Validation of Sinhala Version of Cardiff Wound Impact Schedule in Patients with Diabetic Leg and Foot Ulcers

PURPOSE: To validate the Cardiff Wound Impact Schedule (CWIS) to assess the health-related quality of life (HRQoL) of Sri Lankan patients with diabetic leg and foot ulcers. METHODS: English version of CWIS was examined for cultural compatibility, translated into Sinhala and pretested. The Sinhala versionwas administered in parallel with the validated Sinhala version of SF-36 by an interviewer to all patients (n = 140) at baseline to determine the construct validity. Reliability of CWIS was measured by internal consistency and test-retest stability. The instrument was readministered in 2 weeks on 33 patients with nonhealing ulcers to determine the test-retest stability and in 3 months on 50 patients with healed ulcers to determine the ability of CWIS to discriminate HRQoL between patients with healed versus nonhealed ulcers. Acceptability of CWIS was assessed by the response rate, completion rate and the average time taken to complete a single interview. RESULTS: The construct validity demonstrated moderately significant correlations between related subscales of CWIS and SF-36 (Spearman's r = .32–.51, p = .021 to p < .001) for the whole study sample. Internal consistencies (Cronbach α = .68–.86) and test-retest stability (.56–.70) were acceptable. The tool was sensitive in discriminating the impact of the wound on HRQoL in healed versus nonhealed status (p ≤ .001). The tool showed good acceptability. CONCLUSIONS: The Sinhala version of CWIS is valid, reliable and acceptable for assessing the impact of wound on HRQoL. This instrument is sensitive in detecting the differences of the impact of healed and nonhealed ulcers on QoL in patients with diabetic leg and foot ulcer.

Identification of coronary heart disease in asymptomatic individuals with diabetes mellitus: to screen or not to screen / Identificación de enfermedad cardiaca coronaria en individuos asintomáticos con diabetes mellitus: Tamizar o no tamizar

Coronary heart disease (CHD) is highly prevalent in patients with diabetes mellitus (DM), and remains the single most common cause of death among this population. Regrettably, a significant percentage of diabetics fail to perceive the classic symptoms associated with myocardial ischemia. Among asymptomatic diabetics, the prevalence of abnormal cardiac testing appears to be high, raging between 10% and 62%, and mortality is significantly higher in those with abnormal scans. Hence, the potential use of screening for CHD detection among asymptomatic DM individuals is appealing and has been recommended in certain circumstances. However, it was not until recently, that this question was addressed in clinical trials. Two studies randomized a total of 2,023 asymptomatic diabetics to screening or not using cardiac imaging with a mean follow up of 4.4 ±1.4 yrs. In combination, both trials showed lower than expected annual event rates, and failed to reduce major cardiovascular events in the screened group compared to the standard of care alone. The results of these trials do not currently support the use of screening tools for CHD detection in asymptomatic DM individuals. However, these studies have important limitations, and potential explanations for their negative results that are discussed in this manuscript.

La enfermedad de la arterias coronarias (EAC) es muy prevalente en pacientes con diabetes mellitus (DM), y continúa siendo la principal causa de muerte en estos pacientes. Desafortunadamente, muchos diabéticos pueden carecer de síntomas de alerta en la presencia de isquemia miocárdica, por lo cual el diagnóstico de EAC puede ocurrir de manera tardía. Estudios observacionales han sugerido que la prevalencia de isquemia miocárdica puede ser alta en diabéticos asintomáticos (10 al 62% según la serie) y la mortalidad es mayor en esos pacientes. Por esto, el uso de pruebas para detección de EAC en el paciente diabético asintomático parece atractivo y es recomendado en ciertas circunstancias. Sin embargo, no fue si no hasta hace poco que dos estudios investigaron el verdadero rol de estas pruebas de manera randomizada. En conjunto, 2,023 pacientes diabéticos asintomáticos fueron aleatorizados a recibir o no una prueba para detección de EAC y fueron seguidos en promedio por 4.4 ±1.4 años. Al final de seguimiento, ambos estudios mostraron menos eventos cardiovasculares de los esperados, y el uso de pruebas para detección de EAC no redujo la tasa de eventos cardiovasculares comparado al no uso de estas pruebas. Los resultados de estos ensayos clínicos no soportan actualmente el uso de estas pruebas en el paciente diabético asintomático. Sin embargo, estos estudios tienen limitaciones importantes, y posibles hipótesis para explicar los resultados que son discutidas en el artículo.

Aspectos clínico-epidemiológicos de pacientes geriátricos con pie diabético / Clinical and epidemiological aspects of geriatric patients with diabetc foot

INTRODUCCIÓN: en el mundo, actualmente se estima que padecen de diabetes mellitus alrededor de 285 millones de personas y de ellas el 15 % sufre de pie diabético. Las principales complicaciones tardías son de patogenia vascular y metabólica; las úlceras en las extremidades inferiores, en especial en el pie, resultan una de las complicaciones más frecuentes. OBJETIVO: caracterizar a los pacientes geriátricos con pie diabético, según diferentes variables clínico-epidemiológicas. MÉTODOS: estudio descriptivo en 106 pacientes geriátricos con pie diabético, que fueron tratados en el Hospital "Dr. Mario Muñoz Monroy" de Matanzas entre septiembre de 2010 y marzo de 2012. Se confeccionó una planilla de recolección de datos que se completó a partir de las historias clínicas de los pacientes incluidos en el estudio. Las variables estudiadas fueron: edad sexo, factores de riesgo, enfermedades asociadas, color de la piel, tipo de pie diabético según la clasificación de Mc Cook, y estado de convivencia. RESULTADOS: la población más afectada fue la de 60-64 años (26,4 %). Predominó el sexo masculino (54,5 %). Prevalecieron los pacientes con un elevado tiempo de evolución de la diabetes, entre 11 y 20 años (66,9 %). El pie diabético isquémico resultó el de mayor frecuencia de aparición (52,8 %). Los pacientes de color de piel negra tuvieron menor afectación (10,3 %) que los de piel blanca. Los gerontes que vivían solos evidenciaron mayor cantidad de amputaciones (de 11 amputados, 7 vivían solos). El tabaquismo como factor de riesgo se presentó en el 66 % de los pacientes y la hipertensión arterial como enfermedad asociada en el 81,1 %. CONCLUSIÓN: llegar a la edad geriátrica representa una mayor preocupación para los pacientes diabéticos, pues en esta etapa aparece con más frecuencia el pie diabético. El sexo masculino, la hipertensión arterial, el tabaquismo, ser blanco o mestizo, así como vivir solo, constituyen elementos a valorar en el pronóstico de esta entidad.

