Extremities Of Diabetic Patients Research Articles

Adverse plasma branched-chain amino acid profile mirrors fatty muscle degeneration in diabetic heart failure patients.

Elevated plasma branched-chain amino acids (BCAAs) are tightly linked to incident diabetes and its complications, while lower BCAAs are associated with adverse outcomes in the elderly and heart failure (HF) patients. The interplay between body compositions and plasma BCAAs, especially under the influence of co-morbid diabetes in HF patients, is not well understood. Here, we examined the impact of diabetes on the prognostic value of plasma BCAA and its association with body compositions in HF patients. We retrospectively examined 301 HF patients (70±15years old; 59% male), among which 36% had diabetes. Blood samples for plasma BCAA measurements were collected in a fasting state after stabilization of HF and analysed using ultraperformance liquid chromatography. A dual-energy X-ray absorptiometry scan assessed regional body compositions, and muscle wasting was defined as appendicular skeletal muscle mass index (ASMI)<7.00 and <5.40kg/m2 for males and females, respectively, according to the criteria of the Asian Working Group for Sarcopenia. Although analyses of covariance revealed that plasma BCAAs were significantly higher in diabetic patients, low valine (<222.1nmol/mL) similarly predicted adverse events defined by HF hospitalization, lethal arrhythmia, or all-cause death in both diabetic and non-diabetic patients independently of age, sex, and NT-proBNP (adjusted hazard ratio [HR] 3.1, 95% confidence interval [CI] of 1.1-8.6 and adjusted HR 2.67, 95% CI 1.1-6.5, respectively; P for interaction 0.88). In multivariate linear regression analyses comprising age, sex, and regional body compositions as explanatory variables, plasma BCAAs were positively correlated with visceral adipose tissue area in non-diabetic patients (standardized β coefficients [β]=0.44, P<0.001). In contrast, in diabetic patients, plasma BCAAs were correlated positively with ASMI (β=0.49, P=0.001) and negatively with appendicular fat mass index (AFMI; β=-0.42, P=0.004). Co-morbid diabetes was independently associated with muscle wasting (adjusted odds ratio 2.1, 95% CI 1.1-4.0) and significantly higher plasma 3-methylhistidine level, a marker of myofibrillar degradation. In diabetic patients, ASMI uniquely showed a J-shaped relationship with AFMI, and in a subgroup of HF patients with muscle wasting, diabetic patients showed 12% higher AFMI than non-diabetic patients despite comparable ASMI reductions. Despite higher plasma BCAA levels in HF patients with diabetes, the prognostic value of low valine remained consistent regardless of diabetes status. However, low BCAAs were distinctly associated with fatty muscle degeneration in the extremities in diabetic patients, suggesting the importance of targeted interventions to prevent such tissue remodelling in this population.

Assessment of foot deformities in patients with type 2 diabetes mellitus

Background: Affection of lower extremity in diabetic patients leads to development of several foot deformities. The knowledge so far about the particulars of foot deformity in diabetic population is limited. The current study aimed to assess prevalence of foot deformities in known diabetics and to compare it with non-diabetic population. It also aimed to know its association with various risk factors. Methods: Foot was evaluated for presence of deformity in 80 patients with type 2 diabetes mellitus and was compared with the control group of 80 non-diabetic individuals. Type of deformity was noted and its prevalence was compared between the two groups. Statistical analysis was done to see the association of foot deformity with various risk factors. Results: Prevalence of foot deformity was more in diabetics as compared to normal population (p&lt;0.004). Forefoot was involved in majority of cases (84.93%) and nail deformities were most commonly seen (38.35%). Deformities were less common in patients who were aware of diabetic foot care measures (p&lt;0.004) and were more common in presence of diabetic neuropathy, vasculopathy and uncontrolled glycaemic index. Conclusions: All patients with diabetes should be screened for presence of neuropathy as this is the most common factor for development of a foot deformity and hence a foot ulcer. Other helpful screening measures include assessment for peripheral vascular disease and monitoring of glycaemic index (HbA1c). Patients should be educated about the diabetic foot care measures to avoid potential complications.

