Analysis of patient satisfaction and donor-site morbidity after different types of breast reconstruction.

BACKGROUND AND AIMS: Breast reconstruction has been shown to improve quality of life. However, factors involved in long-term patient satisfaction are largely unknown. Our aim was to evaluate patient satisfaction and donor-site morbidity in five types of breast reconstruction. MATERIAL AND METHODS: A prospectively collected database of all breast surgery patients at Hospital Rudolfstiftung, Vienna, Austria, was searched for five types of breast reconstruction (2000-2006): implant, latissimus dorsi-flap, latissimus dorsi-flap with implant, free transverse rectus abdominis musculocutaneous-flap, and deep inferior epigastric perforator-flap. Patients were sent a study-specific questionnaire to assess satisfaction. Short-form 36-item health survey was used to analyze (quality of life), and complication data were retrieved from the database and assessed during a follow-up visit. RESULTS: There were 257 patients identified, of whom, 126 responded to the survey (17 implant, 5 latissimus dorsi + implant, 64 latissimus dorsi, 22 transverse rectus abdominis musculocutaneous, and 18 deep inferior epigastric perforator reconstructions). No statistical differences were found in complication or reoperation rates. Deep inferior epigastric perforator-flap patients were significantly more satisfied compared to patients from the implant group (p = 0.007). However, there was no significant difference regarding quality of life scores among the groups. After logistic regression analysis, only "impairment on daily life" showed to be independently correlated with patient satisfaction. This contrary to both operation type and complication rate which did not correlate with patient satisfaction. CONCLUSIONS: Our results indicate that operation type, complication rate, and revision rate did not independently correlate with patient satisfaction. Therefore, to further improve patient satisfaction, future research should be focused on other pro-operative factors, for example, patient education, expectations, and personality characteristics.

[Reduction of influenza-like infections by a phytoextract-vitamin-combination: a randomized, double-blind, placebo-controlled study]. / Reduktion grippaler Infekte durch eine Phytoextrakt-Vitamin-Kombination. Eine randomisierte, doppelblinde, placebokontrollierte Studie.

BACKGROUND: Recurrent infections are signs of a weakened immune system, and can be traced to a lack of vitamins and minerals. The objective of this study was to investigate the effect of a nutriological combination of vitamins, trace elements and phytochemicals on the incidence and duration of influenza-like infections. METHODS: Healthy subjects at risk of increased infection exposure took part in a randomized, double-blind, placebo controlled study, each involving a supplementation period of 12 weeks. The occurrence and severity of influenza-like infections and resort to study medication was documented by diary entries. SF-36 questionnaires to measure the health-related quality of life were completed at the start and end of the study. At final examination compliance was examined with respect to returned study medication, diaries and a questionnaire administered to evaluate the effect, safety, and tolerability of the test substance. RESULTS: Of 100 randomized participants, 80 (38 test treatment and 42 placebo) completed the study according to the protocol. In the test treatment group there were 60 influenza-like infections (1.6 infections/12 weeks), significantly fewer (p = 0.0003) compared with the placebo group with 113 episodes (2.7 infections/12 weeks). Further, the average number of days that the infection lasted was shorter in the test treatment group at 10.0 +/- 6.7 days, which was significantly shorter (p = 0.0003) than the placebo group at 28.5 +/- 13.6 days. The influenza-like symptom score and the mean duration of sick leave did not differ statistically between groups. Participants in the test treatment group assessed the global effectiveness of the test substance significantly better (p < 0.0001) than the participants of the placebo group. At the beginning of the study there was no difference between groups with respect to SF-36 results. However, at the completion of the study 6 of the 8 scales of SF-36 in the test treatment group were significantly better compared with the placebo group. CONCLUSION: In summary, consumption of the complex nutriological test preparation was associated with a significant reduction in the incidence of influenza-like infections, as well as their duration, and it was associated with significantly improved vitality, social functioning, and psychological well-being.

[Screening for hyperlipidemia in cardiovascular high-risk patients in austrian diabetes ambulances]. / Hyperlipidämie-Screening bei kardiovaskulären Hochrisikopatienten. Beobachtungsstudie in österreichischen Diabetesambulanzen.