INTRODUCTION: globally, 285 million people are estimated to suffer diabetes mellitus and 15% of them suffer from diabetic foot. The major late complications are vascular and metabolic pathogenesis; ulcers in the lower limbs, especially in foot, are one of the most frequent complications. OBJECTIVE: characterize geriatric patients suffering from diabetic foot according to different clinical and epidemiological variables. METHODS: a descriptive study in 106 elderly patients with diabetic foot was conducted from September 2010 to March 2012. These patients were treated at Dr. Mario Muñoz Monroy hospital in Matanzas. A form for data collection was designed to be completed from the patients´s medical records included in the study. The variables studied were: age sex, risk factors, associated diseases, skin color, type of diabetic foot as rated by Mc Cook, and state of coexistence. RESULTS: population aging 60-64 years were the most affected (26.4 %). There was male predominance (54.5 %). Patients with high duration of diabetes (11 and 20 years) (66.9 %) prevailed. The ischemic diabetic foot had the highest frequency of occurrence (52.8 %). black skinned patients were less affected (10.3 %) than white skinned ones. The elderly people living alone showed higher number of amputations (out of 11 amputees, 8 were living alone). Smoking as a risk factor occurred in 66% of patients and hypertension as associated disease in 81.1 %. CONCLUSIONS: reaching geriatric age represents a major concern for diabetic patients, because at this stage diabetic foot appears more frequently. Male gender, hypertension, smoking, white or mixed race and living alone, are elements to assess this entity prognosis.

Manejo de las complicaciones oftalmológicas de la Diabetes Mellitus / Management of ophthalmological complications of Diabetes Mellitus

Esta guìa contiene datos generales relacionados con la ceguera la edad en pacientes diabeticos no controlada. hay un incremento de casos por ceguera a nivel mundial que son de alta prevalencia y severidad. algunas clsificaciones de la diabetes mellitus oftalmopatìas; retinopatìa, opacidades del cristalino o cataratas, glaucoma, lesiones de la cornea, paresia o paralisis de musculos extraoculares secundario a neuropatìa. aunque existen alguna medidas de estricto control metabolico.

Complicaciones microvasculares en niños con diabetes mellitus tipo I / Microvascular complications in children with type I diabetes mellitus

Introducción: la diabetes mellitus (DM1) es la enfermedad crónica endocrinológica más frecuente en pediatría y de mayor repercusión sanitaria por la gravedad de sus complicaciones. Dentro de estas complicaciones tienen especial relevancia la afectación de la microvasculatura, que causa retinopatía, neuropatía y nefropatía. Estas complicaciones, si bien se manifiestan durante la edad adulta, comienzan a desarrollarse en la niñez. Existen normas internacionales para su identificación. Se citan factores de riesgo que favorecen su desarrollo. Objetivos: determinar la prevalencia de complicaciones microvasculares en niños y adolescentes portadores de DM1; evaluar si las recomendaciones internacionales para su búsqueda se cumplen; describir la presencia de factores de riesgo asociados a su desarrollo. Material y método: estudio descriptivo retrospectivo, en base a la revisión de historias clínicas de pacientes menores de 15 años con diagnóstico de DM1, asistidos en el Centro Hospitalario Pereira Rossell en el período comprendido entre el 1/1/2000 y el 31/12/2009. Resultados: en el período analizado se identificaron192 pacientes; con una media de edad al debut de 7,5años, con un promedio de 5,8 años de evolución deDM1. El 73,4% tenía mal control metabólico, casi 18%tenía sobrepeso, 2,1% presentaba obesidad, 22,6%tenía dislipemia y 17% eran sedentarios. Se habíasolicitado albuminuria al 39,6% y fondo de ojo al 77%de los que deberían haber sido estudiados, deacuerdo a pautas internacionales.

Introduction: type 1 diabetes mellitus (DM1) is themost common chronic endocrine pediatric disease. Ithas a greater impact by the severity of it chroniccomplications. Among these complications areparticularly relevant microvasculature involvement,causing retinopathy, neuropathy and nephropathy.These complications, although manifested inadulthood begin to develop in childhood. There areinternational standards for identification. Risk factorsthat favor its development are mentioned.Objectives: to determine the prevalence ofmicrovascular complications in children andadolescents with DM1; assess whether internationalrecommendations for the search are met; describe thepresence of risk factors associated with theirdevelopment.Methods: retrospective descriptive study, based on areview of medical records of patients younger than 15years diagnosed with DM1, assisted in the PereiraRossell Hospital in the period between 1/1/2000 and31/12/2009. Results: during the reporting period 192 patients wereidentified, with a mean age at onset of 7,5 years, withan average of 5,8 years of evolution of DM1. 73,4% hadpoor metabolic control, almost 18% were overweight,2,1% were obese, 22,6% had dyslipidemia, and 17%were sedentary...

