Chronic Venous Disease and Its Intersections With Diabetes Mellitus.

Chronic venous disease (CVD) is a vascular disorder in which blood return is severely compromised and CVD is usually characterized by venous hypertension. Along with obesity and diabetes mellitus, CVD is one of the most common civilization diseases. In general, the estimated prevalence of CVD ranges from 60-80 %. Early diagnosis and adequate treatment are important for preventing progression to more severe stages of the disease like venous leg ulcers. Clinical manifestations of CVD in initial stages of the disease are often asymptomatic. However, as CVD progresses, symptoms begin to develop. Treatment of CVD could be divided into conservative and surgical. Conservative therapy consists of compression, pharmacological treatment and lifestyle change. In cases where conservative therapy is ineffective, surgical or endovascular treatment may be required. The intersections between diabetes mellitus (DM) and CVD are not to be underestimated. CVD and DM have often the same risk factors. Symptoms of CVD can be modified by late complications of DM, but the incidence of different CVD degrees seems to be the same as in diabetics as in non-diabetics population. We are particularly concerned in diabetics about worse compliance with treatment due to their often-poorer adherence to treatment of DM and lifestyle changes. Moreover, there exist a higher risk of CVD and peripheral arterial disease in diabetics patients. Patients with CVD should always be inspected for the presence of DM, considering its presence can have a bearing on CVD symptoms, diagnostic procedures, and therapeutic strategies.

Factors Influencing the Risk of Major Amputation in Patients with Diabetic Foot Ulcers Treated by Autologous Cell Therapy.

Introduction: Autologous cell therapy (ACT) is one of the last options for limb salvage in patients with chronic limb-threatening ischemia (CLTI) and diabetic foot ulcers (DFU). However, some patients may still undergo a major amputation even after ACT, but the risk factors for this are not known. Therefore, the aim of our study was to assess the risk factors for major amputation in patients with CLTI and DFU during a 2-year follow-up after ACT. Methods: One hundred and thirteen patients after ACT were included in our study and divided into two groups: Group 1 with major amputation (AMP; n = 37) and Group 2 without amputation (nAMP, n = 76). The risk factors for major amputation were evaluated before ACT and included factors relating to the patient, the DFU, and the cell product. Results: The AMP group had significantly higher C-reactive protein (CRP) levels compared to the nAMP group (22.7 vs. 10.7 mg/L, p = 0.024). In stepwise logistic regression, independent predictors for major amputation were mutation of the gene for methylenetetrahydrofolate reductase (MTHFR) with heterozygote and homozygote polymorphism 1298 (OR 4.33 [95% CI 1.05-17.6]), smoking (OR 3.83 [95% CI 1.18-12.5]), and CRP > 10 mg/L (OR 2.76 [95% CI 0.93-8.21]). Lower transcutaneous oxygen pressure (TcPO2) values were observed in AMP patients compared to the nAMP group at one month (24.5 vs. 33.2, p = 0.012) and at 3 months (31.1 vs. 40.9, p = 0.009) after ACT. Conclusion: Our study showed that the risk for major amputation after ACT in patients with CLTI and DFU is increased by the presence of MTHFR heterozygote and homozygote gene mutations, smoking, and higher CRP at baseline. Lower TcPO2 at one and 3 months after ACT may also have a predictive value. Therefore, it is necessary to stop smoking before ACT, treat any infection, and, above all, consider antiaggregation or anticoagulant treatment after the procedure.

Incidence and Risk Factors of Diabetic Foot Syndrome in Patients Early After Pancreas or Kidney/Pancreas Transplantation and its Association with Preventive Measures.

