Managing diabetic foot infections: a review of the new guidelines.

Foot infections are amongst the most frequent and severe complications linked to diabetes mellitus and are the most common non-traumatic cause of lower limb amputation. Appropriate management of these infections, however, can improve their outcome. The Infectious Diseases Society of America (IDSA) constituted a panel of multidisciplinary experts in 2004 to develop guidelines for the diagnosis and treatment of diabetic foot infections, which have been widely used and validated. Because there have been many new publications in the field, and the IDSA updated the format for all guidelines, they asked the diabetic foot infection committee to revise the 2004 publication. The revised guidelines, based on a thorough and systematic review of the literature, were published in 2012. They are built around 10 key questions concerning diagnosis and treatment; these are answered, with a summary of the evidence provided, and given a GRADE rating for the strength of the recommendation and quality of the evidence. The updated guidelines also include advice on implementing these recommendations, suggestions for regulatory changes to enhance care for diabetic foot infections, recommendations on performance measures and suggested areas for future research. They also include 14 tables, 1 figure, and 345 references, most of which were published after the first guidelines in 2004. Implementing these guidelines should improve outcomes in patients with a DFI.

Diabetic foot infections: state-of-the-art.

Foot infections are frequent and potentially devastating complications of diabetes. Unchecked, infection can progress contiguously to involve the deeper soft tissues and ultimately the bone. Foot ulcers in people with diabetes are most often the consequence of one or more of the following: peripheral sensory neuropathy, motor neuropathy and gait disorders, peripheral arterial insufficiency or immunological impairments. Infection develops in over half of foot ulcers and is the factor that most often leads to lower extremity amputation. These amputations are associated with substantial morbidity, reduced quality of life and major financial costs. Most infections can be successfully treated with optimal wound care, antibiotic therapy and surgical procedures. Employing evidence-based guidelines, multidisciplinary teams and institution-specific clinical pathways provides the best approach to guide clinicians through this multifaceted problem. All clinicians regularly seeing people with diabetes should have an understanding of how to prevent, diagnose and treat foot infections, which requires familiarity with the pathophysiology of the problem and the literature supporting currently recommended care.

Non-alcoholic fatty liver disease and insulin resistance: from bench to bedside.

Non-alcoholic fatty liver disease (NAFLD) is now the most frequent chronic liver disease in the developed countries. There is also growing evidence from basic and clinical research that NAFLD has a strong relationship to insulin resistance, which is a key factor in the development of type 2 diabetes. The aim of this review is to summarize the recent important findings linking NAFLD and insulin resistance. Lipid accumulation, particularly of diacylglycerol, appears to be of major importance in this process. Mitochondrial dysfunction, through decreased mitochondrial biogenesis, increases oxidative stress, and ageing also plays an important role. Finally, endoplasmic reticulum stress and inflammation also probably contribute to the development of insulin resistance via mechanisms that are still not well understood. Clinical aspects of NAFLD, such as its diagnosis and management, are also investigated in this review.

[Performance of natriuretic peptide as a marker in patients with chronic obstructive pulmonary disease]. / Faut-il doser le BNP chez les patients avec BPCO?

The dosage of natriuretic peptides improves diagnostic performance in patients with acute dyspnea when combined with clinical elements. The high sensitivity of this test allows reasonably excluding heart failure when the value is normal. Nevertheless, an increased level of this biomarker is not specific of heart failure and can be observed in different pathologies such as renal failure, sepsis or elevated pulmonary arterial pressure. We therefore analyse the diagnostic performance of natriuretic peptide in COPD patients and discuss its use for the detection of heart failure in this population.

Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes.