Infarto muscular diabético: relato de caso / Diabetic muscle infarction: case report

JUSTIFICATIVA E OBJETIVOS: Diabetes mellitus (DM) é uma das doenças mais prevalentes e o conhecimento das suas complicações vasculares garante melhor tratamento aos pacientes.O infarto muscular diabético (IMD) é uma situação pouco reconhecida, que deve entrar no diagnóstico diferencial das lesões tumefactas, dolorosas, restritas a um grupamento muscular.A presença de outras lesões de órgãos-alvo indica maior risco de desenvolver o IMD. O objetivo deste estudo foi apresentar um caso incomum e, deste modo, contribuir para o maior reconhecimento e diagnóstico dessa doença. RELATO DO CASO: Paciente do sexo feminino, 24 anos, apresentando dor e aumento do volume da coxa e joelho esquerdos, iniciados há 15 dias, com piora gradual no período. Os exames de sangue evidenciaram aumento da creatinoquinase para níveis de 601U/L (valor de referência: 26 - 174 U/L) e velocidade de hemossedimentação igual a 126 mm/1ª hora. A ultrassonografia e a ressonância magnética foram sugestivas de um processo inflamatório muscular localizado. A biópsia confirmou o IMD.Tratada com repouso e analgésicos, com melhora completa. Duas recidivas subsequentes apontaram para possível efeito prejudicial do anticoncepcional oral. Feita a sua substituição, bem como otimização das medidas reológicas, sem mais recidivas. CONCLUSÃO: O caso relatado representa o típico IMD, com lesão localizada, autolimitada, conforme previamente publicado.Uma possível associação do IMD com o uso de contraceptivo oral,bem como o beneficio do uso de dois fármacos antiplaquetários,em associação, foram observados no presente caso. O IMD deve ser considerado no diagnóstico diferencial das lesões musculares dolorosas, em pacientes diabéticos. O efeito dos contraceptivos orais no surgimento dessas complicações, bem como o benefício dos agentes antiplaquetários merece investigação adicional.

BACKGROUND AND OBJECTIVES: Diabetes mellitus is one of the most frequent diseases and the awareness of its vascular complications promises a better treatment to the patients.Muscle diabetic infarction (MDI) is one of such situations, usually not recognized, which must be considered on differential diagnosis of edematous, painful lesions, restricted to muscle group.The presence of other target-organ lesions points toward a higher risk of developing MDI. The aims of the present study included the description of an unusual medical condition, thereby contributing to its recognition and diagnosis. CASE REPORT: Female patient, 24 years-old, presenting with pain and edema in the left thigh and knee, started 15 days ago,with progressive worsening. Blood sample examination has shown increased creatinokinase levels of 601U/L (reference range: 26 - 174 U/L) and erythrocyte sedimentation rate of 126 mm/h.Ultrasound and magnetic resonance suggested a localized inflammatory muscle process with areas of necrosis. Muscle biopsy has confirmed MDI. Management was based on bed resting and analgesia,with consequent improvement. Two recurrences in the sequence were possibly associated with oral contraceptive intake.No recurrence has been observed after the contraceptive withdrawal and association of antiplatelets agents. CONCLUSION: The present case is typical once the lesion was restricted to the thighs, recurrent, self-limited, in accordance with data reported elsewhere. The possible association observed between MDI and contraceptive intake as well as the benefit of antiplatelets cannot be confirmed to date, but highlights the need of further observations. MDI should be considered on differential diagnosis of painful and swelling lesions in diabetic patients.The harm of oral contraceptives and the benefit of antiplatelets agents deserve future studies.

Spirometry and diffusion studies in patients with type-2 diabetes mellitus and their association with microvascular complications.

Background. Diabetes is a systemic disease with-well known complications involving eyes, kidneys and nerves. The presence of an extensive pulmonary microvascular circulation and abundant connective tissue raises the possibility that lung may also be a target organ in diabetes. Methods. A total of 45 subjects were included in the study. All patients were evaluated for diabetic microangiopathies: nephropathy (by 24-hour protein excretion), retinopathy (by direct ophthalmoscopy) and neuropathy (by clinical examination). The patients were divided into following three groups: Group A: patients with type-2 diabetes mellitus (DM) with evidence of microangiopathy (n=15); Group B: patients with type-2 DM without any evidence of microangiopathy (n=15); Group C: non-diabetic subjects (n=15) as controls. Glycosylated haemoglobin (HbA1C) was measured as an indicator of glycemic control. Spirometry and single-breath diffusion capacity for carbon-monoxide (DLCO) were performed on all patients using Elite Series Body Plethysmograph machine. Results. A significant reduction of diffusion capacity corrected for alveolar volume (%DL/VA) was observed in group A (p<0.001), as compared to the other groups. There were no differences among the three groups for other pulmonary functions. There was a significant correlation between DL/VA percent predicted and albuminuria (r= -0.975, p<0.001), and DL/VA percent predicted and the retinopathy (r = -0.550, p< 0.05). Conclusion. This study shows a mild reduction in diffusing capacity in patients with type-2 DM with microangiopathy.

Glucosilación no enzimática y complicaciones crónicas de la diabetes mellitus / Non-enzymatic glycosylation and chronic complications of diabetes mellitus

La hiperglucemia es considerada hoy como un factor patogénico fundamental del desarrollo de las complicaciones neurovasculares diabéticas y, específicamente, desempeña un papel preponderante en el fenómeno de la glucosilación no enzimática y la formación de productos finales de la glucosilación avanzada. Objetivos: describir los mecanismos de la formación de los productos finales de la glucosilación avanzada y su relación con las complicaciones de la diabetes mellitus. Desarrollo: los productos finales de la glucosilación avanzada se producen por la reacción no enzimática de la glucosa y otros derivados glucados (glioxal, metilglioxal y 3-desoxiglucosona) con grupos amino de proteínas de larga vida. La glucosilación altera la estructura, las propiedades físico-químicas y la función de las proteínas intracelulares y extracelulares. En la membrana basal de los pequeños vasos se produce un engrosamiento y una distorsión de su estructura, que ocasiona pérdida de la elasticidad de la pared vascular y una permeabilidad anormal de esta a las proteínas (disfunción endotelial), así como aumento de la génesis de especies reactivas del oxígeno. La unión de productos finales de la glucosilación avanzada a sus receptores de membrana favorece la producción citoquinas y factores de crecimiento por los macrófagos y células mesangiales. Todo lo anterior favorece al desarrollo de aterosclerosis. Los productos finales de la glucosilación avanzada desempeñan un importante papel en el desarrollo de las complicaciones microvasculares y macrovasculares en el diabético. El control metabólico estricto de la glucemia y, en la actualidad, la terapéutica farmacológica con agentes que inhiben la formación de productos finales de la glucosilación avanzada o tienen acción antioxidante, constituyen alternativas terapéuticas para la prevención y solución del problema de las complicaciones crónicas de la diabetes mellitus(AU)

