDTA tubes first and the plain tube last. As soon as the plain tube is collected transfer the blood to the tube containing the preservative free heparin. Invert well to mix. Place this tube and a 7ml EDTA tube in a rack and keep on ice until collected by biochemist.

Centrifuge one 7ml EDTA tube. Collect plasma, label and store at -800C.

66

Appendix B: Blood glucose level interpretation

Fasting Plasma Glucose.

Note: Results for fasting plasma glucose (FPG) test by finger prick maybe between 12% & 15% lower compared to plasma venous samples.

The fasting plasma glucose (FPG) test is the standard test for diabetes. It is a simple blood test taken after eight

hours of fasting. In general, results indicate the following:

FPG levels are considered normal up to 5.5mmol/L.

Levels between 5.6mmol/L to 6.9mmol/L indicate FPG or prediabetes as suggested by the International

Diabetes Institute. They are only slightly above normal but are considered to be risk factors for type 2 diabetes

and its complications.

Diabetes is diagnosed when FPG levels are 7.0mmol/L on two different days. Or a sugar test at anytime is

above 11mmol/L.

The FPG test is not always reliable, so a repeat test is recommended if the initial test suggests the presence of

diabetes, or if the test is normal in people who have symptoms or risk factors for diabetes. For example, people

who take the test in the afternoon and show normal results may actually have abnormal levels that would be

revealed if they are tested in the morning.

Ref: Australian Diabetes Society

67

Appendix C:

What is Waist Circumference?

According to the National Institutes of Health, a high Waist Circumference (WC) is associated with an increased

risk for type 2 diabetes, dyslipidemia, hypertension and cardiovascular disease when the BMI is between 25

and 34.9. (A BMI greater than 25 is considered overweight and a BMI greater than 30 is considered obese.)

Waist Circumference can be useful for those people categorized as normal or overweight in terms of BMI. (For

example, an athlete with increased muscle mass may have a BMI greater than 25 - making him or her

overweight on the BMI scale - but a Waist Circumference measurement would most likely indicate that he or

she is, in fact, not overweight). Changes in Waist Circumference over time can indicated an increase or

decrease in abdominal fat. Increased abdominal fat is associated with an increased risk of heart disease.

To determine your Waist Circumference, locate the upper hip bone and place a measuring tape around the

abdomen (ensuring that the tape measure is horizontal). The tape measure should be snug but should not

cause compressions on the skin.

68

Appendix D: Ewing battery: autonomic nervous system function tests interpretation

Blood pressure response to standingUsing standard sphygmomanometer measure BP whilst lying down twice and take average and then when

standing (1 min and 3 post standing). A difference (fall) of 30mmHg systolic and/or a 15mmHg fall diastolic

indicates postural hypotension. Consider whether participant is on antihypertension medication!

Blood pressure response to sustained handgripExplain instrument and determine maximum hand grip. Measure resting blood pressure. Handgrip is

maintained at 30% maximum voluntary contraction up to a maximum of five minutes and BP recorded each

minute. The difference between the highest and resting diastolic blood pressure is the measure of

response.

Heart rate deep breathing.Patient has 3 min quite rest then heart rate is recorded whilst performing 5 cycles of deep breathing (5 sec

inspiration and 5 second expiration). All patients need to have a training session before commencement of

recording. The maximum and minium heart rate for each breathing cycle is measured and the mean of the

successive breathing cycles are taken to give the maximum-minimum heart rate.

NOTE you can also calculate the ratio: Expiration/inspiration (E/I) R-R ratio was calculated as the average

of the quotient between the longest R-R intervals during expiration and shortest R-R intervals during

inspiration (E/I) ratio).

Heart rate response to standing up.Measure heart rate as standing from lying position Take 30:15 interval. The 30th and 15th beat is determined

from the time the participant stands. In some cases there is noise at the beginning of this phase in the ECG.

Therefore take the time interval of the first clear beat divide this into the time interval between standing and

the first clear beat. This provides information of how many beats were missed. Then count starting from the

first clear beat to the 15th and 30th beat. Take the ratio

Heart rate response to lying.Same as above just measure as patient lying down.

Valsalva manoeuvrePatient sits quietly and then blows into mouthpiece at 40mmHg or holds breath whilst pushing into pelvic

cavity for 15sec. Rest 30 sec and then repeats three times. Heart rate increases normally followed by

rebound bradycardia after release. The ratio of the longest RR interval shortly after the manoeuvre to the

shortest RR interval during the manoeuvre is measured. The Valsalva ratio is the mean of three successive

manoeuvres.

