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We aimed to identify if any differences existed in spatiotemporal parameters during gait among different densities of rocker soles in patients with a history of neuropathic ulcerations and the differences in comfort between shoe conditions. This study was a cross-sectional study of 24 patients with diabetes and a history of neuropathic diabetic foot ulcers (DFUs). Spatiotemporal parameters (duration of stance phase (ms), stride length (cm), and step velocity (m/s)) were analyzed in barefoot, semirigid outsole, and rigid outsole footwear conditions. A dynamic pressure measurement system (Footscan® system, RSscan International, Belgium) was used to assess shoe conditions. We also analyzed differences in comfort between the shoe conditions using a visual analog scale. A Wilcoxon test for paired samples was used to assess gait differences. Result showed that a rigid outsole causes changes in the subphases of the stance phase (p < 0.001; Cohen d = 0.6) compared to a semirigid outsole. Stride length (p < 0.001; Cohen d = 0.66) and step velocity were significantly longer (p < 0.001; Cohen d = 2.03) with the use of rigid outsole footwear. A rigid rocker sole reduces the time of the stance phase, in addition to increasing the stride length and velocity of step in patients with a previous history of DFUs.
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Diabetic foot syndrome (DFS) is a complex disease. The best outcomes are reported with the multi-disciplinary team (MDT) approach, where each member works collaboratively according to his/her expertise. However, which health provider should act as the team leader (TL) has not been determined. The TL should be familiar with the management of diabetes, related complications and comorbidities. He/she should be able to diagnose and manage foot infections, including prompt surgical treatment of local lesions, such as abscesses or phlegmons, in an emergent way in the first meeting with the patient. According to the Organization for Economic Co-operation and Development (OECD) reports, Italy is one of countries with a low amputation rate in diabetic patients. Many factors might have contributed to this result, including 1)the special attention directed to diabetes by the public health system, which has defined diabetes as a "protected disease", and accordingly, offers diabetic patients, at no charge, the best specialist care, including specific devices, and 2)the presence of a network of diabetic foot (DF) clinics managed by diabetologists with medical and surgical expertise. The health care providers all share a "patient centred model" of care, for which they use their internal medicine background and skills in podiatric surgery to manage acute or chronic needs in a timely manner. Therefore, according to Italian experiences, which are fully reported in this document, we believe that only a skilled diabetologist/endocrinologist should act as a TL. Courses and university master's degree programmes focused on DF should guarantee specific training for physicians to become a TL.
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Pé Diabético/terapia , Endocrinologistas/organização & administração , Liderança , Equipe de Assistência ao Paciente/organização & administração , Papel do Médico , Atitude do Pessoal de Saúde , Competência Clínica , Tomada de Decisão Clínica , Consenso , Pé Diabético/diagnóstico , Educação de Pós-Graduação em Medicina , Endocrinologistas/educação , Endocrinologistas/psicologia , Conhecimentos, Atitudes e Prática em Saúde , Humanos , ItáliaRESUMO
BACKGROUND: Health-related quality of life (HRQoL) is poor in patients with persistent diabetic foot ulcers and poor HRQoL predicts worse outcomes in these patients. Amputation is often considered a treatment failure, which is why conservative treatment is generally preferred over amputation. However, it is unclear whether minor amputation negatively affects HRQoL compared with conservative treatment in patients with diabetic foot ulcers. METHODS: In the cohort of the multicenter, prospective, observational Eurodiale study, we determined difference in change of HRQoL measured by EQ-5D between patients with a diabetic foot ulcers that healed after conservative treatment (n = 676) and after minor amputation (n = 145). Propensity score was used to adjust for known confounders, attempting to overcome lack of randomization. RESULTS: Baseline HRQoL was not significantly different between patients treated conservatively and undergoing minor amputation. In addition, there was no difference in the change of HRQoL between these groups. In patients who healed 6 to 12 months after the first visit, HRQoL on the anxiety/depression subscale even appeared to improve more in those who underwent minor amputation. CONCLUSIONS: Minor amputation was not associated with a negative impact on HRQoL in patients with a diabetic foot ulcers. It may therefore not be considered treatment failure in terms of HRQoL but rather a viable treatment option. A randomized controlled trial is warranted to further examine the influence of minor amputations on health-related quality of life.
