Eighty-five diabetic patients who were proficient in English were studied to assess the impact of educational material of varying literacy levels on patient comprehension. Two samples of available diabetes foot care material of Grade 11 and 9 readability (measured by SMOG formula) and purposely written in-house material of Grade 6 readability were used. Patients were randomized to read information of either Grade 6 and Grade 11 or Grade 6 and Grade 9 readability. Socio-demographic data and reading habits were collected to allow for identification of literacy markers. The mean CLOZE score (a measure of comprehension) was better in patients who read the Grade 6 information than for both the Grade 11 and Grade 9 information (59.5 +/- 11.8, 46.8 +/- 22.0, 45.8 +/- 22.2 respectively, p < 0.001). When evaluated in terms of percent of patients that could independently understand the material, Grade 6 information outperformed the Grade 11 and Grade 9 information (60%, 19%, 21%, respectively, p < 0.001). For the Grade 11 and Grade 9 information, poorer comprehension was associated with a non-English speaking background, early school leaving age, infrequent reading habits, and preference for tabloids (p < 0.02). Comprehension when patients read the Grade 6 information was no longer dependent on two of the four identified literacy markers. We conclude that reducing literacy demands of health literature improves patients' comprehension. Attention to socio-demographic data and reading habits can assist educators in assessing patients' literacy status and ensuring patients are given literature of compatible readability.

Transition from paediatric to adult care is a major milestone in the life of a young person with diabetes, yet it is commonly poorly done. This finding is supported by the dearth of publications in the literature that particularly relate to transition in diabetes care. Other transitions occur at this time of life, for example: from parental supervision to growing independence and from secondary school to post-school options. Health professionals know, from anecdotal evidence, that this is the period when young people with diabetes ‘drop out’ of the system. They often have no specialist follow-up and attend only the primary care physician for insulin prescriptions. Then, inevitably, a problem occurs that cannot be managed by the family doctor, such as diabetic ketoacidosis or pregnancy, and the patient is finally referred to an adult unit. There are many contributing factors to poor transition but two major reasons are that members of this age group are classic non-attenders and, importantly, they have not been well prepared for the transition. Preparation is the key to success and this must include parents as well as the young person. Components of transition preparation include: self-advocacy, independent health care behaviours, sexual health, psychosocial support, education and vocational planning, and health and lifestyle (drugs, alcohol, etc.). Considerable differences exist between many of the paediatric and adult services, and this cultural shift has significant impact on the success or otherwise of transition. Paediatric care is often multidisciplinary, family focused, prescriptive and requires parental direction and consent. Adult care is often provided by a single doctor, is patient focused, more investigational and requires autonomous, independent skills on the part of the user. Young people and their families, unless well prepared, become confused and disillusioned with the adult system. To avoid this situation, there is a variety of solutions, including adolescent transition clinics attended by both paediatric and adult teams, a transition coordinator who is responsible for making the transfer as smooth as possible, etc. Unfortunately, the very nature of the group in question means that none of these solutions is perfect. In reality, transition is a process that takes place over a number of years and should not be considered an event. The transition process needs to begin in early adolescence, to foster independence and communication skills, and to incorporate health education.

In a large country such as Australia, using telemedicine in management of diabetic foot disease may minimise unnecessary patient travel and also facilitate regular clinical monitoring. We tested a cost effective simple clinical system that accommodates routine and urgent consultations between an urban Diabetes Centre and rural sites. Routine consultations are organised by prior arrangement without the patient needing to be present. Process includes: (a) Digital images of foot e-mailed in advance to enable the Diabetes Centre foot team to review before phone linkup, (b) Images displayed on computer monitors during the phone linkup, (c) Patient management plan documented at both urban and local sites and implemented locally. Urgent consultations are booked on demand. The only limiting factor is the time taken for images to arrive at the Diabetes Centre. It is essential that at least one person from the Diabetes Centre foot team is available for immediate advice until further review can be arranged. We conclude that telemedicine is a useful adjunct to networking between rural and urban diabetic foot treatment services. It facilitates routine clinical care, allows for urgent consultations, research and ongoing training of this serious diabetic complication. This simple system is very portable relying on e-mail, and thus has the potential for use in very remote regions of Australia and in countries where diabetic foot services are limited.

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