Eficacia de plantillas y zapatos terapéuticos en la reducción de la incidencia de ulceración en pacientes con neuropatía diabética: una revisión sistemática con metaanálisis / Efficacy of insoles and therapeutic shoes in the reduction of the ulceration incidence in diabetic neuropathy patients: A Systematic Review with meta-analysis

Objetivo Investigar el nivel de eficacia de plantillas personalizadas y zapatos terapéuticos en la reducción de la presión plantar y la incidencia de ulceración en presencia de neuropatía diabética. Metodología Las bases de datos PubMed, Scopus, Web of Science, Cinahls, Central Cochrane y Lilacs fueron encuestados en enero de 2020. Se incluyeron ensayos clínicos aleatorizados (ECA) que reportaron pacientes con neuropatía diabética sometidos a intervención con plantillas y calzado terapéutico en comparación con un grupo control. La calidad de las publicaciones se evaluó mediante la escala PEDro y la evidencia mediante la clasificación GRADE. En cuanto al metaanálisis, se realizó la agrupación de datos homogéneos y comparables. Resultados Se incluyeron 11 estudios, lo que resultó en una muestra de 1.443 participantes. Siete artículos presentaron datos suficientes para el metaanálisis. En el corto plazo, el riesgo relativo de protección fue de 0,23 (IC 95%; 0,07; 0,72), mientras que en el largo plazo el riesgo fue de 0,32 (IC 95%; 0,21; 0,48). La escala GRADE señaló baja calidad de evidencia en cuanto a la protección a corto plazo y alta calidad a largo plazo En el análisis cualitativo, seis estudios concluyeron que hubo reducción en la presión plantar del grupo de intervención. Conclusión Se encontró efecto protector del uso de plantillas en el desarrollo de úlceras a corto y largo plazo. (AU)

Objective To investigate the level of efficacy of personalized insoles and therapeutical shoes in plantar pressure and ulceration incidence reduction in the presence of diabetic neuropathy. Methodology The data bases PubMed, Scopus, Web of Science, Cinahls, Central Cochrane and Lilacs were surveyed in January/2020. Randomized clinical trials (RCT) were included that reported diabetic neuropathy patients submitted to intervention with insoles and therapeutical shoes compared to a control group. The quality of the publications was evaluated using the PEDro scale and the evidence by the GRADE classification. Regarding the meta-analysis, the grouping of homogeneous and comparable data was carried out. Results Eleven studies were included, which resulted in a sample containing 1,443 participants. Seven papers presented enough data for the meta-analysis. In the short term, the protection relative risk was 0.23 (IC95% 0.07;0.72), while in the long term, the risk was 0.32 (IC95% 0.21;0.48). The GRADE scale pointed out low evidence quality regarding short-term protection and high quality in the long term. In the qualitative analysis, six studies concluded that there was reduction in the plantar pressure of the intervention group. Conclusion Protective effect of using insoles was found in the development of ulcers in the short and long term. (AU)

Eficacia de plantillas y zapatos terapéuticos en la reducción de la incidencia de ulceración en pacientes con neuropatía diabética: una revisión sistemática con metaanálisis / Efficacy of insoles and therapeutic shoes in the reduction of the ulceration incidence in diabetic neuropathy patients: A Systematic Review with meta-analysis

Objetivo Investigar el nivel de eficacia de plantillas personalizadas y zapatos terapéuticos en la reducción de la presión plantar y la incidencia de ulceración en presencia de neuropatía diabética. Metodología Las bases de datos PubMed, Scopus, Web of Science, Cinahls, Central Cochrane y Lilacs fueron encuestados en enero de 2020. Se incluyeron ensayos clínicos aleatorizados (ECA) que reportaron pacientes con neuropatía diabética sometidos a intervención con plantillas y calzado terapéutico en comparación con un grupo control. La calidad de las publicaciones se evaluó mediante la escala PEDro y la evidencia mediante la clasificación GRADE. En cuanto al metaanálisis, se realizó la agrupación de datos homogéneos y comparables. Resultados Se incluyeron 11 estudios, lo que resultó en una muestra de 1.443 participantes. Siete artículos presentaron datos suficientes para el metaanálisis. En el corto plazo, el riesgo relativo de protección fue de 0,23 (IC 95%; 0,07; 0,72), mientras que en el largo plazo el riesgo fue de 0,32 (IC 95%; 0,21; 0,48). La escala GRADE señaló baja calidad de evidencia en cuanto a la protección a corto plazo y alta calidad a largo plazo En el análisis cualitativo, seis estudios concluyeron que hubo reducción en la presión plantar del grupo de intervención. Conclusión Se encontró efecto protector del uso de plantillas en el desarrollo de úlceras a corto y largo plazo. (AU)