BACKGROUND: Incidence of coronary heart disease is 2-4 fold increased in type 2 diabetic patients and diabetic dyslipidemia is a major risk factor.To reduce cardiovascular risk in diabetes decreasing LDL-cholesterol (LDL-C) is the major goal in lipid management. Evidence-based limits for LDL-C levels are for patients without cardiovascular complications <100 mg/dl and for patients with cardiovascular complications <70 mg/dl. The aim of the present screening initiative was to investigate the status quo of LDL-C levels in consecutively recruited diabetic patients suffering cardiovascu-lardisease. METHOD: A total of 921 type 2 diabetic patients with coronary, peripheral or central vascular complications were included in 2007 in 15 Austrian diabetes centers. Level of lipids and HbA(1c) were analyzed as well as data on patient's history and medical therapy were collected. Subjects (n=355) with LDL-C level <70 mg/dl at the beginning were not further evaluated. In the remaining 566 patients with baseline LDL-C >70 mg/dl, routine treatment was followed; 231 of them had a follow-up evaluation, 335 did notattend thecenterfor routine treatment again. RESULTS: LDL-C at the beginning was < 70 mg/dl in 355 patients (38.5%), in between 70-100 mg/dl in 348 patients (37.8%) and > 100 mg/dl in 218 patients (23.7%). All butonepatientswerealreadytreatedwith lipid lowering agents at baseline, whereas 96.4% got at least one standard statin or a statin with high potency. During lipid therapythe percentage of standard statins decreased significantly (p < 0.0001), whereas the percentage of high potency statins increased significantly (p < 0.0001 ). The percentage of ezetimib also increased significantly (p < 0.0001), fibrate nearly remained constant. The median LDL-C levels decreased from 97 mg/dl at baseline to 77 mg/dl at follow-up in subjects who attended the sites for follow-up (n = 231). CONCLUSION: This screening initiative demonstrated a more successful therapy if only lipid levels were followed more consequently.

Persistent arterial stiffness and endothelial dysfunction following successful pancreas-kidney transplantation in Type 1 diabetes.

OBJECTIVE: Successful simultaneous pancreas-kidney transplantation (SPK) in Type 1 diabetic (T1DM) patients results in improved cardiovascular outcome and survival. However, it is doubtful whether the impairment of cardiovascular and endothelial function in T1DM can be completely reversed. METHODS: Pulse-wave velocity, stroke volume, heart rate, serological markers of endothelial dysfunction (soluble intercellular, vascular cell-adhesion molecules, E-selectin, and plasminogen-activator-inhibitor-1) were measured in 10 T1DM patients after SPK with non-diabetic glucose levels, 10 T1DM patients with poor [T1DM>8; glycated haemoglobin (HbA1c)>8%], and 10 with good glucose control (T1DM<7, HbA1c<7%), in 6 non-diabetic patients after kidney transplantation (KT) and 9 non-diabetic control subjects (CON), matching for major anthropometric characteristics. RESULTS: Pulse-wave velocity was increased in SPK (P < 0.02 vs. CON, KT, T1DM<7) and in T1DM>8 (P < 0.02 vs. T1DM<7). Systolic blood pressure was increased in SPK (P < 0.05 vs. CON). Stroke volume was reduced in SPK, T1DM>8 and T1DM<7 and KT (P < 0.01 vs. CON). Heart rate was elevated in SPK and in T1DM>8 (P < 0.0003 vs. CON and T1DM<7). In SPK, soluble intercellular and vascular cell-adhesion molecules were 100% and 44% higher (P < 0.03 vs. CON), respectively, while plasminogen-activator-inhibitor-1 was decreased in SPK (P < 0.02 vs. CON). CONCLUSION: T1DM patients after SPK experience arterial stiffness, a higher heart-rate and blood pressure, reduced stroke volume and serological signs of endothelial dysfunction. Thus, functional and structural cardiovascular alterations as a result of glucotoxicity, uraemia and hypertension in T1DM might not be completely resolved by SPK.

Long-term mortality and incidence of renal dialysis and transplantation in type 1 diabetes mellitus.

