Influence of infection on clinical picture of diabetic foot syndrome.

The aim of our study was to analyse the foot infections in diabetic patients. We analysed foot ulcerations in 124 diabetics who attended outpatient foot clinic, or were hospitalized in the period from 1996 to 2006. Basic neuropathy screening examination was made with cotton wisp, pin-prick, tuning fork, and monofilament. For evaluation of leg ischemia, besides the evaluation of the presence of pedal pulses, the ankle-brachial pressure index was measured. If the infection of foot ulceration was clinically present, bacteriology examinations was performed. In the case of deep wound infection, x-ray examination was made. If bone destruction was present, osteomyelitis was diagnosed by technecium bone scanning and by technecium-labelled leukocyte scan. Deformation and destruction of the bone without infection was appoited as Charcot neuroarthropathy. Foot ulcer infection was found in 58 % diabetic patients, wounds were more often deep (80 %). Infection was not associated with special location of foot ulcer. Two-third of the total infected wounds were associated with leg ischemia and 30.6 % of infected ulcer ended with leg amputation. More foot ulcer infections were found in the diabetics with HbAlc over 8 %. Infection was coupled with diabetic retinopathy (in 63 % patients) (p=0.023), and also with diabetic nephropathy (in 66 % patients) (p=0.012). Bacteriology examination revealed most often Staphylococci (45.8 %), antibiotic therapy was made most often with chinolones. Osteomyelitis was present in 34.7 % of foot ulcer infections. In 14 diabetics (56 %) after antibiotic therapy it was not necessary to perform a leg amputation. HbAlc seems to be a significant predictor of osteomyelitis (p<0.02; OR=1.76). In conclusion, we confirmed that diabetic foot infections, especially on ischemic leg, in diabetics with poor metabolic control and chronic diabetic microvascular complications, are associated with a higher risk of leg amputations. Further, it is possible to cure osteomyelitis successfully without surgery in more than half the cases (Tab. 1, Ref. 24). Full Text in free PDF www.bmj.sk.

Cryoglobulinemia manifested by gangraene of almost all fingers and toes.

Cryoglobulinemia is a rather rare condition accompanying quite a broad spectrum of different states and diseases. Mixed or polyclonal cryoglobulins can be seen in patients with autoimmune disorders, chronic infections and lymphoproliferative disorders. Monoclonal cryoglobulins are often revealed in patients with multiple myeloma or Waldenström's macroglobulinemia. Cryoglobulinemia is in most cases asymptomatic. Cryoglobulinemic vasculitis is an immune complex-mediated systemic disorder involving mostly small, but sometimes also larger vessels. In this report, we describe a case of a patient presented with gangrene of almost all fingers and toes, who was finally diagnosed and treated as cryoglobulinemic vasculitis due to multiple myeloma.

[Characteristics of foot ulcers in diabetic patients]. / Charakteristika ulcerácií na nohách u diabetikov.

INTRODUCTION: Diabetic foot syndrome is often presented as a skin lesion in diabetics. The aim of our study was to analyse foot ulcerations in diabetics, together with ethiopatogenesis, location and grade of impairment. METHODS: We analysed foot ulcerations in 124 diabetics who attended outpatient foot clinic, or were hospitalized in the period from 1996 to 2006. Basic neuropathy screening examination was made with cotton wisp, pin-prick, tuning fork, and monofilament. Beside the evaluation of the presence of pedal pulses, the ankle-brachial pressure index was measured. If the infection of foot ulceration was present, bacteriology examinations was performed. Wagner and University of Texas classifications of foot ulcerations were applied, moreover, location of ulcerations was analysed. RESULTS: Neuropathic ulcer was diagnosed in 46 patients of the total number of 124 (37%), neuroischemic in 76 patients (61%) and pure ischemic ulcer only in 2 patients (2%). Neuropathy was present in 122 (98%) patients with diabetic foot, limb ischemia in 78 patients (63%). Fifty four per cent of foot ulcers were located on toes and 43% ulcers on plantar surface. Foot ulcer infection was detected in 72 patients (58%). We found 48 superficial ulcers (38.7%) and 76 deep ulcers (61.3%). In diabetics without foot ischemia and infection 39% deep ulcers were present whereas in the group with ischemia and infection the proportion amounted to 80% (p < 0.05). CONCLUSION: Diabetic foot syndrom was present more often in type-2 diabetics with longer disease duration, in those on insulin treatment, in men of older age, further in the diabetics with pure glycemic control and/or with chronic microvascular diabetic complications.

Endothelaemia--a marker of vascular damage.

