human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Purpose The purpose s of this study were to assess the level of foot self-care performed in a rural , multiethnic population of older adults and to identify factors associated with foot self-care . Methods The Evaluating Long-term Diabetes  Self-management  Among Elder Rural Adults study included a r and om sample of 701 African American , Native American , and white adults from 2 rural North Carolina counties . Participants completed in-home interviews , 5 foot selfcare practice s from the Summary of Diabetes Self-Care Activities ( SDSCA )  , functional status measures , and measures of education and support for foot care . Results Foot care practice s/behaviors reported at least 6 days/week ranged from 35.6 % for inspecting shoes to 79.2 % for not soaking feet . Four independent predictors of the SDSCA summary foot care index score were observed : having been shown how to care for feet ( P < .0001 ) , female gender ( P= .03 ) , having had a doctor check nerves in feet in past year ( P= .02 ) , and not receiving support caring for feet ( P = .0425 ) . Conclusions These findings indicate that educating patients about foot self-care may encourage routine foot care but that those dependent on either formal or informal support to perform foot care do so less frequently than those who perform it independently PURPOSE The purpose of this study was to evaluate an intensive diabetes foot education program for veterans at high risk for foot ulcer . METHODS We invited 100 consecutive patients with diabetes from a Department of Veterans Affairs Medical Center clinic who were insensate to the Semmes-Weinstein 5.07 monofilament to participate in a foot care education program . Two sessions were conducted by a nurse diabetes educator 3 months apart . Multiple educational approaches were used to teach patients foot self-examination , foot washing , proper footwear , and encouragement in enlisting proper physician foot care . Knowledge and satisfaction with care was measured before and after each visit . RESULTS The 34 patients who attended both education sessions improved their foot care knowledge over the course of the program . After the second session , the mean improvement over baseline was 14 % . These patients also reported improved satisfaction with foot care ; mean improvement was 33 % . CONCLUSIONS An intensive education program improved the foot care knowledge and behavior of high-risk patients . Those who adhered to a foot care education program were more satisfied with their foot care than prior to the program . Ways to improve accessibility of education sessions must be explored Although many studies have shown strong associations between certain causal factors and patients with foot ulcers  , it is unclear how many of these factors interact . A model that could help identify unique causal pathways and pivotal factors associated with the development of foot ulcers may lead to earlier intervention as well as less frequent and less severe complications . Therefore , the purpose of this study was to identify the responsible causal pathways associated with foot ulcers in persons with diabetes , to determine the frequency of components of the pathway and to identify pivotal events of the pathway . Eighty-seven patients with 103 existing or recently healed ulcers were prospect ively evaluated . The data used in the pathway analysis reflected seven variables that have been associated with the development of foot ulcers . The data were interpreted to assess which component causes and pivotal events were responsible for the present ulcer . A cluster analysis was used to confirm findings from the descriptive analysis . Twenty-four pathways were identified . The seven most common unique pathways accounted for 64.1 % of the cases . The results of the cluster analysis showed four consistent , dominant clusters : ( i ) neuropathy , deformity , callus and elevated peak pressure ; ( ii ) peripheral vascular disease ; ( iii ) penetrating trauma and ( iv ) Ill-fitting shoe gear . These results suggest that there is a finite number of key factors that , if identified and addressed with appropriate intervention strategies , may reduce the risk for the cascade of events towards ulceration and subsequent amputation This prospect i ve r and omized study evaluated the influence of a simple education program on the incidence of lower extremity amputation in diabetic patients . Two hundred three patients were r and omized into two groups : Group 1 , education ( 103 patients , 203 limbs ) and Group 2 ,  no education ( 100 patients , 193 limbs ) . There were no significant differences in medical management or clinical risk factors between the two groups . The amputation rate was three times higher in Group 2 ( 21 of 177 limbs versus 7 of 177 limbs ; p less than or equal to 0.025 ) , the ulceration rate was three times higher in Group 2 ( 26 of 177 limbs versus 8 of 177 limbs ; p less than or equal to 0.005 ) , and there was no difference in the overall incidence of infection ( 2 of 177 limbs ) . Overall success in Group 1 was highly significantly different from Group 2 ( 160 of 177 limbs versus 128 of 177 limbs ; p less than or equal to 0.0005 ) . This study demonstrated that a simple education program significantly reduced the incidence of ulcer or foot and limb amputation in diabetic patients Participants who received Pies Sanos , a 15-min intervention design ed to improve diabetes self-efficacy and foot self-care behaviors in adult patients with type 2 diabetes who lived in a predominantly Mexican American community , performed more-complete foot self-care 1 month later in their homes . Recruited when they presented for nonurgent care to the emergency department in two community hospitals near the U.S .