Role of matrix metalloproteinases in diabetic foot ulcers: Potential therapeutic targets

Diabetic foot ulcers (DFUs) are pathological states of tissue destruction of the foot or lower extremity in diabetic patients and are one of the serious chronic complications of diabetes mellitus. Matrix metalloproteinases (MMPs) serve crucial roles in both pathogenesis and wound healing. The primary functions of MMPs are degradation, which involves removing the disrupted extracellular matrix (ECM) during the inflammatory phase, facilitating angiogenesis and cell migration during the proliferation phase, and contracting and rebuilding the tissue during the remodeling phase. Overexpression of MMPs is a feature of DFUs. The upregulated MMPs in DFUs can cause excessive tissue degradation and impaired wound healing. Regulation of MMP levels in wounds could promote wound healing in DFUs. In this review, we talk about the roles of MMPs in DFUs and list potential methods to prevent MMPs from behaving in a manner detrimental to wound healing in DFUs.

Digital processing of ultrasound images on dilated blood vessels from diabetic patients

Introduction Peripheral arterial disease (PAD) is a fairly common degenerative vascular condition in diabetic patients that leads to inadequate blood flow (BF), this disease is mainly due to atherosclerosis that causes chronic narrowing of arteries, which can precipitate acute thrombotic events. In patients with diabetes, atherosclerosis is the main reason for reducing life expectancy, as long as diabetic nephropathy and retinopathy are the largest contributors to end-stage renal disease and blindness, respectively. Objective This was an assessment of dilatation of the blood vessels on diabetic patients vs. healthy volunteers by using digital processing of imaging’s. Materials and Methods The study subject was ultrasound imaging processing of blood vessels dilation on low extremities of diabetic patients, the results were compared with ultrasound images of healthy subjects. Results The digital images processing suggests that there is a significant difference among images experimental of the diabetic group and healthy volunteers’ images, the control group. Discussion The digital imaging processing performed in the Matlab platform is an adequate procedure for blood vessels dilation analysis of the ultrasound images taken from the lower extremities in diabetic patients.

THE SPREAD OF FOOT INFECTION AND ITS IMPACT ON THE OUTCOMES OF MAJOR AMPUTATIONS OF LOWER EXTREMITIES IN DIABETIC PATIENTS

Aim To assess the spread of foot infection and its impact on the outcomes of major amputations of lower extremities in diabetic patients. Method In a multicentre retrospective and prospective cohort study, we included adult diabetic patients (≥ 18 years) who underwent a major amputation of a lower limb in 5 hospitals between 2000 and 2009, 2012 and 2014. A total of 51 patients were included (of which 27 (52.94%) were men and 24 (47.06%) were women) with the mean age of 65.51 years (SD=16.99). Concomitant section9s osseous slice biopsy (BA) and percutaneous bone biopsy of the distal site (BD) were performed during limb amputation. A new surgical set-up and new instruments were used to try and reduce the likelihood of cross-contamination during surgery. A positive culture was defined as the identification of at least 1 species of bacteria not belonging to the skin flora or at least 2 bacteria belonging to the skin flora (CoNS (coagulase negative staphylococci), Corynebacterium spp, Propionibacterium acnes ) with the same antibiotic susceptibility profiles. A doubtful culture was defined as the identification of 1 species of bacteria belonging to the skin flora. The patients were followed-up for 1 year. Stump outcomes were assessed on the delay of complete healing, equipment, need of re-intervention and antibiotics. Results In total, 51 BA were performed during major lower limb amputations (17 above the knee and 34 below the knee) in diabetic patients. Nine (17.65%) bacterial culture results from BA specimens were positive, 7 (13.73%) doubtful and 35 (68.63%) sterile. Before amputation, 23 patients (45.1%) had not received any antibiotics, including 16 (31.37%) with an antibiotic-free interval of 15 days or more. Microorganisms identified in BA were also cultured from the distal site in 33.33% of the cases. Positive BA was associated with prolonged complete stump healing, delay of complete healing (more than 6 months), re-amputation and the need of antibiotics Conclusions The microorganisms identified from BA play a role in stump healing in diabetic patients. BA is useful during major limb amputation due to infectious complications and antibiotic therapy could be corrected on the basis of the BA culture results.