69

For Valsalva

Normal Borderline Abnormal

≥1.21 1.11 - 1.20 ≤1.10

For deep breathing (AV MAX-MIN)


≥ 15 11 to 14 ≤10

For BP change lying to standing


≤ 10mmHg 11 to 29mmHg ≥ 30 mmHg

For handgrip


≥ 16mmHg 11 to 15mmHg ≤10 mmHg

For HRV lying to standing (30:15 ratio)


≥ 1.04 1.01 to 1.03 ≤1.00

EWING 1985Normal (N): all tests normal or one borderline

Early involvement (E): one of the three heart rate tests abnormal or two borderline

Definite involvement (D): two or more of the heart rate tests abnormal

Severe involvement (S): two or more of the heart rate tests abnormal plus one or both of the blood

pressure tests abnormal, or both borderline

Atypical pattern (A): any other combination of abnormal tests

70

Appendix E: CSU 12-lead ECG classification table

CSU 12 - lead ECG classification for referral to physiciansClass 2a - show GP next

visitClass 2b - recommended

visit GP soonClass 3 - immediate

referraln = not referrred

Class 1a Class 1b Class 2a Class 2b (if known 2bn) Class 3 (if known 3n)

Sinus rhythmLVH (left ventricular

hypertrophy)* I° HB (PR>200)

Q waves in > 1 lead (Q 1/4 or more of QRS

height) AF

Sinus arrhythmia

Notched or enlarged P wave (P mitrale/ P

pulmonale)Extensive inverted T

waves VF

Slow rhythm (50>HR<60) Peaked T wavesProlonged QT interval

(QTc>0.5 PR) 2° HB type 2

Conduction delay of atrial

or ventricular origin PVC & PAC (> 6/min) Bigeminy or trigeminy Atrial flutter

LAD or RAD (Left or Right

axis deviation) AV node re-entry PR<120 Multifocal PVC or PAC

Paroxysmal supraventricular

tachycardia

Q waves (<2) indicating

old infarctRBBB (right bundle

branch block) 2° HB type 1 VT

Minor T wave changeLAFB (Left anterior

fascicular block) ST elevation in > 2 leadscomplete atrioventricular

block (3° HB)

occasional PVC/PACRAFB (right anterior

fascicular block)Tachycardia

(100>HR<120) Tachycardia (HR>120)

long QTc > 440 ST depression with LVH Bradycardia HR < 50

LBBB (left bundle branch

block)ST elevation in more than

2 leads

LVH Cornell criteria Add value for aVL & V3; A value > 25 is pathologically significant

LVH Sokolow criteria Add largest peak/decline of: V1 or V2 with V5 or V6. A value >35 is pathologically significant

Appendix F: Diabetic retinopathy chart

FIGURE 1. MINIMAL NON-PROLIFERATIVE DIABETIC RETINOPATHY (NPDR) -- FEW SCATTERED MICROANEURYSMS (m) ONLY, THE REMAINDER OF THE FUNDUS IS NORMAL.

Diabetic Retinopathy ChartExerts from: http://www.eyesondiabetes.org.au/article/9

Prepared by the Diabetic Retinopathy Working Party of the NHMRC in conjunction with the Australian Diabetes Society Retinopathy Sub-Committee.Material derived from NHMRC "Clinical Practice Guidelines for the Management of Diabetic Retinopathy".

FIGURE 2. MILD NON-PROLIFERATIVE DIABETIC RETINOPATHY -- MICROANEURYSMS (m) AND DOT HAEMORRHAGES (h). ALSO DEMONSTRATES MACULAR OEDEMA WITH A SMALL AMOUNT OF LIPID EXUDATE (e) -- NOT CLINICALLY SIGNIFICANT.

FIGURES 3. MODERATE NON-PROLIFERATIVE DIABETIC RETINOPATHY -- COTTON WOOL SPOTS (w) RETINAL HAEMORRHAGES (h) AND MICROANEURYSMS (m)

FIGURE 4. SEVERE NON-PROLIFERATIVE DIABETIC RETINOPATHY -- INTRARETINAL MICROVASCULAR ABNORMALITIES OR IRMA (i) VENOUS BEADING (b) OR VENOUS CALIBER CHANGES, WIDESPREAD RETINAL ISCHAEMIA AND COTTON WOOL SPOTS (w) --BEGINNING OF NEW VESSEL ON OPTIC DISC.

FIGURE 6. HIGH-RISK PROLIFERATIVE DIABETIC RETINOPATHY -- LARGE FROND OF DISC NEW VESSEL (v) AND PRE RETINAL HAEMORRHAGE (h).

Classification, Clinical Signs and Referral Recommendation

Minimal NPDR (fig 1)Isolated Microaneurysms only (m).

Referral may not be needed. Review annually with dilated fundus exam.

Mild NPDR (fig 2)Microaneurysms (m) + retinal haemorrhages (h) Routine

referral to an ophthalmologist.Review with ophthalmologist at least annually.

Moderate NPDR (fig 3)Haemorrhages and microaneurysms (h,m) in at least 1

quadrant + cotton wool spots (w) or venous beading in 1 quadrant only.

Refer to an ophthalmologist as soon as possibleSevere NPDR (fig 4)One of the following:

Intraretinal microvascular abnormalities (IRMA) (i) in 1 or morequadrants

Venous beading (b) in 2 or more quantum Haemorrhages/microaneurysms (h,m) in all 4 quadrants.

Severe NPDR (fig 6)New vessels near disk or elsewhere (v

Pre-retinal haemorrhages (h)Other signs as in NPDR

charles sturt universitycsusap.csu.edu.au/~hjelinek/discri documents/discri st… · web viewif...

Documents