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Amputação Cirúrgica , Diabetes Mellitus Tipo 2/complicações , Pé Diabético/terapia , Qualidade de Vida , Idoso , Tratamento Conservador , Pé Diabético/etiologia , Feminino , Seguimentos , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
AIMS: Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011. METHODS: Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders. RESULTS: A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046). CONCLUSIONS: In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.
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Amputação Cirúrgica/estatística & dados numéricos , Coleta de Dados/normas , Pé Diabético/cirurgia , Organização para a Cooperação e Desenvolvimento Econômico , Qualidade da Assistência à Saúde , Amputação Cirúrgica/normas , Pé Diabético/epidemiologia , HumanosRESUMO
OBJECTIVE: In the past 20 years, research and clinical trials on the healing process of chronic wounds have highlighted the key role of the family of enzymes called matrix metalloproteinases (MMPs). If a strong correlation between the course of healing of chronic wounds and the levels of a biological marker can be demonstrated, then it may be possible to: i) identify the best marker threshold to predict the clinical evolution of the pathology; and ii) if causality has been found between the marker and pathology, to improve the healing outcome, to change the marker level. METHOD: The databases Medline and Embase were searched to identify clinical trials pertaining to the assessment of MMPs in chronic wounds with the following keywords 'metalloproteinase' or 'metalloprotease' and 'wound healing'. Clinical trials were considered for inclusion if they enrolled patients with cutaneous chronic wounds and were published in English. More than 50 clinical trials, consensus documents and guidelines were assessed for this review. RESULTS: MMPs play key roles in the wound healing process, and excessive expression and activation of some of these enzymes is seen in chronic cutaneous wounds where healing is delayed. Levels of MMPs are affected by a number of factors, including patient and wound characteristics. CONCLUSION: Levels of MMPs can be used to indicate the prognosis of chronic wounds and protease modulating treatments used to improve healing rates. DECLARATION OF INTEREST: The authors report no conflicts of interest in this work.
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Metaloproteinases da Matriz/metabolismo , Cicatrização , Ferimentos e Lesões/enzimologia , Doença Aguda , Doença Crônica , Humanos , Individualidade , PrognósticoRESUMO
Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.
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Pé Diabético/terapia , Procedimentos Endovasculares/normas , Salvamento de Membro/normas , Doença Arterial Periférica/terapia , Procedimentos Cirúrgicos Vasculares/normas , Amputação Cirúrgica/normas , Angioplastia com Balão/normas , Fármacos Cardiovasculares/uso terapêutico , Consenso , Pé Diabético/diagnóstico , Pé Diabético/epidemiologia , Humanos , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/epidemiologia , Valor Preditivo dos Testes , Prevalência , Fatores de Risco , Resultado do TratamentoRESUMO
AIM: To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors. METHODS: A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-sectional study. Patient and ulcer characteristics were obtained as well as results from the Euro-Qol-5D questionnaire, a health-related quality of life instrument with five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). To analyse the relative importance of comorbidities and ulcer- and patient-related factors for health-related quality of life, linear regression models were used to calculate the relative contributions of each factor to the fit (R(2) ) of the model. RESULTS: Patients reported poor overall health-related quality of life, with problems primarily in the mobility and pain/discomfort domains. Among the comorbidities, the inability to stand or walk without help was the most important determinant of decreased health-related quality of life in all five domains. Among ulcer-related factors, ulcer size, limb-threatening ischaemia and elevated C-reactive protein concentration also had high importance in all domains. The clinical diagnosis of infection, peripheral arterial disease and polyneuropathy were only important in the pain/discomfort domain. CONCLUSIONS: The factors that determine health-related quality of life are diverse and to an extent not disease-specific. To improve health-related quality of life, treatment should not only be focused on ulcer healing but a multifactorial approach by a specialized multidisciplinary team is also important.