OBJECTIVES: The aim of the study was to determine the amount of circulating endothelial cells (CECs) in patients with an advanced cardiovascular (CV) disease, compare the values with a control group and finally to ascertain if there are statistically significant differences within the studied patient groups. BACKGROUND: Endothelaemia has been intensively studied as a marker of vascular injury. Clinical studies have demonstrated an increased endothelaemia in patients at high CV risk but also in certain non-cardiovascular disorders. Its possible usage in the diagnostics of the acute coronary syndrome and for CV risk assessment needs further investigations. METHODS: Thirty six hospitalized patients were studied. Quantitative measurement of endothelaemia was performed by the method developed by J. Hladovec. It is based on ECs counting in Bürker's chamber after their isolation with platelets and the removal of the latter by an addition of adenosine-diphosphate. RESULTS: The mean baseline endothelaemia was significantly higher in patients with increased cardiovascular risk when compared with the control group (1.38 +/- 0.899): ACS (4.9 +/- 1.59, p < 0.05) and PAOD (3.74 +/- 0.61, p < 0.05). When comparing the mean endothelaemia values in patients with PAOD before (2.67 +/- 0.86) and after (3.88 +/- 0.77) surgery, a significant increase of endothelaemia was observed (p < 0.05). CONCLUSION: Our pilot study, though limited by a relatively small number of patients, proved a significant increase of endothelaemia in patients at high CV risk, which is consistent with other available data. The introduction of newer specific methods based on immunomagnetic principles may provide a wider use of endothelaemia measurement in clinical settings (Fig. 3, Ref. 17). Full Text (Free, PDF) www.bmj.sk.

Microcirculation is similar in ischemic and venous ulcers.

Microcirculation of 15 ischemic and 15 venous ulcers, their scars, and intact surrounding skin were examined in order to demonstrate their similarities in the development and healing process. Subpapillary and nutritive perfusion of four areas were investigated by a laser Doppler perfusion imager (arbitrary units) and capillary microscopy (capillaries/mm2): one ulcer area without granulation tissue (no wound healing) and one with granulation tissue (ulcer healing); one skin area adjacent to the ulcer (1-8 mm) (scar developed from ulcer areas) and one distant (12-25 mm; intact skin). Areas without granulation tissue in ischemic and venous ulcers were similar, demonstrating a lack of capillaries (0.13 +/- 0.52; 0.93 +/- 2.09) and low laser Doppler flux (0.81 +/- 0.69; 1.47 +/- 1.17; P > 0.05 for each). In granulation tissue of both ulcers there was a tendency to a higher capillary density (0.67 +/- 1.40; 5.60 +/- 2.32; P < 0.0001 for venous ulcers) and a higher laser Doppler flux (1.15 +/- 0.67; 4.04 +/- 1.62; P < 0.0001 for venous ulcers) than in areas without granulation tissue. In scars of ischemic and venous ulcers capillary density (8.18 +/- 8.84; 13.60 +/- 5.45) and laser Doppler flux (1.72 +/- 1.00; 1.94 +/- 1.45) were similar (P > 0.05). In skin distant from ischemic ulcers very high capillary density (24.63 +/- 1.89) was associated with low laser Doppler flux (0.99 +/- 0.59); distant from venous ulcer capillary density was moderate (10.47 +/- 3.42) while laser Doppler flux was high (3.77 +/- 1.62; P < 0.0001 between both groups). The development and healing process of ischemic and venous ulcers is similar. Nutritive and subpapillary perfusion are involved in ulcer healing. In intact skin surrounding ischemic and venous ulcers, microcirculation is different due to the underlying pathophysiology.

90 years of Buerger's disease--what has changed?

Thromboangiitis obliterans or Winiwarter-Buerger's disease is a primary systemic vasculitis of an unknown etiology, which affects medium-sized arteries and veins mainly in the lower and upper extremities, causing multiple segmental arterial occlusions especially in young male smokers. The aim of our study is to compare the knowledge on the etiology, epidemiology, clinical presentation, diagnostic and therapeutic possibilities in the time of Leo Buerger (90 years ago) and now. Between 1994 and 1998, 26 patients (19 men and 7 women) were investigated with clinical suspicion for Winiwarter-Buerger's disease. Laboratory and arteriographic investigation revealed typical signs for this disease in 22 of them. To the most common clinical signs or symptoms belong smoking and the onset of the disease before the age of 50 years (in 95.5%), intermittent claudication (in 72.7%), rest pain and ischaemic ulcers or gangrenes in the fingers (in 68.2%). In slightly more than half of the patients migrating superficial thrombophlebitis was present and similarly in one half of the patients Raynaud's phenomenon was found. In conclusion--What has changed from the times of Leo Buerger? 1. Prevalence of TAO increased in women. 2. Older patients (more than 40 years old) are being diagnosed. 3. Upperextremity involvement is more frequently present. 4. Diagnosis of TAO is being more proper, especially due to up-to-date diagnostic methods, like digital subtraction angiography. 5. The treatment is more effective, amputation number is decreased. And what has not changed? Similarly like Leo Buerger we do not known the precise etiology of the disease. Ceasation of smoking has still the most important therapeutic procedure. The clinical course of the disease is individual and in spite of the treatment is the clinical course unpredictable. (Tab. 5, Ref. 47.)