AIMS: We investigated long-term mortality and requirement of renal replacement therapy (RRT) in type 1 diabetes mellitus (T1DM) to study risk factors and late complication incidence of T1DM in a prospective cohort study at Lainz Hospital, Vienna, Austria. METHODS: In 1983-1984, T1DM patients [n = 648; 47% females, 53% males; age, 30 +/- 11 yr; T1DM duration, 15 +/- 9 yr; body mass index, 24 +/- 4 kg/m(2); glycated hemoglobin (HbA1c), 7.6 +/- 1.6%] were stratified into HbA1c quartiles [1st, 5.9 +/- 0.5% (range, 4.2-6.5%); 2nd, 6.9 +/- 0.3% (6.6-7.4%); 3rd, 7.9 +/- 0.3% (7.5-8.4%); and 4th, 9.6 +/- 1.3% (8.5-14.8%)]. Twenty years later, both endpoints (death and RRT) were investigated by record linkage with national registries. RESULTS: At baseline, creatinine clearance, blood pressure, and body mass index were comparable among the HbA1c quartiles, whereas albuminuria was more frequent in the 4th quartile (+15%; P < 0.03). After the 20-yr follow-up, 13.0% of the patients had died [rate, 708 per 100,000 person-years (95% confidence interval, 557-859)], and 5.6% had received RRT [311 per 100,000 person-years (95% confidence interval, 210-412)]. Patients with the highest HbA1c values (4th quartile) had a higher mortality rate and a greater incidence of RRT (P < 0.04). In the Cox proportional hazards analysis, age, male gender, increased HbA1c, albuminuria, and reduced creatinine clearance were predictors of mortality (P < 0.05). Predictors of RRT were albuminuria (P < 0.001), reduced creatinine clearance (P < 0.001), and belonging to the 4th HbA1c quartile (P = 0.06). In Kaplan-Meier analysis, mortality was linearly associated with poor glycemia, whereas RRT incidence appeared to rise at a HbA1c threshold of approximately 8.5%. CONCLUSION/INTERPRETATION: In the Lainz T1DM cohort, 13.0% mortality and 5.6% RRT were directly associated with and more frequently found in poor glycemia, showing that good glycemic control is essential for the longevity and quality of life in T1DM.

Initially elevated osteoprotegerin serum levels may predict a perioperative myocardial lesion in patients undergoing coronary artery bypass grafting.

OBJECTIVE: We investigated whether osteoprotegerin (OPG), an important regulator in the genesis of arteriosclerosis and bone formation, is able to identify patients at risk for perioperative myocardial infarction measured as cardiac troponin I (cTNI) and signs of myocardial ischemia in the electrocardiogram after coronary artery bypass grafting (CABG). DESIGN: Observational study. SETTING: Post-surgical intensive care unit of a tertiary care center. PATIENTS: Ninety-seven patients undergoing elective CABG. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: OPG and cTNI were measured before and 24 hrs after CABG. Additionally, cTNI was measured after 12 hrs. Electrocardiography was done before and immediately after CABG. OPG before CABG (OPGpre) measurements correlated with cTNI measurements after 12 hrs (cTNI12) (r = 0.56; p < .0001) and with cTNI measurements after 24 hrs (cTNI24) (r = 0.77; p < .0001). OPGpre measurements correlated with electrocardiographic findings after surgery (r = 0.65; p < .0001). There was a positive correlation between OPGpre value and the number of bypasses (r = 0.95; p < .0001). A strong correlation was found between OPGpre and homocysteine (r = 0.96; p < .0001). The median OPG presurgical level for the four patients with cardiac complications was found to be notably elevated (28.1 [26.6/31.0] pmol/L) in comparison with that for patients without complications (10.2 [3.7/16.9] pmol/L). CONCLUSIONS: OPG appears to be a useful marker for estimating risk for perioperative myocardial infarction in patients undergoing CABG, as demonstrated by signs of ischemia on electrocardiography.

Progression and distribution of plantar pressure in Type 2 diabetic patients.