— Mexico border , participants were r and omized into one of three groups . At follow-up , there was a significant difference in observed foot self-care behaviors between groups , F(2 , 135 ) = 2.99 , p < .05 , as well as a significant difference within the intervention , t ( 47 ) = −4.32 , p < .01 , and control group , t ( 46 ) = −2.06 , p < .05 , for baseline and follow-up self-reported foot self-care behaviors . Baseline diabetes self-efficacy was significantly and positively correlated with both baseline ( r = .335 , p < .001 ) and follow-up ( r = .174 , p < .05 ) foot self-care behaviors This quasi-experimental pilot study used a convenience sample of 23 adult men and women with either Type 1 or Type 2 diabetes who received hemodialysis three times a week . The experimental group received a four-part intervention that included individual and group foot care education , foot assessment , and special shoes . Pre- and posttesting of foot care knowledge was done using the Siriraj question naire . Out of a possible score of 20 , those in the experimental group had a mean score of 15.3 versus 14.33 in the control group on the posttest . The nephrology nurse has the opportunity to play a role in early detection and intervention in clients with ESRD Despite the established role of foot care education in diabetes management , reports evaluating such interventions are rare . The effectiveness of an intensive foot care intervention programme and a conventional one were therefore compared in Type 2 diabetes . The intensive group showed significantly greater improvements than the conventional group in foot care knowledge ( p less than 0.001 ) , compliance with the recommended foot care routine ( p = 0.012 ) , and compliance with the initial advice to consult  a podiatrist ( other than the project podiatrist ) for further treatment ( p = 0.008 ) . At the first follow-up visit the intensive group also showed a significantly greater reduction in the number of foot problems requiring treatment than the conventional group PURPOSE the purpose of this study was to test the effectiveness of an educational intervention to improve patients ' foot care knowledge , self-efficacy , and self-care practice s. METHODS A prospect i ve , r and omized , single center , 2-group design was used with a convenience sample of 40 home care patients from a Medicare-certified home health agency . Baseline measures of foot care knowledge , self-efficacy , and reported self-care practice s were obtained at study entry and 6 weeks later to control for foot care interventions provided during routine home care services . After obtaining the 6-week baseline measures , patients who were r and omized to the intervention group received individualized education about proper foot care . All patients were interviewed a third time 3 months after study entry to determine the effectiveness of the intervention . RESULTS The educational intervention improved patients ' knowledge , confidence , and reported foot care behaviors . CONCLUSIONS A brief , individualized educational intervention about st and ard foot care topics improved patients ' foot care knowledge and self-efficacy as well as reported self-care practice s. Incorporating such interventions into routine home care services may enhance the quality of care and decrease the incidence of lower-extremity complications Associations between specific foot-care behaviors and  foot lesions in patients with non-insulin-dependent diabetes mellitus were prospect ively investigated . Data from a r and omized controlled trial for preventing diabetic foot lesions were analyzed as a prospect i ve cohort using logistic regression . Independent variables included  foot-care behaviors , patient self-foot examination , going barefoot , availability of foot-care assistance , and visits to health-care providers .  