Microcirculation in venous ulcers and the surrounding skin: findings with capillary microscopy and a laser Doppler imager.

BACKGROUND: To obtain more information about microcirculatory disturbances in venous ulcers, we studied their laser Doppler flux images and capillary densities. MATERIALS AND METHODS: On photographs of venous ulcers and the adjacent skin of 17 patients, four regions of interest were marked: one non-granulation tissue area (NGTA) within the venous ulcer, one granulation tissue area (GTA) within the ulcer, one adjacent skin area (ASA) and one distant skin area (DSA). Within these four regions the average laser Doppler area fluxes and capillary densities were determined for each patient using a laser Doppler imager and capillary microscopy respectively. RESULTS: The laser Doppler area flux (mean +/- SD in AU) was significantly lower in NGTA (1.39 +/- 1.12) than in GTA (4.06 +/- 1. 52) or DSA (3.86 +/- 1.54) (P < 0.00001). In addition, the ASA flux (1.95 +/- 1.39) was significantly lower than the GTA or DSA flux (P < 0.0001). Capillary density (capillaries per mm2) in NGTA (0.82 +/- 1.98) was significantly lower than that in GTA (6.00 +/- 2.55), ASA (13.88 +/- 5.16) or DSA (10.29 +/- 3.41) (P < 0.0001). In addition, the capillary density of ASA was significantly higher than that of GTA or DSA (P < 0.05). CONCLUSION: The four areas showed the following characteristics: NGTA, low laser Doppler area flux and lowest capillary density (possible sign of ulcer area without healing tendency); GTA, high laser Doppler area flux and second lowest capillary density (possible sign of wound healing); ASA, low laser Doppler area flux and highest capillary density (possible sign of healing process nearly completed; scar); DSA, high laser Doppler area flux and second highest number of capillaries (sign of microcirculation of chronic venous disorder).

Laser Doppler imaging and capillary microscopy in ischemic ulcers.

The local distribution of laser Doppler flux (mainly thermoregulatory perfusion) and capillary density (nutritive circulation) within 25 ischemic leg ulcers and their adjacent skin were investigated. For this purpose the technique of laser Doppler imaging and capillary microscopy were applied. In each ulcer a non granulation tissue area (NGTA), a granulation tissue area (GTA) and in adjacent skin a skin area (SA) were defined. In these areas the average laser Doppler area flux (arbitrary units, AU) and the number of capillaries/mm2 were determined for each patient. The mean+/-S.D. of laser Doppler area fluxes were: NGTA 1.30+/-1.93, GTA 2.13+/-1.53 and SA 1.21+/-0.77 AU, respectively. The differences between GTA and NGTA or SA was statistically significant (p < 0.001, each) The mean+/-S.D. of capillary densities were as follows: NGTA: 0.56+/-2.06, GTA 6.76+/-8.39 and SA 16.80+/-7.38 capillaries/mm2, respectively. The following differences were statistically significant: NGTA versus GTA (p < 0.01) and SA versus NGTA or GTA (p < 0.001, each). In conclusion following characteristics of the three areas can be described: In NGTA low laser Doppler area flux is combined with very low capillary density (ulcer area without healing). In GTA the highest laser Doppler area flux of all three areas and an intermediate capillary density (wound healing) is found. In SA an intermediate laser Doppler area flux is associated with the highest capillary density of all three areas with the healing process nearly completed and no granulation tissue.

Reproducibility of laser Doppler imager flux measurements within ischemic or venous ulcers and adjacent skin.

BACKGROUND/AIMS: The laser Doppler imager (LDI) is a device that maps the local distribution of the laser Doppler flux of tissues. To facilitate the interpretation of LDI measurements, we investigated their reproducibility. METHODS: We measured 10 arterial ulcers, 10 venous ulcers and their adjacent skin by the use of a LDI. The means were calculated of individual coefficients of variation ± standard error of mean (meanCV ±SEM) of measurements on the same day, on 5 different days and at specific time points (0, 30, 60, 90 and 120 min) during the application of PGE, on 2 different days. RESULTS: The meanCV ±SEM of measurements on the same day were 9.3±0.9% (ulcer), 9.8±0.9% (skin), and on 5 different days they were 21.9±1.9% (ulcer) and 28.6±2.4% (skin). Ulcer measurements on 5 different days were significantly more reproducible than skin measurements, if differences were calculated for all 20 patients or for the 10 patients with venous ulcers separately (P<0.05). During the application of PGE, for 120 min, meanCV ±SEM ranged from 19.2±4.0% to 26.9±5.0% (ulcer) and from 20.5±4.1% to 29.5+3.9% (skin). CV of skin measurements of all 20 patients at 0 min were significantly lower than those after 120 min of PGE(1) -application (P<0.05). CONCLUSION: Our results show an excellent reproducibility of LDI measurements on a single day. The reproducibility of measurements on 5 different days or during the application of PGE1 over a period of 120 min was poorer. Because of the poorer reproducibility, more patients are needed to study long-term or drug effects.