Perfusion Pressures and Distal Oxygenation in Individuals with Diabetes Undergoing Chronic Hemodialysis

The number of diabetic patients worldwide was estimated to be approximately 285 million in 2010. Approximately 5% of all diabetic patients have foot ulcers, often preceded by neuropathy and delayed healing resulting from peripheral vascular disease which leads to increased risk of infection. Additionally, there is a concern that blood flow to the feet may be reduced in patients with diabetes, which may be further compounded by changes in lower extremity perfusion pressure during hemodialysis. Current laser Doppler technology provides the opportunity to identify changes in vascularityin a non-invasive fashion. A prospective, parallel-arm, comparison, pilot study was conducted. A total of 15 patients were enrolled, ten of whom had a documented history of diabetes. All patients required hemodialysis. Peripheral perfusion and oxygenation measurements were obtained before, midway and at the conclusion of three separate dialysis sessions within a 3-week interval for each subject. Preliminary results indicate a significant reduction in toe pressure during and after hemodialysis in the diabetic patient group compared to the non-diabetic group. Significant differences were not found in skin perfusion measurements or in the oxygenation measurements at any time in diabetic and nondiabetic patients undergoing hemodialysis. Preliminary results suggest hemodialysis may significantly affect pressure of the lower extremities in diabetic patients. Trends from these data indicate the need to further investigate the effect of hemodialysis on techniques used to heal wounds and ulcers in patients with diabetes.

Arterial diseases of lower extremities in diabetic patients: current state and prospects of therapy

Peripheral artery diseases (PAD) are most serious diabetic complications responsible for the high risk of amputation of lower extremities. The occurrenceof PAD in diabetic patients is much higher than in subjects with undisturbed carbohydrate metabolism. PAD in diabetic patients is frequentlyan asymptomatic condition affecting distal portions of arterial segments and associated with pronounced mediacalcinosis. Standard diagnostic proceduresfor the screening of arterial lesions must be supplemented by non-invasive visualization and measurement of transcutaneous oxygen tensionin patients at risk of PAD and persisting foot ulcers. Of special importance is early diagnosis of critical limb ischemia and prevention of foot lesions.Combined treatment of diabetic foot syndrome in patients with critical limb ischemia includes normalization of foot circulation, surgical interventionand conservative therapy of the wound, monitoring concomitant micro- and macrovascular diabetic complications?

The role of transcutaneous oxymetry in the assessment of the degree of chronic arterial insufficiency of lower extremities in diabetic patients

Цель. Оценить степень хронической артериальной недостаточности у пациентов с сахарным диабетом с диабетической макроангиопатией нижних конечностей с использованием: нескольких методов: классификации Фонтейна-Лериша-Покровского; ультразвуковой допплерографии (измерение лодыжечно-плечевого индекса (ЛПИ)); транскутанной оксиметрии тканей стоп. Материалы и методы. В исследование включено 30 больных с сахарным диабетом (СД) 2 типа с диабетической макроангиопатией нижних конечностей, подтвержденной ультразвуковой допплерографией артерий нижних конечностей (УЗДГ). УЗДГ проводилось на ультразвуковом допплеровском анализаторе ?Ангиодин ПК? датчиками 4МГц, 8МГц. Транскутанная оксиметрия (Тср02) в тканях стоп проводилась на аппарате ТСМ 4/40 (?Radiometer?, Дания). Результаты. При использовании для оценки степени ишемии конечности классификации Фонтейна-Лериша-Покровского и уровня ЛПИ I стадия ХАН регистрируется чаще (в 1,37 и в 1,2 раза соответственно). Тогда как при определении уровня Тср02 чаще встречается III стадия ХАН (в 1,3 раза чаще, чем при использовании классификации Фонтейна-Лериша-Покровского и в 2,5 раза чаще, чем по данным ЛПИ). Выводы. Для оценки степени хронической артериальной недостаточности в клинической практике используются все обсуждаемые методы, но более информативным является измерение парциального напряжения кислорода в тканях методом транскутанной оксиметрии.