The aim of this prospective 4-yr study was to analyse changes in mean plantar pressure (PP) over time and local shifts of maximal PP in Type 2 diabetic patients. One-hundred fifty-five Type 2 diabetic patients (age 58.9 +/- 7.5 yr, diabetes duration 11.0 +/- 7.6 yr, baseline HbA1c 9.6 +/- 1.6%) were examined with regard to foot abnormalities, neuropathy and measurement of PP during walking (pedobarography). They were assigned to two subgroups, namely normal PP (n=94) and elevated PP (n=57). Patients with an abnormal mean PP did not significantly differ from subjects with a normal PP with regard to sex, age, duration of diabetes and HbA1c. With the exception of the hallux, the mean PP was significantly increased in both groups at all other plantar sites. Maximum PP was located below the metatarsal heads (MTH) 2-5 and significantly increased from baseline (median, lower/upper quartile: 475, 355/715 kPa) to the end of the study (540, 435/749; p<0.0001). On the other hand, PP was normalized in 17 subjects (29.8%) who had an elevated PP at baseline. Furthermore, we observed a local shift in maximal PP towards the MTH 2-5 region. The percentage of patients who had their highest PP under MTH 2-5 was increased from 54.0% at baseline to 61.1% at the end of the study. In general, we registered an elevation of PP over time and a centralization towards sites which are generally prone to ulceration.

The value of the Rydel-Seiffer tuning fork as a predictor of diabetic polyneuropathy compared with a neurothesiometer.

AIMS: The aim of the study was to investigate the predictive value of the Rydel-Seiffer tuning fork for detecting diabetic neuropathy and to compare it with an electronic neurothesiometer. METHODS: In 2022 consecutive diabetic subjects, peripheral polyneuropathy was diagnosed by vibration perception threshold (VPT) at the tip of both great toes using a 128-Hz tuning fork and a neurothesiometer, by simple bedside tests and by the presence of neuropathic symptoms. These evaluations were further combined to diagnose peripheral nerve dysfunction (abnormal bedside tests) and symptomatic neuropathy. VPT was also measured in 175 non-diabetic control subjects to define normal values. RESULTS: VPT was normal in 1917 subjects and abnormal in 105 (5.2%) patients when measured by the tuning fork. Patients with an abnormal vibration test were significantly (P < 0.0001) older than subjects with a normal vibration sense, while diabetes duration and HbA(1c) of the former were also significantly elevated. The same was true for the percentages of an abnormal 10-g monofilament test (66.7% vs. 7.2%, P < 0.0001) and a missing Achilles' tendon reflex (68.6% vs. 24.8%, P < 0.0001). Finally, the VPT measured by the neurothesiometer was 2.5 times higher in patients with an abnormal tuning fork test (32.0 +/- 9.8 vs. 12.5 +/- 6.4 V, P < 0.0001). The plot of the difference of both methods against their mean yielded a good agreement of the two VPT measurements, and the tuning fork had a high sensitivity and positive predictive value for the diagnosis of abnormal bedside tests and for symptomatic neuropathy. CONCLUSION: The tuning fork reliably detected peripheral neuropathy in comparison with the neurothesiometer. A tuning fork is a useful screening test for diabetic neuropathy.

Evaluation of granulocyte-colony stimulating factor (Filgrastim) in infected diabetic foot ulcers.

AIMS/HYPOTHESIS: To re-evaluate the use of Granulocyte-Colony Stimulating Factor (G-CSF) in the treatment of infected diabetic foot ulcers. METHODS: Thirty-seven diabetic subjects were randomised to Granulocyte-Colony Stimulating Factor (G-CSF) (n=20) or placebo (n=17). The primary endpoint was resolution of cellulitis, which was evaluated clinically and with an infection summary score. Patients were hospitalised for 10 days and received subcutaneously either 5 microg/kg G-CSF or placebo daily. Ulcers were treated with a standard wound protocol and the patients were instructed to stay in bed. All subjects received antibiotics (clindamycin and ciprofloxacin) intravenously until the inflammation had subsided. RESULTS: Patients who received G-CSF did not have an earlier resolution of clinically defined cellulitis (p=0.57). The infection summary score declined, but comparably, in both groups (G-CSF: 29.5+/-18.4 to 6.7+/-6.3 p<0.001, placebo: 24.2+/-16.9 to 8.9+/-7.2 p<0.001). The ulcer volume, which was not greater among placebo patients, was reduced by 59% in G-CSF and by 35% in placebo patients. CONCLUSION/INTERPRETATION: We conclude that antibiotic and non weight-bearing therapy (bed rest) accelerated the resolution of cellulitis in infected foot ulcers. Additional treatment with G-CSF had no further beneficial effect.