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Pé Diabético/psicologia , Qualidade de Vida , Idoso , Estudos Transversais , Pé Diabético/epidemiologia , Pé Diabético/terapia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Prospectivos , Autocuidado/estatística & dados numéricosRESUMO
Diabetic foot ulceration remains one of the most common and most serious consequences of diabetes. Persistently high levels of matrix metalloproteases (MMPs) contribute to wound chronicity. Our aim was to assess the concentrations of MMPs and tissue inhibitors of metalloproteinases (TIMPs) in neuropathic and ischemic diabetic foot ulcers by analyzing biopsy samples. In this study, biopsies were taken from 35 diabetic foot ulcers of type 2 diabetes mellitus patients and distinguished in neuropathic (n = 14) or ischemic (n = 21). Zymography assay was utilized for the analysis of MMP-2 and MMP-9 activity. TACE activity was evaluated by a specific fluorimetric assay. mRNA levels of MMPs as well as TIMPs were detected using quantitative real-time polymerase chain reaction. The activity of MMP9 and A Disintegrin and A MetalloProtease Domain 17/TNF-Alpha Converting Enzyme (ADAM17/TACE) was significantly increased in ischemic compared to neuropathic biopsies. No differences were detected between both groups for the mRNA levels of MMPs as well as of ADAMs. However, TIMP3 mRNA expression was decreased in ischemic samples. The combination of increased activity of MMP9 and ADAM17/TACE with decreased concentrations of TIMP-3 mRNA expression in ischemic diabetic foot ulcers compared to neuropathic samples suggests that the increased proteolytic environment may represent a causative factor in the ulcer progression. New treatment strategies for healing diabetic foot ulcers could be directed toward increasing levels of TIMP3.
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Diabetes Mellitus Tipo 2/complicações , Diabetes Mellitus Tipo 2/genética , Pé Diabético/genética , Neuropatias Diabéticas/genética , Isquemia/genética , Inibidor Tecidual de Metaloproteinase-3/genética , Proteínas ADAM/metabolismo , Proteína ADAM17 , Idoso , Idoso de 80 Anos ou mais , Diabetes Mellitus Tipo 2/metabolismo , Pé Diabético/complicações , Pé Diabético/metabolismo , Neuropatias Diabéticas/complicações , Neuropatias Diabéticas/metabolismo , Progressão da Doença , Regulação para Baixo , Feminino , Humanos , Isquemia/complicações , Isquemia/metabolismo , Masculino , Pessoa de Meia-Idade , Inibidor Tecidual de Metaloproteinase-3/metabolismoRESUMO
OBJECTIVES: The incidence of minor amputation may vary significantly, and determinants of minor amputation have not been studied systematically. We evaluated minor amputation rate, the determinants of minor amputation and differences in amputation rate between European centres. METHODS: In the Eurodiale study, a prospective cohort study of 1232 patients (1088 followed until end-point) with a new diabetic foot ulcer were followed on a monthly basis until healing, death, major amputation or up to a maximum of 1 year. Ulcers were treated according to international guidelines. Baseline characteristics independently associated with minor amputation were examined using multiple logistic regression modelling. Based on the results of the multivariable analysis, a disease severity score was calculated for each patient. RESULTS: One hundred and ninety-four (18%) patients underwent a minor amputation. Predictors of minor amputation were depth of the ulcer (odds ratio 6.08, confidence interval 4.10-9.03), peripheral arterial disease (odds ratio 1.84, confidence interval 1.30-2.60), infection (odds ratio 1.56, confidence interval 1.05-2.30) and male sex (odds ratio 1.42, confidence interval 0.99-2.04). Minor amputation rate varied between 2.4 and 34% in the centres. Minor amputation rate in centres correlated strongly with disease severity score at the moment of presentation to the foot clinic (r=0.75). CONCLUSIONS: Minor amputation is performed frequently in diabetic foot centres throughout Europe and is determined by depth of the ulcer, peripheral arterial disease, infection and male sex. There are important differences in amputation rate between the European centres, which can be explained in part by severity of disease at presentation. This may suggest that early referral to foot clinics can prevent minor amputations.