Hyperglycemia is nowadays considered as a fundamental pathogenic factor for development of diabetic neurovascular complications and, specifically, plays a prevailing role in phenomenon of non-enzymatic glycosylation and the formation of end-products of advanced glycosylation. Objetives: to describe the mechanisms of end-products of advanced glycosylation and its relation to complications of diabetes mellitus. The above mentioned end-products are produced by the non-enzymatic reaction of glucose and other derivatives including glioxal, methylglioxal and 3-desoxiblucosone with amines groups of long-life proteins. The glycosylation changes the structure, the physical-chemical properties and the function of intracellular and extracellular proteins. In basal membrane of small vessels it is produced a thickening and a structure distortion provoking the elasticity of the vascular wall and its abnormal permeability to proteins (endothelial dysfunction), as well as an increase of genesis of oxygen-reactive species. The link of end-products of advanced glycosylation with its membrane receptors favor the production of cytokines and growth factors by macrophages and mesangial cells. All above mentioned favor the development of atherosclerosis. The end-products of advanced glycosylation play a significant role in the development of microvascular and macrovascular complications in the diabetic patient. The strict metabolic control of glycemia and at present time, the pharmacologic therapeutics including agents inhibiting the formation of end-products of the advanced glycosylation have antioxidant action or are therapeutical alternatives for prevention and solution of the problem related to chronic complications of diabetes mellitus(AU)

challenge of undiagnosed pre-diabetes, diabetes and associated cardiovascular disease

To present the challenges of undiagnosed pre-diabetes, diabetes and associated cardiovascular disease. A substantial number of people with diabetes and pre-diabetes remain undiagnosed worldwide. Without preventive measures, pre-diabetes progresses to overt diabetes at the rate of approximately 5% per year. Both diabetes and pre-diabetes are associated with vascular complications. Undiagnosed pre-diabetes and diabetes is a major health problem, and we recommend widespread screening for diabetes. An international expert committee has recommended that HbAlc be used for the diagnosis of diabetes. Further studies are needed before HbAlc can be used as a diagnostic test for gestational diabetes

Complicações macrovasculares do diabetes melito: peculiaridades clínicas, de diagnóstico e manejo / Macrovascular diabetic complications: clinical characteristics, diagnosis and management

O diabetes melito (DM) é um fator de risco independente para doença arterial coronariana, acidente vascular cerebral, doença vascular periférica e insuficiência cardíaca, que são as principais causas de morte nesses pacientes. Além disso, pacientes com DM e doença cardiovascular têm pior prognóstico, por apresentarem menor sobrevida, maior risco de recorrência da doença e pior resposta aos tratamentos propostos. Os avanços diagnósticos e terapêuticos das últimas décadas já mostram uma redução do risco de eventos cardiovasculares nesses pacientes, mas o risco absoluto desses é ainda duas vezes maior em relação ao dos pacientes não diabéticos. Portanto, é prioritária a adoção de um manejo intensivo, com controle rígido dos fatores de risco cardiovasculares. Esta revisão trata das principais características clínicas e apresenta uma abordagem prática do rastreamento, diagnóstico e tratamento da doença macrovascular nos pacientes com DM.

Diabetes mellitus (DM) is an independent risk factor for coronary heart disease, stroke, peripheral arterial disease and heart failure, which are the main causes of death in these patients. Moreover, patients with DM and cardiovascular disease have a worse prognosis than nondiabetics, present lower short-term survival, higher risk of recurrence of the disease and a worse response to the treatments proposed. In the last decades, diagnostic and therapeutic progress had already shown benefits concerning cardiovascular risk reduction in these patients, but their absolute mortality risk is still twice that of non-diabetic patients. Because of this, the adoption of intensive treatment, with strict cardiovascular risk factor control, is a priority. The present study presents the main clinical characteristics and also the practical approach for screening, diagnosis and treatment of patients with diabetic macrovascular disease.

Microvascular reactivity in type 1 diabetics / Reatividade microvascular em diabéticos tipo 1

OBJECTIVE: To evaluate whether differences are present in microvascular response to the schemia induced by dynamic videocapillaroscopy (VCD), through analysis of the measured capillar transverse segment area (CTSA) in patients with type 1 diabetes mellitus (T1DM). METHODS: The vascular reactivity of the CTSA was studied by VCD, using a reactive hyperemia test in 61 volunteers, being 31 healthy controls without diabetes family history (Group 1) and 30 patients with T1DM without complications (Group 2). The images were captured every two seconds, during reperfusion after one minute induced ischaemia, and they were analyzed by the program Studio Version 8 and Motic Image Plus. The pre-ischemia capillary transverse segment (basal area, BA), the maximum strain post-ischemia (maximum area, MA), and time to achieve it (MAt) were measured during reperfusion, and the increased area percentage (Ap) was estimated. RESULTS: The mean differences between groups were evaluated by the t-test. The median comparisons between the groups were studied by the Mann-Whitney test. There was no difference in BA between the groups. The Ap was significantly lower among the diabetic patients, and there was a significant increase in the Mat among the patients of Group 2 when compared to Group 1. CONCLUSIONS: These data suggest that type 1 diabetes provokes earlier endothelial dysfunction, before the onset of clinically detectable degenerative complications. The outcomes from these alterations need further studies.