Diabetic foot (DF) can develop in diabetic patients after organ transplantation (Tx) due to several factors including peripheral arterial disease (PAD), diabetic neuropathy and inappropriate DF prevention. Aim: To assess the occurrence of DF and associated risk factors in transplant patients. Methods: Fifty-seven diabetic patients were enrolled as part of this prospective study. All patients underwent organ Tx (01/2013-12/2015) and were followed up for minimum of 12 months up to a maximum of 50 months. Over the study period we evaluated DF incidence and identified a number of factors likely to influence DF development, including organ function, presence of late complications, PAD, history of DF, levels of physical activity before and after Tx, patient education and standards of DF prevention. Results: Active DF developed in 31.6% (18/57) of patients after organ Tx within 11 months on average (10.7 ± 8 months). The following factors significantly correlated with DF development: diabetes control (p = .0065), PAD (p<0.0001), transcutaneous oxygen pressure (TcPO2;p = .01), history of DF (p = .0031), deformities (p = .0021) and increased leisure-time physical activity (LTPA) before Tx (p = .037). However, based on logistic stepwise regression analysis, the only factors significantly associated with DF during the post-transplant period were: PAD, deformities and increased LTPA. Education was provided to patients periodically (2.6 ± 2.5 times) during the observation period. Although 94.7% of patients regularly inspected their feet (4.5 ± 2.9 times/week), only 26.3% of transplant patients used appropriate footwear. Conclusions: Incidence of DF was relatively high, affecting almost 1/3 of pancreas and kidney/pancreas recipients. The predominant risk factors were: presence of PAD, foot deformities and higher LTPA before Tx. Therefore, we recommend a programme involving more detailed vascular and physical examinations and more intensive education focusing on physical activity and DF prevention in at-risk patients before transplantation.

Perfusion scintigraphy in the assessment of autologous cell therapy in diabetic patients with critical limb ischemia.

Perfusion scintigraphy with technetium-99-methoxy-isobutyl-isonitrile ((99m)Tc-MIBI) is often used for assessing myocardial function but the number of studies concerning lower limb perfusion is limited. The aim of our study was to assess whether (99m)Tc-MIBI was an eligible method for evaluation of the effect of cell therapy on critical limb ischemia (CLI) in diabetic patients. (99m)Tc-MIBI of calf muscles was performed before and 3 months after autologous cell therapy (ACT) in 24 diabetic patients with CLI. Scintigraphic parameters such as rest count and exercising count after a stress test were defined. These parameters and their ratios were compared between treated and untreated (control) limbs and with changes in transcutaneous oxygen pressure (TcPO(2)) that served as a reference method. The effect of ACT was confirmed by a significant increase in TcPO(2) values (p<0.001) at 3 months after ACT. We did not observe any significant changes of scintigraphic parameters both at rest and after stress 3 months after ACT, there were no differences between treated and control limbs and no association with TcPO(2) changes. Results of our study showed no significant contribution of (99m)Tc-MIBI of calf muscles to the assessment of ACT in diabetic patients with CLI over a 3-month follow-up period.

[Special contact splints in postoperative care for patients with the diabetic foot]. / Pouzití speciálních kontaktních dlah v pooperacní péci u syndromu diabetické nohy.

UNLABELLED: Adequate stabilization and off-loading of the lower limb is an integral part of postoperative care for patients with the diabetic foot. Off-loading can accelerate the healing process and reduce the number of complications and reoperations. The newly introduced method of the performance of removable contact splints (modified contact removable casts) seems to fulfil a number of requirements for stabilization and off-loading devices - the method is safe and can actually reduce the healing time and the number of reoperations in patients with the diabetic foot. KEY WORDS: diabetic foot - off-loading - splints.

[Transcutaneous oximetry in the diagnosis of ischemic disease of the lower extremities in diabetics]. / Transkutánní oxymetrie v diagnostice ischemické choroby dolních koncetin u diabetiku.

In diabetic patients with ischaemia of the lower extremities and mediocalcinosis the diagnosis of ischaemia is still difficult. One of the methods which give an objective idea of the microcirculation is transcutaneous oximetry. In the submitted paper the authors explain the principle and problems of assessment with recommendations for the practical application of the method, in particular in indication for angiography of the lower extremities in the presence of the diabetic foot syndrome with regard to probable spontaneous healing of defects and application of the method for following up the effect of revascularization operations.

Identification of patients at risk for diabetic foot: a comparison of standardized noninvasive testing with routine practice at community diabetes clinics.