Arterial imaging in patients with lower extremity ischemia and diabetes mellitus

Precise, comprehensive imaging of the arterial circulation is the cornerstone of successful revascularization of the ischemic extremity in patients with diabetes mellitus. Arterial imaging is challenging in these patients because the disease is often multisegmental with a predilection for the distal tibial and peroneal arteries. Occlusive lesions and the arterial wall itself are often calcified and patients presenting with ischemic complications frequently have underlying renal insufficiency. Intra-arterial digital subtraction angiography (DSA), contrast enhanced magnetic resonance angiography (MRA), and more recently, computerized tomographic angiography (CTA) have been used as imaging modalities in lower extremity ischemia. Each has specific advantages and shortcomings in this patient population, which will be summarized and contrasted in this review. DSA is an invasive technique most often performed from a femoral arterial puncture and requires the injection of arterial contrast, which can occasionally cause allergic reactions. In patients with pre-existing renal insufficiency, contrast infusion can result in worsening renal failure; although usually self-limited, it may occasionally require hemodialysis, especially in patients with diabetes. However, DSA provides the highest degree of spatial resolution and image quality. It is also the only modality in which the diagnosis and treatment of arterial disease can be performed simultaneously. MRA is noninvasive, and when enhanced with gadolinium contrast injection provides arterial images of comparable quality to DSA and in some circumstances may uncover distal arterial targets not visualized on DSA. However, spatial resolution is inferior to DSA and erroneous interpretations due to acquisition artifacts are common. Specialized equipment and imaging techniques are necessary to minimize their occurrence in the distal lower extremity. In addition, due to the risk of inducing nephrogenic systemic fibrosis, gadolinium-enhanced MRA cannot be used in patients with renal insufficiency. CTA is noninvasive and rapidly performed, with better spatial resolution than MRA, but requires the largest volume of contrast infusion, exposes patients to high-doses of radiation, and is subject to interpretive error due to reconstruction artifacts especially in heavily calcified arteries, limiting its usefulness in many patients with diabetes. For patients in whom the planned intervention is a surgical bypass, DSA and MRA will provide high quality images of the lower extremity arterial anatomy. For patients in whom a catheter-based intervention is the likely treatment, a diagnostic DSA immediately followed by a catheter-based treatment in the same procedure is the preferred approach. In patients with pre-existing renal dysfunction, in which gadolinium-enhanced MRA is contraindicated, DSA or CTA can be performed. However, patients should have an infusion of intravenous normal saline solution or sodium bicarbonate before the procedure to reduce the incidence of contrast-induced nephropathy.

Estudo comparativo da sensibilidade nos pés de diabéticos com e sem úlceras utilizando o PSSD™

INTRODUÇÃO: Determinar e comparar limiares de sensibilidade cutânea nos pés de pacientes diabéticos com úlcera em apenas um dos membros inferiores. MATERIAIS E MÉTODOS: 20 pacientes foram estudados, a média de idade e de conhecimento do diabetes foi 61,6 e 12,4 anos, respectivamente. Todos os pacientes foram previamente testados com o monofilamento de Semmes-Weinstein nº 5,07. A sensibilidade foi avaliada usando o teste de discriminação entre dois pontos e o PSSD™ (Pressure-Specified Sensory Device) para avaliar os limiares de sensibilidade de maneira quantitativa, em g/mm². Testadas três áreas da pele: polpa do hálux, dorso do pé e parte medial do calcâneo, incluindo-se quatro testes, um ponto estático, um ponto dinâmico, dois pontos estáticos e dois pontos dinâmicos. RESULTADOS: A distância média de discriminação de dois pontos em mm foi superior nos pés com úlceras, mas a diferença entre os membros inferiores teve significância estatística apenas para o hálux. Com o PSSD™, todos os pacientes tiveram limiares de pressão superior nos pés com úlcera, em comparação com os pés sem úlcera, em todos os testes e com significância estatística. CONCLUSÃO: O PSSD™ foi capaz de diferenciar níveis de sensibilidade entre membros com e sem úlcera em pacientes diabéticos, com significância estatística.