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Amputação Cirúrgica/estatística & dados numéricos , Pé Diabético/cirurgia , Neuropatias Diabéticas/cirurgia , Idoso , Intervalos de Confiança , Pé Diabético/epidemiologia , Pé Diabético/fisiopatologia , Neuropatias Diabéticas/epidemiologia , Neuropatias Diabéticas/fisiopatologia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
There is evidence that platelets may be used locally as a source of growth factors that play a fundamental role in wound healing. From October 2008 to September 2009, at Tor Vergata Rome University Hospital, seven patients were enrolled in the study. All of these patients had ulcers with a extension over 3.5 cm(2). Four patients achieved a total recovery of the ulcers, while three experienced a reduction of the diameter of the ulcers. Our data are preliminary, but it is possible to suggest that recovery of the ulcers using the FIBRINET® system is related to platelet activation in the specific ulcer area.
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Plaquetas/citologia , Pé Diabético/diagnóstico , Fibrina/química , Cicatrização , Idoso , Pressão Sanguínea , Pé Diabético/patologia , Desenho de Equipamento , Equipamentos e Provisões , Feminino , Citometria de Fluxo/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Ativação PlaquetáriaRESUMO
AIM: The aim of this study was to assess the feasibility, safety and efficacy of percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI) using a novel balloon designed for below-the-knee (BTK) indications. METHODS: The authors have prospectively collected baseline, periprocedural and mid-term data of all consecutive patients with CLI due to BTK disease in which PTA was attempted using a long (210 mm), conically-shaped balloon (0.5 mm tapering from proximal to distal balloon edges). The primary objective was the assessment of acute success (composite of technical, angiographic and procedural success). The secondary assessments included limb salvage rate, major (above the ankle) and minor (below the ankle) amputation, change in Rutherford class and cutaneous oxygen tension, reocclusion/restenosis, rehospitalization, and repeat revascularization after one year. RESULTS: A total of 31 patients were treated with 36 long tapered balloons. Ten patients presented with ischemic tissue loss. Target lesions were mostly occlusive and diffuse, commonly involving the tibial arteries as well as the in-flow and out-flow vessels. Acute success was achieved in 100% of the cases without periprocedural complications. Clinical improvement in functional status was obtained and maintained after an average of 12 months, with a significant (P<0.001) decrease in Rutherford class, 100% limb salvage, no major amputation and five (16.1%) minor amputations. Duplex ultrasound control showed restenosis/reocclusion in two (6.5%) cases, whereas a total of seven (22.6%) patients underwent repeat revascularization (2 [6.5%] target lesion re-PTA). CONCLUSIONS: Infra-popliteal PTA with this new, BTK dedicated, long tapered balloon in patients with CLI was feasible and safe, and was associated favorable clinical results at both acute and mid-term follow-up.
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Angioplastia Coronária com Balão/instrumentação , Arteriopatias Oclusivas/terapia , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Idoso , Amputação Cirúrgica , Angioplastia Coronária com Balão/efeitos adversos , Arteriopatias Oclusivas/complicações , Arteriopatias Oclusivas/diagnóstico , Arteriopatias Oclusivas/fisiopatologia , Estado Terminal , Desenho de Equipamento , Estudos de Viabilidade , Feminino , Humanos , Isquemia/diagnóstico , Isquemia/etiologia , Isquemia/fisiopatologia , Salvamento de Membro , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Grau de Desobstrução VascularRESUMO
AIMS/HYPOTHESIS: The aim of the present study was to investigate resource utilisation and associated costs in patients with diabetic foot ulcers and to analyse differences in resource utilisation between individuals with or without peripheral arterial disease (PAD) and/or infection. METHODS: Data on resource utilisation were collected prospectively in a European multicentre study. Data on 1,088 patients were available for the analysis of resource use, and data on 821 patients were included in the costing analysis. Costs were calculated for each patient by multiplying the country-specific direct and indirect unit costs by the number of resources used from inclusion into the study up to a defined endpoint. Country-specific costs were converted into purchasing power standards. RESULTS: Resource use and costs varied between outcome groups and between disease severity groups. The highest costs per patient were for hospitalisation, antibiotics, amputations and other surgery. All types of resource utilisation and costs increased with the severity of disease. The total cost per patient was more than four times higher for patients with infection and PAD at inclusion than for patients in the least severe group, who had neither. CONCLUSIONS/INTERPRETATION: Important differences in resource use and costs were found between different patient groups. The costs are highest for individuals with both peripheral arterial disease and infection, and these are mainly related to substantial costs for hospitalisation. In view of the magnitude of the costs associated with in-hospital stay, reducing the number and duration of hospital admissions seems an attractive option to decrease costs in diabetic foot disease.