Limited joint mobility in selected hand and foot joints in patients with type 1 diabetes mellitus: a methodology comparison.

OBJECTIVES: First to determine the range of motion (ROM) of selected foot and hand joints with a goniometer, 2.) to determine joint limitation by prayer sign and 3.) to compare both methods used. METHODS: Maximal active ROM was measured by goniometry (Method 1) in 50 patients with Type 1 diabetes and in 44 healthy controls, respectively. The lower limits for normal ranges were defined as mean minus 2 SD. To elicit the prayer sign (Method 2) subjects were asked to put their hands together in a praying position with the fingers fanned. The number of missing joint contacts between the fingers was counted and correlated to ROM. RESULTS: The ROM of all joints measured, except that of the thumb, was significantly smaller in diabetic patients than in control subjects. The degree of the prayer sign was well correlated to the ROM of most hand joints, but was solely correlated in feet to ankle ROM. In diabetic patients the prevalence of limited joint mobility (LJM) measured by goniometry ranged from 2 to 20% in hand joints and from 10 to 14% in foot joints. By the prayer sign 33% of the diabetic patients had LJM. CONCLUSION: With both methods, diabetic patients had more limitations in joint motion than control subjects, as was their prevalence of LJM higher. Since the prayer sign was correlated to exactly measured ROMs, we would suggest using the prayer sign as a simple clinical indicator for LJM in diabetic subjects.

A prospective study of predictors for foot ulceration in type 2 diabetes.

One hundred eighty-seven type 2 diabetic patients without a history of foot ulceration were followed for a mean period of 3.6 years to investigate the incidence of foot ulceration in a diabetes cohort and to analyze risk factors for foot ulceration by multivariate means. During the study, 10 subjects developed 18 forefoot ulcerations. In multivariate logistic regression, significant predictors for foot ulceration were an elevated vibration perception threshold (VPT) (relative risk [RR] = 25.4), an increased plantar pressure (RR = 6.3), and daily alcohol intake (RR = 5.1). This is the first prospective study to demonstrate plantar pressure and daily alcohol intake as predictors of foot ulceration among patients without previous ulceration. Further, VPT could be confirmed as the strongest predictor for foot ulceration, and it was clearly demonstrated that the more pronounced severity of complications occurred among subjects with elevated VPT.

Estimation of risk for plantar foot ulceration in diabetic patients with neuropathy.

The main risk factors for plantar forefoot ulcers are loss of protective sensation due to sensory neuropathy and increased mechanical stress on the sole of the foot. The aim of this study was to find a better parameter than the plantar pressure to explain the occurrence of plantar ulcers under the metatarsalheads (MTHs). Twenty diabetic patients (3 Type 1 and 17 Type 2) each with 1 plantar ulcer and 23 Type 2 diabetic patients without plantar ulceration (controls), were investigated. The parameters of plantar pressure, length of contact time and pressure-time integral (PTI) were determined by pedography at defined foot regions. PTI represents the duration of mechanical stress on the foot. Based on the distribution of ulcers, the ratio of stress on the MTHs to that on the big toe was calculated. In diabetic patients with ulcers the difference of PTI between MTHs and hallux was higher at 153% and hence 3.2 times greater than the difference in plantar pressure between MTHs and hallux of 47.3%. In the control group the ratio of difference had a factor of 2 only because the corresponding difference in PTI was 85.1% and the difference in plantar pressure was 43.1%. These results may indicate that increased stress at the MTHs is responsible for the occurrence of planar ulcers compared with other regions of the sole. Diabetic patients with elevated PTI ratio are at risk of developing foot ulcers and therefore have to be provided with orthopaedic shoes to prevent foot ulceration.

[Intensified smoking cessation for diabetic patients--preliminary results]. / Intensivierte Raucherentwöhnung für Diabetiker--Vorläufige Ergebnisse.