The aim of the study was the comparison of a simple standardized noninvasive examination of neuropathy and angiopathy with routine diagnostic practice in community diabetes clinics for the identification of patients at risk of foot ulceration. Consecutive patients (n=322), aged 30 years and more, with a diabetes duration of more than 5 years, were examined by trained podiatric nurses in six diabetes clinics over a 1-year period; 44 of these patients had active or previous foot ulcerations. We evaluated the differences between the routine diagnostic practice (based on the patient's medical history and a physical examination) and noninvasive testing of peripheral neuropathy [vibration perception threshold (VPT) and the Semmes-Weinstein 10-g monofilament wire system] and angiopathy [Doppler ankle/brachial index (ABI)]. Using receiver operating characteristic (ROC) analysis, we evaluated the sensitivity and specificity of noninvasive testing methods for identifying patients at risk and selecting the optimal diagnostic cutoff points. Patients with severe neuropathy, as determined by noninvasive testing (VPT > or =30 V and/or insensitivity to 10 g monofilament), had been diagnosed to have neuropathy in diabetes clinics in 54% of cases. Patients with angiopathy at risk of developing diabetic foot ulcers (ABI < or =0.8) had been diagnosed, in diabetes clinics, to have peripheral arterial disease in 50% (they reported claudications in 41%, had femoral artery bruits detected in 29% and nonpalpable peripheral pulsations in 12%). Our findings stress the importance of using standardized simple noninvasive testing methods to increase the accuracy of identifying patients at risk for the diabetic foot at the community level.

[The Ewing test for autonomic neuropathy and spectral analysis of heartrate variability aid in the diagnosis of Charcot's osteoarthropathy]. / Vysetrení autonomní neuropatie Ewingovými testy i spektrální analýzou variability srdecní frekvence pomáhá diagnostikovat Charcotovu osteoartropatii.

UNLABELLED: The objective of the work was to evaluate the contribution of examining autonomic neuropathy in diabetic patients to early diagnosis of Charcot's osteoarthropathy by classical Ewing's tests, as well as the more recent method--spectral analysis of heart rate variability. The authors examined 18 diabetic patients in the early stage of Charcot's osteoarthropathy and the results were compared with a group of 30 subjects matched for age and sex. The results of examination by Ewing's test (heart rate variability during deep breathing, in orthostasis and during Valsalva's manoeuvre and blood pressure changes during orthostasis) revealed autonomic neuropathy in all examined patients, in one subject incipient neuropathy and in 17 of 18 patients manifest or severe neuropathy. The patients differed from controls highly significantly in all parameters of Ewing's tests with the exception of parameter 30:15 in orthostasis. The greatest sensitivity was recorded in the examination of the I-E difference during deep respiration. RRmax/RRmin and the brake index in orthostasis and Valsalva's ratio. The lowest sensitivity was recorded in the examination of the orthostatic fall of blood pressure. On spectral analysis the patients differed highly significantly from controls in all investigated parameters, the highest discriminating value was found in parameters of the total spectral power in the standing position (2) and the power in the low-frequency area in position 2, the first parameter alone was correctly discriminated in 94%. SUMMARY: Examination of autonomic neuropathy significantly improves the diagnosis of Charcot's osteoarthropathy. In addition to the classical Ewing tests spectral analysis of heart rate variability proved also a suitable method for its evaluation.

[Non-invasive diagnosis of angiopathies and neuropathies in screening for the diabetic foot syndrome]. / Význam neinvazivní diagnostiky angiopatie a neuropatie pri screeningovém vysetrení syndromu diabetické nohy.

As part of screening focused on the incidence and risk of the diabetic foot syndrome in patients in a model area the authors compared values of different parameters of non-invasive examination methods of angiopathy and neuropathy in patients with diabetic foot and in diabetic patients without diabetic foot. They compared the data with normal clinical diagnosis and used them to assess the degree of risk of diabetic foot. Patients with diabetic foot had when examined for the threshold of vibration perception (VPT) by a biothesiometer, as compared with patients without diabetic foot, significantly higher VPT levels 361 +/- 16 vs. 25 +/- 12 V, p < 0.001. For assessment of a high risk of diabetc foot in this age group of diabetics it proved useful to use as a critical VPT level, values above 30 V. During the non-invasive diagnosis of angiopathy in the group with diabetic foot a significantly lower ratio of systolic pressures ankle/arm (0.82 +/- 0.43 vs. 0.92 +/- 0.26, p < 0.05) was found. The critical value for high risk of diabetic foot is the ratio 0.8. Both non-invasive methods make current clinical diagnosis markedly more accurate when assessing the risk of diabetic foot. Patients with diabetic foot had, as compared with other diabetics, a poorer compensation of diabetes (HbA1c 8.6 +/- 2 vs. 8.0 +/- 1.5%, p < 0.05) and poorer renal functions (creatinine 114 +/- 57 vs. 94 +/- 25 umol/l, p < 0.01), the cholesterol and triacyglycerol levels were higher in both groups, however they did not differ significantly.