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Pé Diabético/economia , Custos de Cuidados de Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Custos e Análise de Custo , Pé Diabético/tratamento farmacológico , Pé Diabético/terapia , Europa (Continente) , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/tratamento farmacológico , Doenças Vasculares Periféricas/economia , Doenças Vasculares Periféricas/terapia , Estudos Prospectivos , Adulto JovemRESUMO
AIMS: To determine current management and to identify patient-related factors and barriers that influence management strategies in diabetic foot disease. METHODS: The Eurodiale Study is a prospective cohort study of 1232 consecutive individuals presenting with a new diabetic foot ulcer in 14 centres across Europe. We determined the use of management strategies: referral, use of offloading, vascular imaging and revascularization. RESULTS: Twenty-seven percent of the patients had been treated for > 3 months before referral to a foot clinic. This varied considerably between countries (6-55%). At study entry, 77% of the patients had no or inadequate offloading. During follow-up, casting was used in 35% (0-68%) of the plantar fore- or midfoot ulcers. Predictors of use of casting were male gender, large ulcer size and being employed. Vascular imaging was performed in 56% (14-86%) of patients with severe limb ischaemia; revascularization was performed in 43%. Predictors of use of vascular imaging were the presence of infection and ischaemic rest pain. CONCLUSION: Treatment of many patients is not in line with current guidelines and there are large differences between countries and centres. Our data suggest that current guidelines are too general and that healthcare organizational barriers and personal beliefs result in underuse of recommended therapies. Action should be undertaken to overcome these barriers and to guarantee the delivery of optimal care for the many individuals with diabetic foot disease.
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Atenção à Saúde/normas , Pé Diabético/terapia , Assistência Ambulatorial/normas , Assistência Ambulatorial/estatística & dados numéricos , Métodos Epidemiológicos , Europa (Continente) , Feminino , Humanos , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Reperfusão/estatística & dados numéricosRESUMO
AIMS/HYPOTHESIS: Outcome data on individuals with diabetic foot ulcers are scarce, especially in those with peripheral arterial disease (PAD). We therefore examined the clinical characteristics that best predict poor outcome in a large population of diabetic foot ulcer patients and examined whether such predictors differ between patients with and without PAD. METHODS: Analyses were conducted within the EURODIALE Study, a prospective cohort study of 1,088 diabetic foot ulcer patients across 14 centres in Europe. Multiple logistic regression modelling was used to identify independent predictors of outcome (i.e. non-healing of the foot ulcer). RESULTS: After 1 year of follow-up, 23% of the patients had not healed. Independent baseline predictors of non-healing in the whole study population were older age, male sex, heart failure, the inability to stand or walk without help, end-stage renal disease, larger ulcer size, peripheral neuropathy and PAD. When analyses were performed according to PAD status, infection emerged as a specific predictor of non-healing in PAD patients only. CONCLUSIONS/INTERPRETATION: Predictors of healing differ between patients with and without PAD, suggesting that diabetic foot ulcers with or without concomitant PAD should be defined as two separate disease states. The observed negative impact of infection on healing that was confined to patients with PAD needs further investigation.