Cigarette smoking is the most prominent yet avoidable cause of illness in the general population as well as in patients with diabetes. The danger of developing late complications is much higher for smoking than for non-smoking diabetic patients. The aim of this study was to determine whether an intensified smoking cessation program for patients with diabetes, including an initial 3 week-period of inpatient cessation, is effective and more successful than a mere outpatient program. The outpatient program consisted of at least 7 consultations within 2 years, and included nicotine replacement therapy, steps for modifying the smokers' behavioural patterns, advice in dietary and exercise as well as measurements of amounts of exhaled carbonmonoxide and lung function. In the inpatient program the patients passed the first 3 cessation weeks in a specialised clinic providing a similar, but intensified program, aside from daily life and professional routine. The following consultations corresponded to those of the outpatient program. Altogether we analysed 89 patients (64 in the outpatient and 25 in the inpatient program).

[Risk factors for increased plantar pressure in type 2 diabetes]. / Risikofaktoren für einen erhöhten plantaren Druck bei Typ 2 Diabetes.

Diabetic foot ulcers develop at high pressure sites, whereby causal factors for increased plantar pressure are insufficiently investigated. We clinically inspected the feet of 186 Type 2-diabetic patients and measured peripheral neuropathy and plantar pressure during walking. Subjects were assigned into a group with normal (n = 113) and elevated (n = 73) plantar pressure. In patients with elevated plantar pressure body weight was significantly increased (85.4 +/- 12.3 kg vs. 80.7 +/- 13.8), as was plantar pressure increased at the hallux (519 +/- 322 kPa vs. 346 +/- 154), at the metatarsal head I (MTH) I (442 +/- 270 vs. 235 +/- 95) and at the MTH II-V (788 +/- 277 vs. 446 +/- 145). The vibration perception threshold was significantly higher among these patients (21.8 +/- 11.0 Volt vs. 16.7 +/- 9.0), as was the prevalence of hyperkeratosis (69.9% vs. 43.4) and clawed toes (28.8% vs. 15.9). In a multiple regression analysis, hyperkeratosis (Beta = 0.25, p < 0.001) and body weight (Beta = 0.27, p < 0.001) were significant risk factors, but did not describe the whole variation of plantar pressure in the multivariate model. Limited joint mobility (LJM), which was not measured but estimated in the present study, was slightly more prevalent among patients with elevated plantar pressures (46.6 vs. 33.6%). It could be assumed, that LJM, if exactly measured, is a significant risk factor in a multivariate analysis, too.

[Effect of limited joint mobility on plantar pressure in patients with type 1 diabetes mellitus]. / Der Einfluss der Limited joint mobility auf den plantaren Druck bei Patienten mit Diabetes mellitus Typ 1.

Limited joint mobility (LJM) in the foot as well as the relationship of LJM and plantar pressure have not been well examined in patients with Type 1 diabetes mellitus. Pronation of the foot during stance phase is helping to absorb the shock of impact. Pronation of the foot is inevitably connected with abduction and dorsiflexion of the foot. We investigated the relationship of LJM and plantar pressure in 50 patients with Type 1 diabetes mellitus (age 40 +/- 11 years, duration of diabetes 23 +/- 10 years, HbA1c 8.2 +/- 1.1%) and the differences in joint mobility between these patients and 44 nondiabetic controls (age 35 +/- 10 years). Joint mobility was measured with a pocket-goniometer; plantar pressure was measured with a pedography platform during walking about barefoot. Statistical analysis showed a significant correlation between range of motion at the talocrural joint and the plantar pressure under the metatarsalheads 2-5, and at the right metatarsophalangeal joint 1 and the plantar pressure under the MTHs 4-5 respectively in diabetic patients. That means, the smaller the range of motion, the higher the plantar pressure. The range of motion in diabetic patients was smaller at the talocrural and metatarsophalangealjoint 1 than in controls. Increase of plantar pressure can be caused by LJM because it impares the shock absorbing capability of the forefoot.

Running shoes for relief of plantar pressure in diabetic patients.