Objective To investigate the level of efficacy of personalized insoles and therapeutical shoes in plantar pressure and ulceration incidence reduction in the presence of diabetic neuropathy. Methodology The data bases PubMed, Scopus, Web of Science, Cinahls, Central Cochrane and Lilacs were surveyed in January/2020. Randomized clinical trials (RCT) were included that reported diabetic neuropathy patients submitted to intervention with insoles and therapeutical shoes compared to a control group. The quality of the publications was evaluated using the PEDro scale and the evidence by the GRADE classification. Regarding the meta-analysis, the grouping of homogeneous and comparable data was carried out. Results Eleven studies were included, which resulted in a sample containing 1,443 participants. Seven papers presented enough data for the meta-analysis. In the short term, the protection relative risk was 0.23 (IC95% 0.07;0.72), while in the long term, the risk was 0.32 (IC95% 0.21;0.48). The GRADE scale pointed out low evidence quality regarding short-term protection and high quality in the long term. In the qualitative analysis, six studies concluded that there was reduction in the plantar pressure of the intervention group. Conclusion Protective effect of using insoles was found in the development of ulcers in the short and long term. (AU)

Inadequacies of micronutrient intake in normal weight and overweight young adults aged 18-25 years: a cross-sectional study.

OBJECTIVES: This study aims to assess adequacy in micronutrient intake in comparison with reference nutrient intakes (RNI) and to identify differences in intakes between normal weight and overweight individuals. STUDY DESIGN: A sample of 542 university students (18-25 years), normal weight (N = 369) and overweight (N = 173), were included in a cross-sectional study. METHODS: A three-day diet diary was used to assess energy and nutrient intake. Body mass index (BMI) and waist circumference were measured. RESULTS: Mean dietary vitamin D intake was lower than RNI in both men (4.44 µg) and women (5.04 µg). Mean intakes of calcium (597.44 mg), iron (8.62 mg) and folate (171.29 mg) were also lower than recommendations in women. Weight status (normal weight versus overweight) was significantly associated with micronutrient intake, and a trend towards a decrease in vitamin and mineral intake with increasing weight was noted. CONCLUSIONS: Results suggest the need to increase the intake of some micronutrients to meet the RNI, to ensure optimal health. This study provides a helpful tool to reinforce recommendations and potential health promotion and intervention strategies in university settings and could influence manufacturers involved in new food product development targeted to this young population.

Effect of pomegranate extract on blood pressure and anthropometry in adults: a double-blind placebo-controlled randomised clinical trial.

Pomegranate (Punica granatum), a polyphenol-rich fruit, has been suggested to reduce cardiovascular risk due to its antioxidant properties. Hypertension and obesity are the most preventable cardiovascular risk factors. Few studies on blood pressure and/or body-weight status have been conducted in human subjects. Previous investigations have tended to focus on pomegranate juice. The aim of the present study was to investigate the effect of pomegranate extract (PE) on blood pressure and anthropometric measures in adults with no symptomatic disease. A total of fifty-five participants enrolled in a randomised double-blinded placebo-controlled clinical trial where they were assigned to either PE capsules or placebo capsules for 8 weeks. Blood pressure, body weight, waist circumference, waist:hip ratio (WHR) and body composition (lean body mass, body fat) were measured at baseline, week 4 and week 8. Results showed a significant decrease in diastolic blood pressure after 8 weeks (by 2·79 (sd 5·32) mmHg; P < 0·05), while the decrease in systolic blood pressure did not reach statistical significance (2·57 (sd 7·4) mmHg; P > 0·05). Body fat percentage, lean body mass, waist circumference and WHR did not significantly differ between groups at the end of the intervention. Results suggest that PE may reduce blood pressure and possibly prevent hypertension in the normotensive population. Further large trials are required to elucidate this effect.

The association of bone mineral density measures with incident cardiovascular disease in older adults.

UNLABELLED: The associations of volumetric and areal bone mineral density (BMD) measures with incident cardiovascular disease (CVD) were studied in a biracial cohort of 2,310 older adults. BMD measures were inversely related to CVD in women and white men, independent of age and shared risk factors for osteoporosis and CVD. INTRODUCTION: We investigated the associations of volumetric (vBMD) and areal (aBMD) bone mineral density measures with incident cardiovascular disease (CVD) in older adults enrolled in the Health, Aging, and Body Composition study. METHODS: The incidence of CVD was ascertained in 2,310 well-functioning white and black participants (42% black; 55% women), aged 68-80 years. aBMD measures of the hip were assessed using DXA. Spine trabecular, integral, and cortical vBMD measures were obtained using QCT. RESULTS: During an average follow-up of 5.4 years, 23% of men and 14% of women had incident CVD. Spine vBMD measures were inversely associated with incident CVD in white men [HR(integral)=1.39, 95% CI 1.03-1.87; HR(cortical)=1.38, 95% CI 1.03-1.84], but not in black men. In women, aBMD measures of the total hip (HR = 1.36, 95% CI 1.03-1.78), femoral neck (HR = 1.44, 95% CI 1.10-1.90), and trochanter (HR = 1.34, 95% CI 1.04-1.72) exhibited significant associations with CVD in blacks, but not in whites. All associations were independent of age and shared risk factors between osteoporosis and CVD, and were not explained by inflammatory cytokines or oxidized LDL. CONCLUSION: Our results provide support for an inverse association between BMD and incident CVD. Further research should elucidate possible pathophysiological mechanisms linking osteoporosis and CVD.

