TUNEL-positive cells in the surgical border of an amputation due to infected diabetic foot.

Diabetic infected foot is the outcome of progressive vascular and neurological damage caused by persistent chronic hyperglycemia. Due to acute hypoxia and infection, the tissues develop extensive necrosis and gangrene, which often require amputation. The decision regarding the level of amputation relies mainly on the personal experience of the surgeon who must identify the healthy tissue without necrosis. However, tissue cells under stress may succumb before clear evidence of necrosis is present. In this study, dying cells with DNA damage were identified in the necrotic lesions and surgical borders of amputations. Therefore, the main purpose of this study was to identify apoptosis in the surgical borders of amputations required to treat infected diabetic foot. Apoptosis was identified by terminal deoxynucleotidyl transferase-mediated bio-dUTP nick-end labeling (TUNEL) in the superficial and deep tissues of wounds, and in the surgical borders of 10 consecutive adult patients with diabetes mellitus type 2 (DM2) who underwent amputation due to infected diabetic foot. The severity of the disease was classified by the Acute Physiological and Chronic Health Evaluation II (APACHE II) score on admission, and laboratory data were collected and bacteriological cultures were obtained from the lesions. The ankle/arm blood pressure index was measured, the blood flow in the affected limb was evaluated by high-resolution ultrasonography and color Doppler and pulse oximetry were performed during surgery. A total of 5 males and 5 females, aged 45-84 years (58.8 ± 14.1), were included. The APACHE II score was 2-18 points (8 ± 5.7). A total of 9 patients developed sepsis and 2 succumbed. A total of 5 patients required above-ankle amputation, and 5 required toe disarticulation. The ankle/arm blood pressure index ranged from 0.23-0.85 (0.51 ± 0.23). Apoptotic cells were found in ulcers and abscesses, and in areas without necrosis. In the surgical borders of the amputations, apoptotic cells were found in skeletal muscle, blood vessels and peripheral nerves, particularly Schwann cells. Morphometric analysis revealed that the extent of apoptosis was 2-3 logarithms higher in the surgical borders of the infected diabetic foot compared to the venous ulcers, which were used as the reference. In conclusion, apoptosis was identified in regenerating tissues within diabetic foot wounds and in the surgical borders of amputations, where the surgeon considered the tissues to be undamaged. This information suggests that apoptosis may be present before visible signs of necrosis appear in the diabetic foot and may be caused by hypoxia, acidosis or proinflammatory cytokines. The extent of apoptosis in tissues proximal to necrotic areas may anticipate the development of diabetic foot and help the surgeon to make decisions regarding the need and extent of amputation.

Haplotype distribution of class II MHC genes in Mexican patients with systemic lupus erythematosus.

The objective of this project was to determine the association of the DQA1*0501 allele in the susceptibility to develop systemic lupus erythematosus (SLE) in Mexicans. Frequencies of generic MHC Class II genes (HLA-DR, DQA and DQB1) were determined by DNA typing in 58 Mexican mestizo SLE patients and 96 ethnically matched controls. Statistical analysis was performed by chi-square and Fisher's exact tests. The DQA1*0501 allele was found to be in linkage disequillibrium with H LA-DR3, DR11, and DR14. This explains the lack of association with the allele alone, and the evident strong association of SLE with the [HLA-DR3-DQA1*0501-DQB1*0201] and [HLA-DR1-DQA1*0101-DQB1*0501] haplotypes. It was also found a significant decrease (protection) of the [HLA-DR8-DQA1*0401-DQB1*0402] haplotype which is known to be a characteristic haplotype among the indigenous population of Mexico. These data shows that the susceptibility to SLE in Mexicans is more strongly influenced by the MHC haplotypes than by single alleles. The suggestion that these genes do not act alone but in combination, makes the identification of haplotypes mandatory.