OBJETIVO: Avaliar se há diferença de resposta microcirculatória à isquemia induzida pela videocapilaroscopia dinâmica (VCD), por meio da análise de medida da área do segmento transverso capilar (ASTC) em pacientes com diabetes melito tipo 1 (DMT1). MÉTODOS: A reatividade vascular do ASTC foi estudada pela VCD usando o teste de hiperemia reativa em 61 voluntários, sendo 31 controles sadios sem história familiar de diabetes (Grupo 1) e 30 pacientes com DMT1, sem complicações (Grupo 2). As imagens foram capturadas a cada dois segundos, durante a reperfusão após um minuto de isquemia induzida, e analisadas pelo programa Studio Version 8 e Motic Image Plus. O segmento transverso pré-isquemia (área basal, AB), a área máxima pós-isquemia (área máxima, AM) e o tempo para alcançá-la foram medidos durante a reperfusão, e o percentual de incremento foi estimado. RESULTADOS: As principais diferenças entre os grupos foram avaliadas pelo teste t. As médias comparativas entre os grupos foram avaliadas pelo teste Mann-Whitney. Não houve diferença na área basal entre os dois grupos. O percentual de incremento foi significativamente menor entre os pacientes diabéticos e houve um aumento significativo no ASTC entre os pacientes do Grupo 2 quando comparados com o Grupo 1. CONCLUSÕES: Os dados sugerem que o diabetes tipo 1 provoca disfunção endotelial precoce, antes mesmo de complicações degenerativas serem detectadas clinicamente. Os fatores que levam a essas alterações necessitam de estudos adicionais.

Epistemologia sobre amputações e desbridamentos de membros inferiores realizados no Hospital Universitário de Maringá / Epistemology of lower limb amputations and debridements at Hospital Universitário de Maringá

CONTEXTO: Não há estatísticas precisas sobre o número de amputações realizadas anualmente, mas é conhecido o comprometimento da qualidade de vida desses indivíduos e a necessidade de uma equipe multiprofissional para sua reabilitação. OBJETIVO: Analisar todas as amputações de membros inferiores realizadas pelo Serviço de Angiologia e Cirurgia Vascular do Hospital Universitário Regional de Maringá entre 2000 e 2006. MÉTODOS: Estudo descritivo e retrospectivo a partir dos prontuários de pacientes submetidos a amputação ou desbridamento cirúrgico de membros inferiores por trauma ou doença vascular. RESULTADOS: Ocorreram 116 procedimentos, sendo 84,5 por cento amputações e 15 por cento desbridamentos cirúrgicos, em 111 pacientes, sendo 78 homens e 33 mulheres, cuja média das idades foi de 63,4 anos (4 a 100 anos), sendo os principais fatores etiológicos: doenças vasculares (92,8 por cento) e trauma (7,2 por cento). As comorbidades e fatores de risco mais prevalentes foram: hipertensão arterial sistêmica (66 por cento), diabetes melito (60 por cento), tabaco (28 por cento) e arritmia cardíaca (0,9 por cento). Quanto à escolaridade, se observou que 52,2 por cento dos pacientes cursaram apenas o ensino fundamental, 6,5 por cento fizeram o ensino médio, completo ou incompleto, e 41,3 por cento eram analfabetos. A percentagem de pacientes submetidos à amputação primária foi de 94,9 por cento, e secundárias, 5,1 por cento. No entanto, houve diminuição progressiva do coeficiente desses procedimentos a cada ano. CONCLUSÕES: Este trabalho permite inferir que a incidência de amputação de membros inferiores foi maior no sexo masculino e teve como principal causa a doença aterosclerótica, mas apresentou uma redução progressiva.

BACKGROUND: There are no precise data on the number of amputations performed every year. However, the decrease in quality of life of patients submitted to amputation is well-known, as is the need to involve a multidisciplinary team in the rehabilitation of these individuals. OBJECTIVE: To analyze all lower limb amputations performed by the Angiology and Vascular Surgery at Hospital Universitário Regional de Maringá, from 2000 to 2006. METHODS: A descriptive and retrospective study was performed to review medical records of patients submitted to amputation or surgical debridement of lower limbs to treat vascular diseases or trauma. RESULTS: A total of 116 procedures were carried out (84.5 percent amputations and 15 percent debridements) in 111 patients; 78 were males and 33 were females, with a mean age of 63.4 years (4-100 years). The main etiological factors were vascular diseases (92.8 percent) and trauma (7.2 percent). The most prevalent comorbidities and risk factors were hypertension (66 percent), diabetes mellitus (60 percent), tobacco (28 percent) and cardiac arrhythmia (0.9 percent). As to schooling, 52.2 percent of the patients had complete elementary school, 6.5 percent had complete or incomplete high school, and 41.3 percent were illiterate. Primary amputation was performed in 94.9 percent of patients, and secondary amputation in 5.1 percent. However, there was a progressive reduction in amputation rate at each year. CONCLUSIONS: Incidence of lower limb amputation was greater in males, had atherosclerotic disease as its main cause, but had progressive reduction.

Modulação autonômica cardíaca em repouso e controle metabólico em diabéticos tipo 2 / Cardiac autonomic modulation in rest and metabolic control in subjectswith type 2 diabetes

O objetivo deste estudo foi analisar a modulação autonômica cardíaca e o controle metabólico durante o repouso em diabéticos tipos 2. O grupo foi composto por 16 voluntários de ambos os sexos, sedentários, com 53,8 ± 8,4 anos. Foram coletados dados de variáveis antropométricas, bioquímicas, pressão arterial, variabilidade da freqüência cardíaca (VFC) e freqüência cardíaca (FC) em repouso. As variáveis fisiológicas e bioquímicas que apresentaram correlações significativas com a VFC de repouso foram pressão arterial sistólica, FC de repouso e glicemia de jejum. A relação cintura quadril e a lipoproteína de alta densidade apresentaram associações significativas com a FC de repouso. Os resultados sugerem que determinadas variáveis morfofisiológicas e bioquímicas podem influenciar na modulação autonômica cardíaca, no repouso, em indivíduos diabéticos tipo 2.

