Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study.

AIM: This study was an analysis of how diabetic patients with infected foot wounds are managed in hospital by departments specializing in diabetic foot pathology, including an evaluation of the outcome 1 year after discharge. METHODS: This was a prospective study of a cohort of patients hospitalized for diabetic foot infection at 38 hospital centres in France and followed-up for 1 year after discharge. RESULTS: Altogether, 291 patients were included (73% male; 85% type 2 diabetes; mean age: 64.3±11.7 years). Most of the wounds were located on the toes and forefoot, and infection was most often graded as moderate; nevertheless, in about 50% of patients, osteomyelitis was suspected. Also, 87% of patients had peripheral neuropathy and 50-62% had peripheral artery disease. Gram-positive cocci, and Staphylococcus aureus in particular, were by far the most frequently isolated microorganisms. During hospitalization, lower-limb amputation was performed in 35% of patients; in 52%, the wound healed or had a favourable outcome. A year after discharge, 150 non-amputated patients were examined: at this time, 19% had to undergo amputation, whereas 79% had healed their wounds with no relapse. Risk factors for amputation were location (toes), severity of the wound and presence of osteomyelitis. Peripheral artery disease was associated with a poor prognosis, yet was very often neglected. CONCLUSION: In spite of being managed at specialized centres that were, in general, following the agreed-upon published guidelines, the prognosis for diabetic foot infection remains poor, with a high rate (48%) of lower-limb amputation.

[Peripheral vascular disease and diabetic foot]. / Artériopathie et pied diabétique.

Peripheral vascular disease is one component of the diabetic foot. Diabetic patients should be assessed for lower limb arterial disease resulting from the high prevalence of this complication. Medical management includes the treatment of vascular risk factors, anti-thrombotic agents, and walking rehabilitation. Vascular testing is required in the presence of a foot wound. Ischemia alone is implicated in only 10% of foot wounds, whereas inadequate tissue perfusion is often a nonhealing factor. Managing a diabetic patient with a foot wound will be more effective in a dedicated center providing vascular assessment, a multidisciplinary pre concerted plan, and vascular management. Lowering the number of major amputations in the diabetic population requires better arterial evaluation and treatment (vascular functional testing and revascularization when possible).

[Transient neurological symptoms in puerperas after epidural analgesia during labor].

The investigation was undertaken to elucidate the impact of epidural analgesia (EA) during labor on the incidence of transient neurological symptoms (TNS). By the agreement of a local ethics committee, an informed consent was obtained from 90 healthy puerperas enrolled in the investigation. The patients were randomized into 3 groups, with 30 patients in each. At the beginning of labor, an epidural catheter was inserted in all the puerperas. For EA, 1% lidocaine solution and 0.2% ropivacaine solution were used in Groups 1 and 2, respectively; Group 3 was control in which EA was not performed. Two days after labor, an independent observer asked the females about possible neurological symptoms, by using the standard questionnaire. TNS included symmetric pain and/or dysesthesia in the buttocks, lower lumbar region, and/or legs. The patients who presented problems were proposed to indicate the degree of discomfort by a 10-score verbal scale. The findings were statistically processed using the U-test and X-test (p < 0. 05). A total of TNS occurred in 22 (25%) patients, including 7 (27%), 8 (27%), and 7 (23%) in Groups 1, 2, and 3, respectively. This difference was not statistically significant. The duration of TNS was generally short; in all the patients, the symptoms were completely resolved after 24-72 hours. Labor EA is not a cause of TNS. The type of a local anesthetic (lidocaine, ropivacaine) does not affect the incidence of TNS in puerperas after labor EA.

[Necessary multidisciplinary management of diabetic foot]. / Sur la nécessité d'une approche multidisciplinaire du pied diabétique.