Volumetric and areal bone mineral density measures are associated with cardiovascular disease in older men and women: the health, aging, and body composition study.

The associations of volumetric (vBMD) and areal (aBMD) bone mineral density measures with prevalent cardiovascular disease (CVD) and subclinical peripheral arterial disease (PAD) were investigated in a cohort of older men and women enrolled in the Health, Aging, and Body Composition Study. Participants were 3,075 well-functioning white and black men and women (42% black, 51% women), aged 68-80 years. Total hip, femoral neck, and trochanter aBMD were measured using dual-energy X-ray absorptiometry. Quantitative computed tomography was used to evaluate spine trabecular, integral, and cortical vBMD measures in a subgroup (n = 1,489). Logistic regression was performed to examine associations of BMD measures with CVD and PAD. The prevalence of CVD (defined by coronary heart disease, PAD, cerebrovascular disease, or congestive heart failure) was 29.8%. Among participants without CVD, 10% had subclinical PAD (defined as ankle-arm index <0.9). Spine vBMD measures were inversely associated with CVD in men (odds ratio of integral [OR(integral)] = 1.34, 95% confidence interval [CI] 1.10-1.63; OR(trabecular )= 1.25, 95% CI 1.02-1.53; OR(cortical )= 1.36, 95% CI 1.11-1.65). In women, for each standard deviation decrease in integral vBMD, cortical vBMD, or trochanter aBMD, the odds of CVD were significantly increased by 28%, 27%, and 22%, respectively. Total hip aBMD was associated with subclinical PAD in men (OR = 1.39, 95% CI 1.03-1.84) but not in women. All associations were independent of age and shared risk factors between BMD and CVD and were not influenced by inflammatory cytokines (interleukin-6 and tumor necrosis factors-alpha). In conclusion, our results provide further evidence for an inverse association between BMD and CVD in men and women. Future research should investigate common pathophysiological links for osteoporosis and CVD.

Effect of antiepileptic drugs on bone density in ambulatory patients.

BACKGROUND: Long-term antiepileptic drug (AED) use causes multiple abnormalities in calcium and bone metabolism that have been most extensively described in institutionalized patients. The objective is to determine the effect of AED on vitamin D levels and bone density in ambulatory patients and to compare the effects of enzyme-inducing and -noninducing AED and of single vs multiple therapy on bone density. METHODS: A cross-sectional evaluation was conducted of 71 patients (42 adults and 29 children/adolescents) on anticonvulsant therapy for at least 6 months who presented to neurologists at a tertiary referral center. Bone mineral density (BMD) as well as serum 25 hydroxy-vitamin D (25-OHD) levels were measured. A detailed questionnaire assessing calcium intake as well as previous and current intake of antiepileptic medications was administered to all patients. RESULTS: Over 50% of adults and children/adolescents had low 25-OHD levels, but this finding did not correlate with BMD. Antiepileptic therapy decreased BMD in adults. Generalized seizures, duration of epilepsy, and polypharmacy were significant determinants of BMD, more so at skeletal sites enriched in cortical bone. Subjects on enzyme-inducing drugs such as phenytoin, phenobarbital, carbamazepine, and primidone tended to have lower BMD than those on noninducers such as valproic acid, lamotrigine, clonazepam, gabapentin, topamirate, and ethosuximide. CONCLUSION: Epilepsy and its therapy, including the newer drugs, are risk factors for low bone density, irrespective of vitamin D levels. Skeletal monitoring with the institution of appropriate therapy is indicated in patients on chronic antiepileptic therapy.

Seasonal changes in the composition of the essential oil extract of East Mediterranean sage (Salvia libanotica) and its toxicity in mice.