The dependent variable was a foot wound on each foot at follow-up . In the final multivariate model , patients who rarely lubricated their feet had an increased risk of foot lesions . Increasing patient use of emollients may be key to preventing foot lesions A cohort of Medicare beneficiaries with diabetes was identified from inpatient and outpatient cl aims data and their risk for foot complications was estimated based on cl aims reflecting services for recent foot problems . A telephone survey of a r and om sample from this cohort was conducted to assess their foot care practice s , barriers , and perceptions of risk . Eight percent of respondents reported a history of foot ulcers and 7 % a history of lower extremity amputation . Based on cl aims data , 30 % of respondents were at high risk for future foot complications . Compared to those at low risk , those at high risk were more likely to report having an  annual foot exam , using protective footwear , and perceiving themselves to be high risk for future foot complications . However , 50 % of those with cl aims indicating a high risk perceived themselves to be at low risk for future foot complications . Overall , 20 % of respondents seldom checked their feet daily for sores or irritations . Among this group , 60 % felt that it was unimportant and 9 % reported they were limited by poor vision or physical problems . Our findings suggest that strategies are needed to improve the delivery of preventive foot care services to older persons with diabetes . Additionally , emphasis is needed to help individuals underst and their risk and seek and perform appropriate preventive foot care This study investigated the effectiveness of a " h and s-on " foot care teaching/learning approach for adults with diabetes . By r and om assignment , the control group received a lecture presentation on foot care , while the experimental group participated in a h and s-on session on foot care in addition to the lecture presentation . Data concerning the subjects ' foot care knowledge and skills , the condition of their feet , and their level of HbA1c were gathered prior to and six months after the foot care educational sessions . No significant increases in knowledge about foot care were observed in the experimental group . The experimental group reported improvements in inspecting and washing their feet on a daily basis , and in care of the toenails . No significant differences were observed in the status of the subjects ' feet . The HbAlc readings were significantly improved for both the experimental ( t=4.10 , df=10 , p=0.002 ) and control ( t=2.25 , df=9 , p=0.051 ) groups . A h and s-on educational session may improve foot care practice s temporarily . However , long term effects need to be studied to discern overall improvement of foot care practice s and physical status of the feet Given that 14 million Americans have diabetes [ 1 ] , the common complications of this disorder , such as foot ulcers and lower extremity amputations , are of major concern to the medical community . Approximately 20 % of all diabetic patients hospitalized in the United States are admitted because of foot complications [ 2 , 3 ] . Furthermore , about 50 % of all nontraumatic amputations in the United States are done in patients with diabetes [ 1 , 4 ] . This proportion equates to about 55 000 amputations a year [ 1 ] or 59.7 amputations for every 10 000 persons with diabetes [ 5 ] . Patients who undergo an amputation are at greater risk for a second similar procedure on either the same or the other leg [ 6 , 7 ] . Yet , it has been estimated that about one half of the amputations in patients with diabetes , or about one fourth of the total amputations done in the United States , are preventable [ 1 , 4 ] . Recently , the focus has been on preventive strategies that minimize foot damage in diabetic patients and thereby reduce the rates of ulcers and amputations . These preventive strategies are based on two observations : first , that simple efforts on the part of the health care provider or patient can reduce the likelihood of subsequent amputation due to diabetes-associated foot disease [ 8 ] ; and second , that many of these simple procedures are not being systematic ally applied by health care providers or patients [ 9 ] . For example , studies indicate that physicians infrequently examine the feet of patients with diabetes [ 9 , 10 ] . Also , most patients with diabetes do not engage in simple foot-care assessment s to identify lesions requiring early treatment [ 11 ] . Preventive strategies are not systematic ally applied for several reasons : First , patients may not be aware of foot-care procedures or how to do them , or they may not believe that such procedures can make a difference ; second , podiatry and orthopedics services that could assist in foot salvage in diabetic patients may not be available ; and , finally , the health care system may make it difficult for patients or health care providers to examine the feet of patients with diabetes [ 10 ] . Several uncontrolled studies found that implementation of improved foot-care programs can significantly reduce lower extremity complications in patients with diabetes ; these studies showed a 44 % to 85 % reduction in the rate of lower extremity amput 
    Output:
    
agent
Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practice s. Conclusion Preventing these complications , underst and ing the risk factors , and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program .