The purpose of the study was to analyze the cardiac autonomic modulation and metabolic control at rest in type 2 Diabetes patients. The group was composed of 16 volunteers of both sexes, sedentary, and aged 53.8 ± 8.4 years. They had data collected of anthropometrics and biochemical variables, blood pressure, heart rate variability (HRV) and rest heart rate. The physiological and biochemical variables significantly associated with HRV were systolic blood pressure, resting heart rate and fasting glycemia. The waist-to-hip ratio and the high-density lipoprotein levels were significantly associated with HR at rest. These results are consistent with morphophysiological and biochemical variables influencing cardiac autonomic modulation, at rest, in type 2 diabetes patients.

Biochemical markers and lipoprotein profile levels in childhood type I diabetes mellitus: early prediction of vascular complications

Diabetes mellitus is the most common endocrine and metabolic disorder in childhood and adolescents, with no cure. In this work, we studied the serum levels of the soluble leucocyte adhesion molecules, vascular adhesion molecules -1 [sVCAM-1], intercellular adhesion molecules -1 [Svcam-1], intercellular adhesion molecules [sICAM-1, sICAM-2], and sE-selectin. Also, we studied the lipoprotein phenotype including: serum triglyceride, serum cholesterol, HDL. VLDL, LDL, apoA, and apoB in the serum of 27 children [13 male 14 female] with type 1 diabetes mellitus with and without vascular complications. Their ages ranged from [2.25-20 years] with a mean 15.6 +/- 5.2 years. They were divided into two groups, group [Ia]comprised 14 patients without vascular complications and group [Ib], 13 patients with vascular complications [microalbuminuria, neuropathy, hypertension and retinopahy] presenting with vaying degrees of metabolic control and disease duration and were compared with age, sex matched healthy subjects [n=22, 10 male, 12 female] mean age 14.9 +/- 4.8 yeas. There were significantly higher concentration of soluble sVCAM-1 [mean 1866.7 +/- 631.6ng/mL], sICAM-1 [mean 581.6 +/- 387.1ng/mL], sICAM-2 [mean 425.1 +/- 215.6ng/mL] in type 1 diabetic patients versus age, sex matched control [mean 947.3 +/- 469.6. 184.8 +/- 62.3, and 193.1 +/- 66.6 ng/mL] respectively, p<0.001. As regards sE-selectin there was no significant differences in the concentration in both diabetic and control groups. Significant positive correlations were found between [sICAM-1, sICAM-2] and HbAlc [r=0.44, r=0.37] respectively p<0.05, but no correlations were found between sVCAM-1 or sE selectin and glycosylated hemoglobin. There was a significant increase in sVCAM-1 serum of diabetic children with vascular complications as compared to diabetic children without vascular complications [mean 2183.6 +/- 600.3 versus 1590.4 +/- 584.2ng/mL] [p<0.05]. In diabetic children with positive microalbuminuria there were significant higher levels of sVCAM-1 concentration when compared with the normoalbuminuric diabetic patients [mean 2343.2 +/- 572.7 versus 1709.4 +/- 576.7 ng/mL] p<0.05. While no significant difference were found in the levels of sICAM-1, sICAM-2 and sE-selectin between both groups of diabetic children with and without vasacular complications. As regard lipid profile there were significant increase in serum triglycerides [mean 140.6 +/- 40.9, p<0.01], serum cholesterol [mean 190.6 +/- 25.7, p<0.001], VLDL [mean 26.2 +/- 7.9, p<0.05], LDL [mean 121.8 +/- 29.6 p<0.001], apoA [mean 208.1 +/- 47.4, p<0.001 and apoB [mean 175.9 +/- 54.8, p<0.001] in diabetic patients as compared with control group [mean 100.7 +/- 32.5, 152.5 +/- 26.7, 20.1 +/- 6.5, 78.7 +/- 29.9, 148.5 +/- 42.9 and 84.53 +/- 33.2] respectively. There was a decrease in HDL in diabetic patients as compared to control group but it was not statistically significant. Correlations between circulating adhesion molecules and lipid profile revealed that there was a significant correlations between sVCAM-1 and serum triglyceride, serum cholesterol, HDL. LDL in diabetic children with vascular complications [r=0.56, r=0.53 p<0.01, r=0.43, r=0.46 p<0.05] respectively. In diabetic children without complication there was a significant correlation between sVCAM-1 and cholesterol. VLDL [r=0.37, r=0.39 respectively p<0.05]. Also, there was a significant positive correlation between sICAM-1 and VLDL [r=0.46, p<0.05], and there was a significant correlation between sICAM-2 and LDL [r=0.37, p<0.05] in diabetic children with vascular complications. But there was no significant correlation between sVCAM-1 and sICAM-1, sICAM-2 and sE-sellectin levels in both groups of diabetic patients and their age, disease duration, mean blood glucose, insulin dose, or frequency of diabetic ketoacidosis or hypoglycemic attack which reflect extreme variation in the glycemic control. In patient with microalbujminuria, there was a significant positive correlation between sVCAM-1 and serum triglycerides, serum cholesterol, LDL [r=0.45, p<0.05, r=0.48 p<0.01, r=0.37 p<0.05] respectively. Also a significant positive correlation was found between intercellular adhesion molecules sICAM-2 and LDL [r=0.39, p<0.05]. sICAM-1 has a positive correlation with triglyceride [r=0.39, p<0.05] and a significant negative correlation with HDL [r=0.4, p<0.05], was identified as well. We concluded that in respective of actual metabolic control, serum concentration of sVCAM-1 sICAM-1 and sICAM-2 but not sE-selection are elevated in patients with type I diabetes mellitus, reflecting ongoing endothelial cell stimulation and leucocyte activation even in the absence of clinically detectable angiopathy. Our results suggest an important role of sVCAM-1 in micro and macrovascular complications which may serve as the basic for further evaluation of circulating sVCAM-1 as a potential serum marker for vascular complications. Also sICAM-1, sICAM-2, seem to be good and reliable indicators of glycemic control. Our finding proved an important relationship between adhesion molecules and dyslipidemia exists in type 1 diabetic patients with vascular complications. It is recommended to screen diabetic children regularly for sole adhesion molecules, lipid profile and microalbuminurea levels for early detection of diabetic vascular complications