The pathogenesis of diabetic foot is multifactorial and optimal management requires a multidisciplinary team. In most cases, the diabetic foot complication is seen as a wound subsequent to trauma, less often as an acute neuroarthropathy or cellulitis without any apparent skin lesion. Patients look for medical care more or less rapidly, depending on the information received previously concerning foot problems. The patient may consult a general practitioner or sometimes directly attend a diabetic foot clinic. The efficiency of treatment depends on early diagnosis, a specific etiology-guided approach to wound care and management of diabetes mellitus. A multidisciplinary team is needed to provide optimal care for foot wounds and neurological, vascular and infections complications, and to control blood glucose in a global approach to management of the diabetic patient. The team must coordinate the actions of its different members, the goal for all being to obtain not only foot healing but also optimal foot function. This requires experience in surgery of the diabetic foot. Creation of special diabetic foot units has been proposed to manage diabetic patients with foot pathologies as outpatients or inpatients when necessary.

[Transcutaneous oxygen pressure (TcPO2): advantages and limitations]. / La pression transcutanée D'oxygène (TcPO2): intèrêts et limites.

The measurement of transcutaneous oxygen pressure (TcPO2), a non-invasive method to quantify skin oxygenation, is particularly useful in advanced stages of arteriopathy of the lower limbs for evaluation of cutaneous ischaemia. It is a predictive factor for spontaneous healing when pressure is above 30 mmHg or, on the contrary, of an unfavourable course when pressure is less than 10 mmHg. Dynamic tests (change in limb position, exercise test, induced ischaemia test, O2 inhalation) have been used to improve prognostic value for measurements between 10 and 30 mmHg. TcPO2 provides additional support for the decision to perform revascularisation surgery and serves as an indicator of amputation level and as a means of quantifying the benefit offered by a surgical procedure or a drug treatment. It is widely used in assessment of trophic disorders of the foot in diabetic patients.

Minimal model for determination of insulin sensitivity: repeatability in control and obese subjects.

A mathematical model was recently developed (minimal model) to estimate insulin sensitivity from the analysis of blood glucose and insulin concentration after a modified intravenous glucose tolerance test. This approach was successfully compared with the euglycemic glucose clamp in humans. In this study, we have analysed the distribution and reproducibility of this method in 10 healthy subjects and seven obese patients. We have observed a lower insulin sensitivity (SI) in obese patients (1.96 +/- 0.38 x 10(-4)/min/microU/ml) than in healthy subjects (8.19 +/- 1.16 x 10(-4)/min/microU/ml) with a small overlap between the two groups. The test was repeated twice and good repeatability was found with the method of Blank and Altman when a log transformation was applied to the data.

Lower-extremity arterial disease in diabetes mellitus due to chronic pancreatitis.

OBJECTIVE: To determine the prevalence of lower-extremity arterial disease and the sites of arterial obstruction in patients with pancreatic diabetes. PATIENTS AND METHODS: The retrospective study included 83 patients with diabetes due to chronic pancreatitis (age [m +/- SD] 54.5 +/- 9.5 yr, diabetes duration 9.7 +/- 7.4 yr) and 83 patients with idiopathic diabetes were carefully matched for sex, age, diabetes duration and treatment. They were screened for arteriopathy by segmental blood pressures and Doppler ultrasound, and for cardiovascular risk factors. The arterial lesions were classified as proximal (above-knee), distal (below-knee), and combined (both above- and below-knee). RESULTS: Lower extremity arterial disease occurred in 25.3% of pancreatitis patients and in 14.5% of idiopathic diabetes patients (p = 0.08). The sites of obstruction in both groups were similar; proximal obstruction: 4 vs 4 cases; distal: 10 vs 5 cases, combined: 7 vs 3 cases. The prevalence of arteriopathy increased with age and diabetes duration in both groups (p < 0.01). Total cholesterol, LDL cholesterol and apolipoprotein B were lower in the pancreatitis patients (p < 0.01); 92% of these were smokers vs 62% of idiopathic diabetes patients (p < 0.001). CONCLUSIONS: Arteriopathy, assessed by non-invasive tests, has the same prevalence and distribution in chronic pancreatitis and idiopathic diabetes patients, despite their different vascular risk factor profiles. This emphasizes the role of chronic hyperglycaemia and its duration in the pathogenesis of macroangiopathy in diabetic patients.