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Purpose The purpose s of this study were to assess the level of foot self-care performed in a rural , multiethnic population of older adults and to identify factors associated with foot self-care . Methods The Evaluating Long-term Diabetes  Self-management  Among Elder Rural Adults study included a r and om sample of 701 African American , Native American , and white adults from 2 rural North Carolina counties . Participants completed in-home interviews , 5 foot selfcare practice s from the Summary of Diabetes Self-Care Activities ( SDSCA )  , functional status measures , and measures of education and support for foot care . Results Foot care practice s/behaviors reported at least 6 days/week ranged from 35.6 % for inspecting shoes to 79.2 % for not soaking feet . Four independent predictors of the SDSCA summary foot care index score were observed : having been shown how to care for feet ( P < .0001 ) , female gender ( P= .03 ) , having had a doctor check nerves in feet in past year ( P= .02 ) , and not receiving support caring for feet ( P = .0425 ) . Conclusions These findings indicate that educating patients about foot self-care may encourage routine foot care but that those dependent on either formal or informal support to perform foot care do so less frequently than those who perform it independently PURPOSE The purpose of this study was to evaluate an intensive diabetes foot education program for veterans at high risk for foot ulcer . METHODS We invited 100 consecutive patients with diabetes from a Department of Veterans Affairs Medical Center clinic who were insensate to the Semmes-Weinstein 5.07 monofilament to participate in a foot care education program . Two sessions were conducted by a nurse diabetes educator 3 months apart . Multiple educational approaches were used to teach patients foot self-examination , foot washing , proper footwear , and encouragement in enlisting proper physician foot care . Knowledge and satisfaction with care was measured before and after each visit . RESULTS The 34 patients who attended both education sessions improved their foot care knowledge over the course of the program . After the second session , the mean improvement over baseline was 14 % . These patients also reported improved satisfaction with foot care ; mean improvement was 33 % . CONCLUSIONS An intensive education program improved the foot care knowledge and behavior of high-risk patients . Those who adhered to a foot care education program were more satisfied with their foot care than prior to the program . Ways to improve accessibility of education sessions must be explored Although many studies have shown strong associations between certain causal factors and patients with foot ulcers  , it is unclear how many of these factors interact . A model that could help identify unique causal pathways and pivotal factors associated with the development of foot ulcers may lead to earlier intervention as well as less frequent and less severe complications . Therefore , the purpose of this study was to identify the responsible causal pathways associated with foot ulcers in persons with diabetes , to determine the frequency of components of the pathway and to identify pivotal events of the pathway . Eighty-seven patients with 103 existing or recently healed ulcers were prospect ively evaluated . The data used in the pathway analysis reflected seven variables that have been associated with the development of foot ulcers . The data were interpreted to assess which component causes and pivotal events were responsible for the present ulcer . A cluster analysis was used to confirm findings from the descriptive analysis . Twenty-four pathways were identified . The seven most common unique pathways accounted for 64.1 % of the cases . The results of the cluster analysis showed four consistent , dominant clusters : ( i ) neuropathy , deformity , callus and elevated peak pressure ; ( ii ) peripheral vascular disease ; ( iii ) penetrating trauma and ( iv ) Ill-fitting shoe gear . These results suggest that there is a finite number of key factors that , if identified and addressed with appropriate intervention strategies , may reduce the risk for the cascade of events towards ulceration and subsequent amputation This prospect i ve r and omized study evaluated the influence of a simple education program on the incidence of lower extremity amputation in diabetic patients . Two hundred three patients were r and omized into two groups : Group 1 , education ( 103 patients , 203 limbs ) and Group 2 ,  no education ( 100 patients , 193 limbs ) . There were no significant differences in medical management or clinical risk factors between the two groups . The amputation rate was three times higher in Group 2 ( 21 of 177 limbs versus 7 of 177 limbs ; p less than or equal to 0.025 ) , the ulceration rate was three times higher in Group 2 ( 26 of 177 limbs versus 8 of 177 limbs ; p less than or equal to 