Vascular complications of the lower extremities in diabetic patients on peritoneal dialysis

Diabetic patients with end-stage renal disease (ESRD) are at high risk for developing foot complications and few have studied this complication in the diabetic patients treated with peritoneal dialysis (PD). The purpose of this study was to examine peripheral vascular disease (PVD) in diabetic patients with ESRD, who are being treated with PD, and to identify those factors that may contribute to its development. We reviewed retrospectively the charts of 71 diabetic patients who started PD between January 1999 and January 2006, inclusive, and recorded their demographic data, their treatment regimens, their complications and the results of biochemical investigation(s) at the beginning and throughout their follow-up period. All patients were under the care of a chiropodist who examined them at regular intervals and more often when needed. We divided the patients into two groups with respect to the presence of complications in the lower extremities, such as ulcers, open wounds, osteomyelitis, necrotizing or gangrenous lesions, and amputations, intermittent claudication and/or the presence on an imaging examination of changes in the leg vessels consistent with vascular disease. 33 of the 71 patients had some type of a foot lesion. There were 8 amputations in the course of 176 patient-years (2 double amputations), or 1 amputation per 30 PD patient-years. Those patients with foot complications were treated more frequently with CCPD (p<0.05), more often had peripheral neuropathy (p<0.002), as well as coronary artery disease (p<0.044). They had lower serum albumin (p<0.005), significantly higher serum phosphorus (p<0.047) and they received higher doses of erythropoietin (p<0.042). There was no statistically significant difference between the groups regarding sex, age at initiation of PD, type of diabetes, use of insulin, levels of HbA(1c), body mass index (BMI), presence of retinopathy, cerebral vascular disease, hyperlipidemia, smoking, rate of transplantation, rate of drop-out from PD, time-averaged Kt/V, creatinine clearance, serum calcium, Ca x P and intact PTH. In a multiple logistics regression model, only peripheral neuropathy and hypoalbuminemia were independently associated with the development of lower-extremity complications (p<0.0066 and p <0.026, respectively). One-, two- and three-year cumulative survival of the whole group was 91.5%, 78.8% and 69%, respectively. Patients with foot lesions had a lower survival than those without. Interestingly though, those patients, who had had an amputation, survived as long as those patients, who did not have foot complications at all. In conclusion, compared to reports in the literature, our diabetic patients on PD had a lower rate of foot complications and amputation probably because of early intervention by our chiropodist. This fact stresses the need for constant and expert monitoring of the condition of the diabetic patient's feet, especially in those with low serum albumin and peripheral neuropathy.

Segmental blood flow and rheological determinants in diabetic patients with peripheral occlusive arterial disease

Vascular abnormalities are more prevalent in the lower extremities in diabetic patients and may cause diminished perfusion to surrounding tissues. We sought to identify blood flow abnormalities in the leg of diabetic patients with peripheral occlusive arterial disease (POAD) and to determine whether these were associated with abnormalities in rheological determinants, namely, plasma fibrinogen concentration (PFC), relative plasma viscosity (RPV), hematocrit (Hct), and whole blood viscosity (WBV). Seventeen diabetic patients with POAD were compared with 40 diabetic patients without POAD and 19 nondiabetic control subjects. Blood flow was measured by venous occlusion plethysmography, RPV was measured by capillary viscometry, WBV was measured by a Wells–Brooksfield viscometer [at high (230 s −1) and low (23 s −1) shear rates], and PFC was measured by the clot–weight method of Ingram [Ingram, G. I. C. (1961). A suggested schedule for the rapid investigation of acute haemostatic failure. Journal of Clinical Pathology, 14, 356–360]. Ankle blood flow ( Q ak) was significantly lower in diabetic patients with POAD than in diabetic patients without POAD ( P<.05). PFC was higher and Hct was lower in diabetic patients with POAD than in diabetic patients without POAD ( P<.05). RPV was 1.97±0.15 versus 1.92±0.15 in diabetic patients with POAD and diabetic patients without POAD, respectively ( P>.05). There was no significant difference in WBV at low or high shear rates between the groups studied. There was a correlation between WBV at low shear rate and arterial flow in the calf ( Q c) ( r=.94) and great toe ( r=.95) in diabetic patients with POAD, and between Q c and WBV at high ( r=−.465) and low ( r=−.472) shear rates in diabetic patients without POAD ( P<.05). We conclude that vasodilatation occurring in diabetic patients without POAD is severely restricted or absent in diabetic patients with POAD. Increased plasma fibrinogen and plasma viscosity may contribute to this phenomenon.