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Angiopatias Diabéticas/complicações , Pé Diabético/terapia , Úlcera do Pé/terapia , Cicatrização , Idade de Início , Idoso , Pé Diabético/complicações , Feminino , Úlcera do Pé/complicações , Úlcera do Pé/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Resultado do TratamentoRESUMO
AIMS/HYPOTHESIS: Large clinical studies describing the typical clinical presentation of diabetic foot ulcers are limited and most studies were performed in single centres with the possibility of selection of specific subgroups. The aim of this study was to investigate the characteristics of diabetic patients with a foot ulcer in 14 European hospitals in ten countries. METHODS: The study population included 1,229 consecutive patients presenting with a new foot ulcer between 1 September 2003 and 1 October 2004. Standardised data on patient characteristics, as well as foot and ulcer characteristics, were obtained. Foot disease was categorised into four stages according to the presence or absence of peripheral arterial disease (PAD) and infection: A: PAD -, infection -; B: PAD -, infection +; C: PAD +, infection -; D: PAD +, infection +. RESULTS: PAD was diagnosed in 49% of the subjects, infection in 58%. The majority of ulcers (52%) were located on the non-plantar surface of the foot. With regard to severity, 24% had stage A, 27% had stage B, 18% had stage C and 31% had stage D foot disease. Patients in the latter group had a distinct profile: they were older, had more non-plantar ulcers, greater tissue loss and more serious comorbidity. CONCLUSIONS/INTERPRETATION: According to our results in this European cohort, the severity of diabetic foot ulcers at presentation is greater than previously reported, as one-third had both PAD and infection. Non-plantar foot ulcers were more common than plantar ulcers, especially in patients with severe disease, and serious comorbidity increased significantly with increasing severity of foot disease. Further research is needed to obtain insight into the clinical outcome of these patients.
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Pé Diabético/epidemiologia , Doenças do Pé/epidemiologia , Doenças do Pé/microbiologia , Doenças Vasculares Periféricas/epidemiologia , Idoso , Estudos de Coortes , Comorbidade , Pé Diabético/patologia , Europa (Continente)/epidemiologia , Feminino , Seguimentos , Doenças do Pé/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/patologia , Prevalência , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: To validate nerve-axon reflex-related vasodilatation as an objective method to evaluate C-nociceptive fibre function by comparing it with the standard diagnostic criteria. METHODS: Neuropathy was evaluated in 41 patients with diabetes (26 men and 15 women) without peripheral vascular disease by assessing the Neuropathy Symptom Score, the Neuropathy Disability Score (NDS), the vibration perception threshold (VPT), the heat detection threshold (HDT), nerve conduction parameters and standard cardiovascular tests. The neurovascular response to 1% acetylcholine (Ach) iontophoresis was measured at the forearm and at both feet by laser flowmetry. An age-matched and sex-matched control group of 10 healthy people was also included. RESULTS: Significant correlations were observed between the neurovascular response at the foot and HDT (r(s) = -0.658; p<0.0001), NDS (r(s) = -0.665; p<0.0001), VPT (r(s) = -0.548; p = 0.0005), tibial nerve conduction velocity (r(s) = 0.631; p = 0.0002), sural nerve amplitude (r(s) = 0.581; p = 0.0002) and autonomic function tests. According to the NDS, in patients with diabetes who had mild, moderate or severe neuropathy, a significantly lower neurovascular response was seen at the foot than in patients without neuropathy and controls. A neurovascular response <50% was found to be highly sensitive (90%), with a good specificity (74%), in identifying patients with diabetic neuropathy. CONCLUSION: Small-fibre dysfunction can be diagnosed reliably with neurovascular response assessment. This response is already reduced in the early stages of peripheral neuropathy, supporting the hypothesis that small-fibre impairment is an early event in the natural history of diabetic neuropathy.