There is a causal relationship between diabetic foot ulceration, elevated plantar pressure, and severe sensory neuropathy. Cushioned footwear intended to relieve plantar pressure is well established for prevention and healing of plantar ulcers. The aim of the present study was to investigate whether pressure relief by means of a running shoe with optimized forefoot pressure damping is comparable to that of a custom-made soft insole placed into an in-depth shoe. The in-shoe pressures were compared to an in-depth shoe with the original cork insole and with a leather-soled Oxford shoe. The maximum reduction of plantar pressure in the running shoe was 47% under the 2nd and 3rd metatarsal heads, 29% at the first metatarsal head, and 32% at the great toe in comparison to the Oxford shoe. This was surpassed only by the custom-made insole, which reduced pressures at the metatarsal heads by 50%. The specially designed running shoe yielded the same pressure relief at the central metatarsal heads as the custom-made insole. Such shoes are likely to be very useful in preventing diabetic foot ulceration in high-risk patients as a comparatively affordable and immediately available device.

Phrenic neuropathy in chronic renal failure.

BACKGROUND: Peripheral neuropathy and alterations in diaphragmatic muscle function are frequently caused by uraemia. Phrenic nerve function in patients with end stage renal failure, however, has not been examined to date. METHODS: An electrophysiological study of the phrenic nerve was performed to determine its possible involvement in 32 nondiabetic patients with end stage renal disease undergoing chronic haemodialysis. RESULTS: Seventeen patients had electrophysiological signs of peripheral neuropathy in at least one of the investigated nerves and 14 of the 17 showed pathological phrenic nerve latencies. Delayed phrenic nerve latencies correlated clearly with pathological peroneal nerve conduction velocities. CONCLUSIONS: Phrenic neuropathy is a frequent complication of uraemia.

Effect of autonomic neuropathy on ventilatory response to progressive hypercapnia in dialysis patients.

The impact of autonomic neuropathy (common in patients on haemodialysis) on ventilatory response to hypercapnia has been studied. We investigated cardiac reflex tests in 20 patients on chronic haemodialysis (8 patients were found with and 12 without neuropathy of the autonomic nervous system). Using the hyperoxic CO2-rebreathing method (according to Read), we tested the above-mentioned two groups of patients and compared them with 14 healthy control subjects. Accumulation of CO2 in blood with hyperoxic CO2 rebreathing stimulates central chemoreceptors, and therefore causes a progressive rise in minute ventilation. In patients with autonomic neuropathy (n = 8), ventilatory response to increasing pCO2 was significantly lower than that in the controls (1.7 +/- 0.3 versus 3.2 +/- 0.5 l/min/mmHg, P < 0.001). On the other hand ventilatory response in patients without autonomic damage (n = 12) showed no significant difference when compared to controls (3.1 +/- 0.8 l/min/mmHg). There were no differences in lung function, arterial blood gas analysis, blood chemistry, duration on dialysis, and demographic data when comparing the patients with and those without autonomic damage. Our analysis shows different patterns of ventilatory response to increasing pCO2 in patients on haemodialysis. Autonomic neuropathy has to be considered when rebreathing tests are interpreted. The clinical relevance of these findings needs further investigation.

[Prevalence of cardiac autonomic neuropathies in uremia and diabetes mellitus]. / Prävalenz der kardialen autonomen Neuropathie bei Urämie und Diabetes mellitus.

In the absence of relevant data, the prevalence of cardiac autonomic neuropathy was investigated in patients with diabetes mellitus or uremia due to other causes and diabetic patients with endstage renal failure. 117 patients (40 on a dialysis program without diabetes, 32 with diabetes mellitus type 1 but no nephropathy, 16 type 1 and 13 type 2 diabetic uremic patients, 16 diabetic patients with a kidney graft) and 25 healthy control subjects underwent assessment of the cardiorespiratory reflexes. The evaluation of parasympathetic damage was of particular interest. Definite parasympathetic dysfunction was detected in 32% of the non-diabetic uremic and in 19% of the non-uremic type 1 diabetic patients. Furthermore, 88% of type 1 and 77% of type 2 diabetic patients on dialysis and 75% of diabetic patients after kidney transplantation had evidence of autonomic neuropathy.