0.005 ) , and there was no difference in the overall incidence of infection ( 2 of 177 limbs ) . Overall success in Group 1 was highly significantly different from Group 2 ( 160 of 177 limbs versus 128 of 177 limbs ; p less than or equal to 0.0005 ) . This study demonstrated that a simple education program significantly reduced the incidence of ulcer or foot and limb amputation in diabetic patients Participants who received Pies Sanos , a 15-min intervention design ed to improve diabetes self-efficacy and foot self-care behaviors in adult patients with type 2 diabetes who lived in a predominantly Mexican American community , performed more-complete foot self-care 1 month later in their homes . Recruited when they presented for nonurgent care to the emergency department in two community hospitals near the U.S .— Mexico border , participants were r and omized into one of three groups . At follow-up , there was a significant difference in observed foot self-care behaviors between groups , F(2 , 135 ) = 2.99 , p < .05 , as well as a significant difference within the intervention , t ( 47 ) = −4.32 , p < .01 , and control group , t ( 46 ) = −2.06 , p < .05 , for baseline and follow-up self-reported foot self-care behaviors . Baseline diabetes self-efficacy was significantly and positively correlated with both baseline ( r = .335 , p < .001 ) and follow-up ( r = .174 , p < .05 ) foot self-care behaviors This quasi-experimental pilot study used a convenience sample of 23 adult men and women with either Type 1 or Type 2 diabetes who received hemodialysis three times a week . The experimental group received a four-part intervention that included individual and group foot care education , foot assessment , and special shoes . Pre- and posttesting of foot care knowledge was done using the Siriraj question naire . Out of a possible score of 20 , those in the experimental group had a mean score of 15.3 versus 14.33 in the control group on the posttest . The nephrology nurse has the opportunity to play a role in early detection and intervention in clients with ESRD Despite the established role of foot care education in diabetes management , reports evaluating such interventions are rare . The effectiveness of an intensive foot care intervention programme and a conventional one were therefore compared in Type 2 diabetes . The intensive group showed significantly greater improvements than the conventional group in foot care knowledge ( p less than 0.001 ) , compliance with the recommended foot care routine ( p = 0.012 ) , and compliance with the initial advice to consult  a podiatrist ( other than the project podiatrist ) for further treatment ( p = 0.008 ) . At the first follow-up visit the intensive group also showed a significantly greater reduction in the number of foot problems requiring treatment than the conventional group PURPOSE the purpose of this study was to test the effectiveness of an educational intervention to improve patients ' foot care knowledge , self-efficacy , and self-care practice s. METHODS A prospect i ve , r and omized , single center , 2-group design was used with a convenience sample of 40 home care patients from a Medicare-certified home health agency . Baseline measures of foot care knowledge , self-efficacy , and reported self-care practice s were obtained at study entry and 6 weeks later to control for foot care interventions provided during routine home care services . After obtaining the 6-week baseline measures , patients who were r and omized to the intervention group received individualized education about proper foot care . All patients were interviewed a third time 3 months after study entry to determine the effectiveness of the intervention . RESULTS The educational intervention improved patients ' knowledge , confidence , and reported foot care behaviors . CONCLUSIONS A brief , individualized educational intervention about st and ard foot care topics improved patients ' foot care knowledge and self-efficacy as well as reported self-care practice s. Incorporating such interventions into routine home care services may enhance the quality of care and decrease the incidence of lower-extremity complications Associations between specific foot-care behaviors and  foot lesions in patients with non-insulin-dependent diabetes mellitus were prospect ively investigated . Data from a r and omized controlled trial for preventing diabetic foot lesions were analyzed as a prospect i ve cohort using logistic regression . Independent variables included  foot-care behaviors , patient self-foot examination , going barefoot , availability of foot-care assistance , and visits to health-care providers .  