AIM: Hypothermia is a recognized complication of severe hypoglycaemia, but its prevalence and characteristics are poorly studied. For this reason, this study aimed to evaluate hypothermia in severely hypoglycaemic patients. METHODS: A retrospective chart review was performed including all patients discharged between 2007 and 2010 from the Emergency Department of the Geneva University Hospital with a diagnosis of severe hypoglycaemia. RESULTS: Hypothermia was identified in 30 (23.4%) out of 128 patients with severe hypoglycaemia. Its incidence was not affected by age, type of diabetes, season or time of day (day/night). Using linear regression, the lowest recorded temperature was associated with the Glasgow coma scale (GCS) score (r2 = 13.8%, P < 0.0001) and inversely associated with the leukocyte count (r2 = 13.1%, P = 0.001). CONCLUSION: Hypothermia is a frequent sign of severe hypoglycaemia in patients with diabetes. The associations between hypothermia and the GCS score and the leukocyte count suggest that it is a marker of hypoglycaemia severity and/or duration. Hypothermia may represent an important compensatory mechanism in severe hypoglycaemia, reflecting a decrease in energy demand during glucose deprivation.

[Diabetic nephropathy: an update]. / Néphropathie diabétique.

Diabetes has a constantly growing prevalence and leads to a number of complications such as diabetic nephropathy. A systematic screening and an adapted management are needed to limit the renal and also the cardiovascular complications linked to diabetic nephropathy. An adequate glycemic and tensional control and control of proteinuria are the priority in the care of diabetic nephropathy. Other aspects such as phospho-calcium balance, lipid panel or lifestyle changes are also important and therefore a multidisciplinary approach is essential. A better understanding of the physiopathology may lead to even more effective treatments in the future. We resume in this article the actual management of a patient suffering from diabetic nephropathy and the future treatment perspectives.

Use of brain natriuretic peptide to detect previously unknown left ventricular dysfunction in patients with acute exacerbation of chronic obstructive pulmonary disease.

BACKGROUND: Up to 30% of patients with chronic obstructive pulmonary disease (COPD) simultaneously suffer from often-unrecognised chronic heart failure (HF). Their timely identification is challenging as both conditions share similar clinical presentations. OBJECTIVE: To assess the performance of BNP in detecting left ventricular systolic dysfunction in patients with no history of HF admitted for acute exacerbation of COPD in a regional second-care hospital. METHODS: Retrospective medical records analysis of all patients hospitalised between January 2003 and May 2009 with the final diagnosis of acute exacerbation of COPD, and who had undergone BNP dosage at admission followed by an echocardiography. RESULTS: Among the 57 patients included, 13 had left ventricular systolic dysfunction. There was a statistically significant difference of mean BNP values between patients with or without systolic dysfunction (mean 689 pg/ml vs. 340 pg/ml, p = 0.007). For the detection of systolic dysfunction, a BNP level inferior to 100 pg/ml yielded a sensitivity of 92% and a negative predictive value of 91%, whereas BNP higher than 500 yielded a sensitivity of 80% and a positive predictive value of 47%. In a multivariate logistic regression analysis, a BNP value ≥500 (odds ratio 8.5, 95% confidence interval 1.9 to 38.2, p = 0.005) and history of coronary heart disease (odds ratio 5.9, 95% confidence interval 1.01 to 34.7, p = 0.048) remained as independent and mutually adjusted predictors of left ventricular systolic dysfunction. CONCLUSIONS: Our study confirms that BNP can help physicians in identifying heart failure in patients suffering from an acute exacerbation of COPD.

[Glycated hemoglobin: a new screening tool?]. / Hémoglobine glyquée: nouvel outil de dépistage?

Evaluation of mean glycemic control in diabetic patients is possible with the measure of glycosylated hemoglobin (HbA1c). Recently, new recommendations were made giving this test a diagnostic value for diabetes. HbA1c is the best prediction parameter of complications linked to diabetes; its measure is relatively accurate and simple. Nevertheless, the threshold value is arbitrary and a standardized method of dosage still remains limited. The aim of this article is to analyze the implementation of this dosage, its advantages and disadvantages as a diagnostic tool in comparison with plasma glycaemia, and current data concerning its sensibility, specificity and clinical implication.