Monitorização ambulatorial da pressão arterial e diabete melito tipo 2 / Ambulatory blood pressure monitoring and type 2 diabetes mellitus

A hipertensão arterial sistêmica (HAS) é um dos principais fatores de risco para a instalação e progressão das complicações crônicas do diabetes melito (DM) tipo 2. A medida da pressão arterial (PA) através da monitorização ambulatorial da PA (MAPA) apresenta melhor correlação com o desenvolvimento de lesões em órgãos-alvo do que a medida no consultório. Além disso, permite a avaliação de parâmetros pressóricos distintos como as médias das PAs sistólica e diastólica das 24 h, do dia e da noite, cargas pressóricas e ausência do descenso noturno, além da identificação de pacientes com HAS do avental branco e mascarada. Os pacientes com DM apresentam maiores médias de PA diurna e noturna do que os sem DM. Além disso, um terço do pacientes normotensos com DM tipo 2 apresentam HAS mascarada, que está associada a um aumento da albuminúria e da espessura das paredes do ventrículo esquerdo. Por outro lado, a prevalência e o efeito da HAS do avental branco nos pacientes com DM ainda não foram adequadamente avaliados. A determinação da ausência do descenso noturno da PA não acrescenta informação às medidas da PA nas 24 h, no dia ou na noite, mas a medida da PA noturna parece ser relevante na retinopatia do DM. Em conclusão, a determinação da PA através da MAPA é capaz de estratificar de forma mais adequada os pacientes em risco para o desenvolvimento das complicações crônicas do DM e tornou-se um instrumento indispensável para o controle efetivo da PA nestes pacientes.

Hypertension is one of the main risk factors for the onset and progression of chronic complications in type 2 diabetes mellitus (DM). Ambulatory blood pressure (BP) monitoring (ABPM) provides a better correlation with target organ lesions than BP obtained in the office. Furthermore, it allows the evaluation of distinct BP parameters such as the 24-h, daytime and nighttime systolic and diastolic BP means, BP loads and the absence of nocturnal drop of BP, as well as the identification of white-coat and masked hypertension. DM patients have higher daytime and nighttime BP means than non-DM patients. In addition, one third of normotensive type 2 DM patients have masked hypertension, which is associated with an increase in albuminuria and in left ventricle wall thickness. On the other hand, the prevalence and effect of white-coat hypertension in type 2 DM patients have not yet been properly evaluated. The absence of nocturnal drop of BP does not add information to the 24 h, daytime or nighttime BP measurements, but the nighttime BP means seem to be relevant in DM retinopathy. In conclusion, BP determination by ABPM allows better patient risk stratification for the development of DM chronic complications and is an essential instrument for effective BP control in these patients.

Doença cardiovascular em mulheres diabéticas assintomáticas / Cardiovascular disease in diabetic women without cardiac symptoms

A doença cardiovascular é a principal causa de morbi-mortalidade em pacientes diabéticos. A isquemia do miocárdio é freqüentemente assintomática, levando a um diagnóstico tardio e prejudicando o prognóstico. Como o risco de eventos cardiovasculares pode ser modificado pela triagem apropriada, a identificação precoce da doença arterial coronária é de grande benefício, em particular no sexo feminino. Ainda não há consenso sobre que paciente deve ser investigada e quando deve ser iniciada a investigação diagnóstica. A decisão sobre qual método diagnóstico não-invasivo deva ser o empregado na triagem inicial é complexa, devendo conhecer-se a prevalência da doença para justificar a investigação de rotina.

Cardiovascular disease is the main cause of cardiac death among diabetic patients. The myocardial ischemia is frequently asymptomatic, leading to late diagnosis and making prognosis worse. This is particularly true for women, for whom this diagnostic is possibility often disregarded. Appropriate screening can modify the coronary artery disease risk. The early diagnosis is highly beneficial, particularly regarding females. The decision of which non-invasive diagnostic method should be used in the initial evaluation is difficult. There are several diagnostic methods to make the preliminary investigation of coronary artery disease in diabetic women even without cardiac symptoms, but there is still no consensus about who should be investigated and when should the first cardiac evaluation start. The prevalence of the disease, as well as the cardiac risk, must be known in order to justify a broad survey, mainly in the female population.

Silent myocardial ischemia screening in patients with diabetes mellitus

The prevalence of diabetes mellitus is fairly increasing, especially in the developing countries. Diabetes is a major cardiovascular risk factor; it often leads to severe cardiovascular complications, and coronary artery disease (CAD) is the main cause of death in diabetic patients. Silent myocardial ischemia (SMI) is more frequent in diabetic patients. The progress made in detection and treatment of CAD allows reconsidering the screening of SMI, in the hope that early CAD diagnosis leads to a more effective therapy and the decrease of cardiovascular complications and mortality. However, the benefit of systematic SMI screening remains discussed. Current guidelines recommend screening SMI in asymptomatic diabetic patients selected for high cardiovascular risk (i.e. with two or more other cardiovascular risk factors, or peripheral or carotid arterial disease, or proteinuria). ECG stress test can be recommended in first intention if maximal heart rate can be achieved. For patient with inconclusive ECG stress test, myocardial scintigraphy seems more accurate than stress echocardiography. Coronary angiogram should be performed in case of positive stress test. Further evaluations of systematic screening have to be conducted on broad randomized trial.