The dependent variable was a foot wound on each foot at follow-up . In the final multivariate model , patients who rarely lubricated their feet had an increased risk of foot lesions . Increasing patient use of emollients may be key to preventing foot lesions A cohort of Medicare beneficiaries with diabetes was identified from inpatient and outpatient cl aims data and their risk for foot complications was estimated based on cl aims reflecting services for recent foot problems . A telephone survey of a r and om sample from this cohort was conducted to assess their foot care practice s , barriers , and perceptions of risk . Eight percent of respondents reported a history of foot ulcers and 7 % a history of lower extremity amputation . Based on cl aims data , 30 % of respondents were at high risk for future foot complications . Compared to those at low risk , those at high risk were more likely to report having an  annual foot exam , using protective footwear , and perceiving themselves to be high risk for future foot complications . However , 50 % of those with cl aims indicating a high risk perceived themselves to be at low risk for future foot complications . Overall , 20 % of respondents seldom checked their feet daily for sores or irritations . Among this group , 60 % felt that it was unimportant and 9 % reported they were limited by poor vision or physical problems . Our findings suggest that strategies are needed to improve the delivery of preventive foot care services to older persons with diabetes . Additionally , emphasis is needed to help individuals underst and their risk and seek and perform appropriate preventive foot care This study investigated the effectiveness of a " h and s-on " foot care teaching/learning approach for adults with diabetes . By r and om assignment , the control group received a lecture presentation on foot care , while the experimental group participated in a h and s-on session on foot care in addition to the lecture presentation . Data concerning the subjects ' foot care knowledge and skills , the condition of their feet , and their level of HbA1c were gathered prior to and six months after the foot care educational sessions . No significant increases in knowledge about foot care were observed in the experimental group . The experimental group reported improvements in inspecting and washing their feet on a daily basis , and in care of the toenails . No significant differences were observed in the status of the subjects ' feet . The HbAlc readings were significantly improved for both the experimental ( t=4.10 , df=10 , p=0.002 ) and control ( t=2.25 , df=9 , p=0.051 ) groups . A h and s-on educational session may improve foot care practice s temporarily . However , long term effects need to be studied to discern overall improvement of foot care practice s and physical status of the feet Given that 14 million Americans have diabetes [ 1 ] , the common complications of this disorder , such as foot ulcers and lower extremity amputations , are of major concern to the medical community . Approximately 20 % of all diabetic patients hospitalized in the United States are admitted because of foot complications [ 2 , 3 ] . Furthermore , about 50 % of all nontraumatic amputations in the United States are done in patients with diabetes [ 1 , 4 ] . This proportion equates to about 55 000 amputations a year [ 1 ] or 59.7 amputations for every 10 000 persons with diabetes [ 5 ] . Patients who undergo an amputation are at greater risk for a second similar procedure on either the same or the other leg [ 6 , 7 ] . Yet , it has been estimated that about one half of the amputations in patients with diabetes , or about one fourth of the total amputations done in the United States , are preventable [ 1 , 4 ] . Recently , the focus has been on preventive strategies that minimize foot damage in diabetic patients and thereby reduce the rates of ulcers and amputations . These preventive strategies are based on two observations : first , that simple efforts on the part of the health care provider or patient can reduce the likelihood of subsequent amputation due to diabetes-associated foot disease [ 8 ] ; and second , that many of these simple procedures are not being systematic ally applied by health care providers or patients [ 9 ] . For example , studies indicate that physicians infrequently examine the feet of patients with diabetes [ 9 , 10 ] . Also , most patients with diabetes do not engage in simple foot-care assessment s to identify lesions requiring early treatment [ 11 ] . Preventive strategies are not systematic ally applied for several reasons : First , patients may not be aware of foot-care procedures or how to do them , or they may not believe that such procedures can make a difference ; second , podiatry and orthopedics services that could assist in foot salvage in diabetic patients may not be available ; and , finally , the health care system may make it difficult for patients or health care providers to examine the feet of patients with diabetes [ 10 ] . Several uncontrolled studies found that implementation of improved foot-care programs can significantly reduce lower extremity complications in patients with diabetes ; these studies showed a 44 % to 85 % reduction in the rate of lower extremity amput 
    Output:
    