Sage (Salvia libanotica) is an East Mediterranean plant, the extract of which is used for the treatment of colds, coughs, and stomach ache. Experimental studies on the toxicity of its oil are scarce despite its wide use in traditional medicine. This study aims to provide data on its acute toxicity and to investigate the relationship between seasonal changes in oil composition and toxicity. The composition of the oil extract from the leaves of this plant was determined at four different times of the year; August (summer), October (fall), January (winter) and April (spring). The toxicity of each fraction was investigated following intraperitoneal (i.p.) injection into mice. Distillations of oils from plants and GC analyses revealed that the main constituent of sage oil is 1,8-cineole. Other components included ketones such as camphor and alpha,beta-thujone, terpenes such as limonene and alpha,beta-pinene, and alcohols such as borneol and linalool. Major seasonal changes were found in the composition of the oil. Essential oil extracted from plants collected in the winter season (January) contained higher levels of camphor (12.3%), alpha,beta-thujone (1.9%), and camphene (4.8%). The winter extract was found to be the most toxic, (LD(50): 839 mg/kg body weight) and exhibited powerful convulsant properties. This indicates a strong correlation between the contents of camphor, thujones and camphene and the oils' toxicity. The spring extract was the least toxic (LD(50): 1200 mg/kg body weight) and contained lower levels of camphor (7.7%), alpha,beta-thujone (1.3%) and camphene (3.1%). Thus, we recommend that oil extracts of sage marketed for use in certain unconventional medicines be prepared from spring plants.

Cerebral oxygenation during warming after cardiopulmonary bypass.

OBJECTIVES: To evaluate jugular venous oxygen saturation (SjVO2), measured with a fiberoptic oximetry catheter, and brain tissue oxygen saturation, measured by near-infrared spectroscopy (NIRSO2), as monitors of cerebral oxygenation during cardiopulmonary bypass surgery. DESIGN: Prospective, clinical study. SETTING: Operating room of a Veterans Administration Hospital. PATIENTS: Nineteen patients undergoing moderate hypothermic cardiopulmonary bypass surgery. INTERVENTIONS: SjvO2 and NIRSO2 were monitored in the patients during the surgical procedure. MEASUREMENTS AND MAIN RESULTS: Moderate hypothermic cardiopulmonary bypass surgery had two distinct cerebral hemodynamic phases. While the patients were hypothermic, SjvO2 averaged 80 +/- 7% and none of the patients had an increase in cerebral lactate production. During the rewarming period, however, reductions in SjvO2 to < 50% occurred in 16 (84%) patients and increased cerebral anaerobic metabolism developed in 11 (58%) patients. SjvO2 during rewarming was dependent on mean arterial pressure, with 60 mm Hg appearing to be a critical value. Two other factors appeared to also contribute to the jugular desaturation, a low hematocrit and a rapid warming time. The SjvO2 catheter had excellent performance during the surgery. The average difference between paired measurements of SjvO2 by the catheter and in blood samples was -0.4 +/- 4.25%, and the correlation between the two measurements was highly significant (r2 = .93; p < .001). The NIRSO2 trended with the SjvO2 in most patients (r2 = .63; p < .001). CONCLUSIONS: The study confirms other studies showing that jugular venous desaturation can occur during rewarming after cardiopulmonary bypass surgery. Presently, SjvO2 appears to be a better monitor of cerebral oxygenation than NIRSO2. However, NIRSO2 has promise as a noninvasive monitor of cerebral oxygenation if future developments allow more quantitative measurements of oxygen saturation.

Subarachnoid neurolytic block under general anesthesia in a 3-year-old with neuroblastoma.

CASE REPORT: A 3-year-old boy with neuroblastoma complained of severe pain in the left lower extremity. Pharmacologic management had previously been attempted, but severe pain continued, and further upward titration was complicated by sedative effects. METHODS AND RESULTS: Because the focus of treatment had become the controlling of pain, a lumbosacral subarachnoid neurolytic block was performed under general anesthesia. One-time neurolysis was more acceptable to the family than a procedure like epidural analgesia, that requires greater management. Contrast medium was used to monitor the spread of the neurolytic. An epidural catheter was inserted during the neurolytic block procedure for possible future use. The short-term results were good--pain reports and opioid doses decreased greatly, although with increased incontinence. The boy had new abdominal distention and pain 5 days after neurolysis. Opioid doses and sedatives were increased. He died 3 days later.

Delayed splenic rupture: real or imaginary?

Although splenic injury is the most frequent abdominal injury resulting from blunt trauma, delayed splenic rupture is a rare event. From 1981 to 1990, 75 patients treated at St. Elizabeth Hospital Medical Center (Youngstown, OH) had blunt splenic injury. Splenic rupture was delayed in six of these patients (8%). More severe trauma, such as occurs with motor vehicle accidents, is more likely to lead to immediate rupture. Lesser trauma resulting from minor falls or fights is more likely to lead to delayed rupture. Subcapsular hematoma is the most common etiology for delayed splenic rupture. Although there is no reliable symptom or sign during the latent period, abdominal pain occurs almost uniformly and Kehr's sign is quite common. Peritoneal lavage and abdominal computerized axial tomography scan are accurate in diagnosing splenic rupture. Unfortunately, they are not always reliable in predicting delayed rupture.