A prevalência do diabetes mellitus está crescendo de forma importante, em especial nos países em desenvolvimento. A isquemia miocárdica silenciosa (IMS) é mais freqüente em diabéticos. Ainda, o diabetes é um forte fator de risco cardiovascular, sendo que, com freqüência, leva a graves complicações cardiovasculares. A doença arterial coronariana (DAC) é a principal causa de morte em pacientes com diabetes. Os progressos alcançados na detecção e tratamento da DAC permitem considerar o rastreamento da IMS, na expectativa de que o diagnóstico precoce levaria a terapias mais efetivas e a redução das complicações cardiovasculares e da mortalidade. Entretanto, o benefício do rastreamento sistemático da IMS permanece discutível. Recomendações atuais sugerem o rastreamento em pacientes diabéticos assintomáticos selecionados por possuírem alto risco cardiovascular (ex. dois ou mais marcadores de risco, ou doença arterial periférica ou doença arterial das carótidas, ou proteinúria). O ECG de stress pode ser considerado como teste inicial se a freqüência cardíaca máxima for atingida. Nos pacientes com este teste inconclusivo, a cintilografia do miocárdio parece ter mais acurácia diagnóstica do que o ecocardiograma de stress. A angiografia coronariana deve ser indicada em casos com teste de stress positivo. Avaliações futuras do rastreamento sistemático devem ser conduzidas em estudos randomizados multicênctricos.

Anthropometric evaluation in diabetic patients with ischemic stroke

O acidente vascular cerebral (AVC) é uma das causas mais freqüentes de mortalidade e de incapacidade. Os fatores de risco para o AVC incluem idade, gênero, diabetes mellitus (DM), hipertensão arterial e muitos outros. OBJETIVO: Avaliar obesidade e hipertensão arterial em pacientes diabéticos acometidos por AVC isquêmico (AVC-I) agudo. MÉTODO: Comparar as variáveis antropométricas entre pacientes diabéticos (grupo estudo) e não diabéticos (grupo controle). Avaliamos um total de 60 pacientes divididos em dois grupos: 34 pacientes não diabéticos e 26 pacientes com DM tipo 2. RESULTADOS: A prevalência de obesidade foi muito elevada entre os grupos estudados, assim como a hipertensão, não havendo diferença entre os valores da relação abdome-quadril (RAQ) do grupo estudo comparando com a do grupo controle. CONCLUSÃO: A prevalência de obesidade foi muito elevada entre os grupos estudados e houve predomínio de obesidade do tipo andróide. Não houve diferença significativa na avaliação antropométrica pela medida da RAQ e da cintura entre os grupos.

Você pensa em infarto muscular no paciente diabético? / Muscle infarction: do you think about it in a diabetic patient?

O infarto muscular diabético (IMD) é uma complicação incomum do diabetes (DM) de longa duração. Esta condição pode ocorrer em pacientes com DM tipo 1 ou 2 mal controlados, com presença de microangiopatia. O quadro clínico é de dor aguda e intensa com edema do músculo afetado, que persiste por muitas semanas e tem melhora espontânea. Apesar de incerta, a etiologia é atribuída à microangiopatia com oclusão das pequenas artérias. É diagnosticado por biópsia, embora os achados em T2 na ressonância magnética sejam típicos. O tratamento de escolha é analgesia apropriada, repouso no leito e cuidadoso controle metabólico. Relatamos 3 casos de IMD admitidos em um hospital geral que não foram de imediato diagnosticados, levando a conduta e tratamentos inadequados. Enfatizamos os aspectos clínico, de imagem e histológico do IMD, permitindo o diagnóstico precoce desta condição incomum, evitando tratamento inapropriado.

Homocysteine in type 2 diabetes mellitus: relation to diabetic vascular complications

Hyperhomocysteinemia has recently been recognized as an independent risk factor for cardiovascular disease. Diabetes mellitus [DM] is know to increase the risk of atherosclerotic vascular diseases. Insulin resistance syndrome is characterized by clustering of cardiovascular risk factors like hyperinsulinemia, hypertension .etc, that has been hypothesized to play an important role in atherosclerosis. The reason for the high susceptibility of diabetic patients to atherosclerosis remain incompletely understood. Plasma homocysteine [HCY] status in diabetics is still a matter of controversy. The aim of our work .was to study plasma level of HCY in type 2 diabetic patients and to study the relation of plasma HCY level to different diabetic vascular complications. The study included 40 patients with type 2 [DM] [aged 52.9 +/- 6.3 years]. and 25 apparently healthy controls matched in age and sex with the patients. Both groups were evaluated thoroughly and the following parameters were assessed, fasting blood post prandial blood glucose [PPBG], uric acid, serum creatinine, lipid fasting plasma insulin [FPI], homeostasis model assessment of insulin resistance [HOMA-IR] and plasma HCY level. Our study revealed significant increase in systolic blood pressure [SBP], diastolic blood pressure [DBP], FBG, PPBG, plasma cholesterol, triglycerides [TG] and low density lipoprotein cholesterol [LDL-c] but significant decrease in high density lipoprotein cholesterol [HDL-c] in diabetic patients vs control group. We found also significant increase in plasma HCY, FPI and HOMA-IR in diabetic patients vs control group, all [p<0,001].Thestudy also showed highly significant increase in plasma HCY in patients with macrovascular complications vs those with microvascular complications [31 +/- 1.69 vs 22.3 +/- 226, p<0.001]. In patients with type 2 DM there were significant positive correlation between HCY level and age, SBP, DBP, FBG, PPBG, serum creatinine, total cholesterol TG, LDL-c, FPI, proteinuria and HOMA-IR but significant negative correlation with HDL-c [all p<0.001]. From this study, it is concluded that hyperhomocysteinemia is present in type 2 DM especially in patients with concomitant macrovascular complications, and it can be considered as a definite risk factor for vascular complications in those patients