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Axônios/patologia , Fibras Colinérgicas/patologia , Neuropatias Diabéticas/diagnóstico , Reflexo Anormal , Idoso , Eletrofisiologia , Feminino , Humanos , Iontoforese , Masculino , Pessoa de Meia-Idade , Condução Nervosa , Exame Neurológico , Curva ROC , Sensibilidade e Especificidade , VasodilataçãoRESUMO
AIM: To evaluate the prevalence of peripheral arterial disease (PAD) with the ankle-brachial index (ABI) in newly diagnosed Type 2 diabetic subjects. METHODS: Between autumn 2002 and spring 2003, 2559 newly diagnosed Type 2 diabetic subjects (about 15% of the cases/year in Italy) were enrolled in 265 diabetology centres. Family history of diabetes, smoking, height, weight, waistline, fasting glycaemia, glycosylated haemoglobin, total and HDL-cholesterol and triglyceride values were collected. Claudication, cyanosis, cold foot, foot hair anomalies, skin thinning and femoral, popliteal, posterior tibial and dorsalis pedis pulses were assessed. The ABI was measured with a portable Doppler continuous-wave instrument. RESULTS: An ABI < 0.9 was found in 539 (21.1%) patients. Claudication was present in 187 (7.3%). Femoral pulse was absent in 218 (8.5%), popliteal in 316 (12.3%), tibial in 563 (22.0%) and dorsalis pedis in 578 (22.6%). Foot cyanosis was observed in 88 (3.4%), cold foot in 359 (13.9%), skin thinning in 468 (18.3%) and hair anomalies in 857 (33.5%). Multivariate analysis of the variables associated with ABI < 0.9 in the univariate analysis confirmed the independent role of age [relative risk (RR) 1.02, P < 0.001, confidence interval (CI) 1.01, 1.04], claudication (RR 4.53, P < 0.001, CI 2.97, 6.93), absence of tibial pulse (RR 3.45, P < or = 0.001. CI 2.54, 4.68) and pedis pulse (RR 1.96, P < or = 0.001, CI 1.4, 2.68). CONCLUSIONS: PAD, as represented by ABI < 0.9, is common in newly diagnosed Type 2 diabetic patients.
Assuntos
Tornozelo , Artéria Braquial/fisiopatologia , Diabetes Mellitus Tipo 2/diagnóstico , Angiopatias Diabéticas/diagnóstico , Doenças Vasculares Periféricas/diagnóstico , Adulto , Fatores Etários , Idoso , Pressão Sanguínea , Diabetes Mellitus Tipo 2/fisiopatologia , Angiopatias Diabéticas/fisiopatologia , Feminino , Humanos , Claudicação Intermitente/fisiopatologia , Masculino , Pessoa de Meia-Idade , Doenças Vasculares Periféricas/fisiopatologia , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: The diabetic foot often undergoes abnormal plantar pressures, changing in walking strategy, ulcerative processes. The present study focuses on the effects that diabetes-induced alterations of Achilles tendon, plantar fascia and first metatarso-phalangeal joint-both anatomical and functional-may have on foot loading. METHODS: Sixty-one diabetic patients, with or without neuropathy, and 21 healthy volunteers were recruited. Thickness of Achilles tendon and plantar fascia was measured by ultrasound. Flexion-extension of the first metatarso-phalangeal joint was measured passively. Main biomechanic parameters of foot-floor interaction during gait were acquired and related to the above measurements. FINDINGS: Plantar fascia and Achilles tendon were significantly (P<0.05) thicker in diabetics than in controls; mean values (SD) for controls, diabetics without and with neuropathy were 2.0 mm (0.5), 2.9 mm (1.2) and 3.0 mm (0.8) for plantar fascia, respectively, and 4.0 mm (0.5), 4.6 mm (1.0) and 4.9 mm (1.7) for Achilles tendon, respectively. Flexion-extension of the first metatarso-phalangeal joint was significantly (P<0.05) smaller in diabetics than in controls; mean values (SD) for controls, diabetics without and with neuropathy were 100.0 degrees (10.0), 54.0 degrees (29.4) and 54.9 degrees (17.2), respectively. The increase in the vertical force under the metatarsals was strongly related (R=0.83, explained variance=70.1%) to the changes in the three above parameters. INTERPRETATION: Thickening of plantar fascia and Achilles tendon in diabetics, more evident in the presence of neuropathy, concurs to develop a rigid foot, which poorly absorbs shock during landing (performs the physiological impact force absorption during landing). More generally, an overall alteration of the foot-ankle complex motion likely occurs throughout the whole gait cycle, which partly explains the abnormal loading under the forefoot.