[Medical and surgical management of septic diabetic foot]. / Prise en charge médico-chirurgicale du pied diabétique septique.

Infected wounds in diabetic patients are still frequent and the main cause of amputations. The experience of 180 patients admitted for foot lesions between june 1988 and september 1993 shows us the importance of combined medical and chirurgical cares. Non invasive vascular evaluation is reliable and often sufficient for preoperative vascular assessment. Total excision of infected and necrotic tissues is essential for the control of septic conditions. Conservative surgery can be considered a possibility as atypic amputations and adapted footwear may allow quick recovery and early walking. Resigned attitudes and pejorative outlooks are out-of-date, when faced with a diabetic foot problem. Optimal metabolic control and full preoperative assessment guide surgical possibilities.

[Medical treatment of diabetic arteriopathy]. / Les particularités du traitement médical chez les artéritiques diabétiques.

Medical care of arteriopathy of leg in a diabetic patient involves control of diabetes combined with a series of non specific measures applicable to all atheromatous arteriopathies. Allowance must be made for the often silent nature of the arterial lesion, explicable by the associated peripheral neuropathy and the site of the lesions, generally more distal or staged than in non diabetics. A stable blood sugar level must be obtained to provoke improvement in hemorrheologic parameters and to slow the atheromatous process. A dietary regimen is associated with oral hypoglycemic agents or insulin therapy, the latter systematically for trophic disorders, administered as multiple injections or by insulin pump until complete healing is obtained. Insulin therapy normalizes abnormal blood lipid levels secondary to an uncontrolled diabetes. Other vascular risk factors (primary hyperlipoproteinemia, hypertension, smoking) must be allowed for. Of major importance in these patients at risk are foot hygiene, prevention of local trauma and correction of plantar anomalies. Aggravating factors in patients with arteritis are diabetic neuropathy and foot deformities. Regular walking is encouraged. Drug therapy (oral or injectable vasoactive agents, platelet antiaggregants, prostacyclin, normal blood volume restoration) depends on the severity of the arteriopathy and any complications. Analgesics are often required in advanced stages. Local therapy and sometimes antibiotics are necessary for trophic disorders. The frequent asymptomatic character up to the stage of gangrene should not, because of the diabetic diathesis, induce a wait and see attitude, and revascularization by angioplasty or shunt operation should be envisaged. A frequent complication of sugar diabetes, arteriopathy of the leg should be diagnosed early before it is revealed by a gangrenous lesion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Classification of primary dyslipoproteinemias]. / Classification des dyslipoprotéinémies primitives.

The prevention of atherosclerosis implies a better knowledge of dyslipoproteinemias. The metabolic disease must first be defined before considering its treatment and evaluate the atherogenic risk. The clinician must take advantage of two different classifications. The WHO classification (WHO: World Health Organization) permits to consider six phenotypes (I, IIa, IIb, III, IV, V), according to the serum levels of cholesterol and triglycerides. The genetic classification permits to relate one or several genetic anomaly to these phenotypes. The main clinical and biological characteristics of primary dyslipoproteinemias are summarily reported.

[Diet therapy of hypercholesterolemia. From theory to practice]. / Traitement diététique des hypercholestérolémies. De la théorie à la pratique.

Hypercholesterolemia, quite frequent in industrialized countries is a major risk factor of atherosclerosis, especially in the coronary arteries. Consensus conferences, in the United States as well as Europe, have established a practical approach to this field. The dietetic treatment, from a population standpoint, remains the corner-stone of the treatment of primary dyslipoproteinemias. The quality and quantity of lipids in the food, play a definite role. In order to lower cholesterolemia, the intake of total lipids and cholesterol must be lowered and the consumption of polyunsaturated or mono-unsaturated fatty acids must be increased. The advantage of fish (omega 3 fatty acid), soy-bean and food fibers, are discussed.