Assuntos
Tendão do Calcâneo/diagnóstico por imagem , Tendão do Calcâneo/fisiopatologia , Pé Diabético/diagnóstico por imagem , Pé Diabético/fisiopatologia , Fáscia/diagnóstico por imagem , Fáscia/fisiopatologia , Articulação Metatarsofalângica/diagnóstico por imagem , Articulação Metatarsofalângica/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estresse Mecânico , Ultrassonografia , Suporte de CargaRESUMO
OBJECTIVE: To monitor transcutaneous oxygen tension (TcPO2) after percutaneous transluminal angioplasty (PTA) in diabetic patients with ischaemic foot ulcers. RESEARCH DESIGN AND METHODS: Twenty-three diabetic patients with ischaemic foot ulcers who underwent successful revascularization by PTA (SR group) were retrospectively selected. Twenty diabetic patients who underwent unsuccessful revascularization (UR group) were also included. Transcutaneous oxygen tension was measured at the dorsum of the foot before and 1 (+/- 1), 7 (+/- 1), 14 (+/- 1), 21 (+/- 1) and 28 (+/- 1) days after the surgical procedure. RESULTS: After PTA, TcPO2 progressively improved in the SR group, reaching its peak 4 weeks after angioplasty. A concomitant decrease of cutaneous carbon dioxide tension (TcPCO2) was also observed immediately after PTA which reached the lowest levels 3 weeks later. In the UR group, TcPO2 showed a slight improvement immediately after PTA but remained stable throughout the observation, while TcPCO2 levels did not change. Finally, the percentage of SR patients with a TcPO2 > or = 30 mmHg was 38.5% 1 week after PTA, while it increased to 75% 3 weeks later. CONCLUSION: Transcutaneous oxygen tension monitoring showed that after successful revascularization it takes 3-4 weeks for cutaneous oxygenation to improve and reach the optimal levels for wound healing. Transcutaneous carbon dioxide tension monitoring may be more useful to identify the negative outcome of a revascularization procedure. Our findings suggest that, when the surgical approach can be delayed, the best timing to perform a more aggressive debridement or minor amputations is 3-4 weeks after successful revascularization.
Assuntos
Angioplastia com Balão , Monitorização Transcutânea dos Gases Sanguíneos , Pé Diabético/terapia , Idoso , Idoso de 80 Anos ou mais , Desbridamento , Pé Diabético/sangue , Pé Diabético/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Oxigênio/sangue , Pressão Parcial , Fluxo Sanguíneo Regional , Estudos Retrospectivos , Pele/irrigação sanguínea , Fatores de TempoRESUMO
AIM: The aim of this study was to examine foot function in the presence of diabetes-induced alterations of the anatomical and biomechanical unit formed by the Achilles tendon, plantar fascia and metatarso-phalangeal joints. More specifically, we focused on the Windlass mechanism, the physiological mechanism which entails stiffening of the foot during propulsion. METHODS: Sixty-one diabetic patients, with or without neuropathy, and 21 healthy volunteers were recruited. The thickness of Achilles tendon and plantar fascia was measured by ultrasound. The main biomechanical parameters of foot-floor interaction during gait were acquired by means of dedicated platforms. The range of motion of the 1st metatarso-phalangeal joint was measured passively. RESULTS: The plantar fascia (PF) and Achilles tendon (AT) were significantly thickened in diabetic patients [control subjects: PF 2.0+/-0.5 mm, AT 4.0+/-0.5 mm; diabetic patients without neuropathy: PF 2.9+/-1.2 mm (P=0.002), AT 4.6+/-1.0 mm (P=0.016); diabetic patients with neuropathy: PF 3.0+/-0.8 mm (P<0.0001), AT 4.9+/-1.7 mm (P=0.026)]. Joint mobility was significantly reduced [control subjects: 100.0+/-10.0 degrees; diabetic patients without neuropathy: 54.0+/-29.4 degrees (P<0.0001); diabetic patients with neuropathy: 54.9+/-17.2 degrees (P<0.0001)]. Loading times and force integrals under the heel and the metatarsals increased [metatarsal loading time (% stance phase): control subjects 88.2+/-4.1%; diabetic patients without neuropathy 90.1+/-4.7% (P=0.146); diabetic patients with neuropathy 91.7+/-6.6% (P=0.048)]. CONCLUSIONS: Increased thickness of Achilles tendon and plantar fascia, more evident in the presence of neuropathy, may contribute to an overall increase of tensile force and to the occurrence of an early Windlass mechanism, maintained throughout the whole gait cycle. This might play a significant role in the overall alteration of the biomechanics of the foot-ankle complex.