Incidence of Peripheral Arteriosclerotic Complications of the Lower Extremities in Diabetic Patients With Chronic Renal Failure

Patients with diabetes mellitus are at high risk of arteriosclerotic complications. The same is true for those with chronic renal failure (CRF). The present study evaluated clinical factors on the occurrence of peripheral arterial diseases. The severity of peripheral arterial disease was defined as mild (plaque, calcifications) or severe (70% stenosis, obstructions) based upon ultrasonographical examination. Overall in diabetic patients, mild ultrasonographical findings such as plaque and calcification were observed in 25% (17/69) of predialysis patients and in 18% (7/38) of those on hemodialysis (HD). Severe arteriosclerotic findings such as stenosis and obstruction were seen in 42% (29/69) of predialysis patients and in 50% (19/38) of those on HD. The incidence is identical between predialysis patients and patients on HD, regardless of the severity of peripheral arterial diseases. In an attempt to compare diabetics with non-diabetics, the incidence of mild abnormal findings was found in 22% (24/107) of diabetics and in 30% (11/37) of non-diabetics. Similarly, the percentage of patients with severe arteriosclerotic findings was found in 45% (48/107) in diabetics and 11% (4/37) in non-diabetics. The incidence of the severe type findings in the diabetics is significantly more frequent than that in the non-diabetics (P < 0.01, by the chi(2) test). In non-diabetic predialysis patients, the incidence of mild arteriosclerotic findings was observed in 30% (7/23), and 29% (4/14) of non-diabetic patients on HD. Similarly, the percentage of severe type was 9% (2/23) in non-diabetic predialysis patients, and 14% (2/14) in non-diabetic patients on HD. These data are not only supportive of previous data that diabetes is a risk factor for arteriosclerosis, but also suggestive that, even before the initiation of dialysis, patients with CRF are already susceptible to arteriosclerotic assault of peripheral arterial complications.

Infections of the upper extremity in hospitalized diabetic patients: A prospective study

To study the clinical characteristics of a group of patients with diabetes and established upper extremity infections and to determine the causative factors of hand infections. Prospective study of diabetic patients referred in to our service with infections of the upper extremity from January 1992 to December 2001. Twenty-six diabetic patients with an infection of the upper extremity were studied (17 F, 9 M). The admission rate equalled 0.7%. Twenty-one patients (80.8%) presented a Type 2 diabetes and 5 a Type 1 diabetes (19.2%). The diagnosis age of diabetes was 44.6 +/- 13.8 Years (range: 16-62). The average age at the occurrence of the lesion was 52.5 +/- 15.1 Years (range: 21-73). The average duration of diabetes was 8.3 +/- 5.9 Years (range: 0-22). Diabetes was, in all the cases, poorly controlled because of an inadequate hypoglycaemic treatment and/or bad compliance. The patients had a high prevalence of peripheral neuropathy (n=17; 65.4%). The delays in presentation to the doctor and those related to hospitalization were respectively 9.1 +/- 10.0 days (n=23) and 16.8 +/- 12.1 days. The hospitalization length reached 33.6 +/- 22.6 days (range: 7-93). The final results, 6 Months after hospitalization, were as follows: the death rate reached 19.2% (n=5); 23.1% of the patients (n=6) had a minor amputation; for 53.8% of the patients (n=14), the lesions healed without any amputation. One patient left hospital against medical advice. Eleven out of 20 patients (55%), amputated or not, were left with deformities and a subjective dysfunction of the affected limb. Infections of the upper extremity in diabetic patients constitute an uncommon but serious complication. They seem to be more frequent in housewives. They result in a high morbIdity. Prevention of these infections should be based on patients' education (compliance with diabetes treatment, hand care, prompt visit to the doctor) and General Practitioners' training for an adequate treatment and/or a rapId patient referral to hospital.

Effects of beraprost sodium (Dorner) in patients with diabetes mellitus complicated by chronic arterial obstruction.

The effects of the prostaglandin I2 derivative beraprost sodium (Dorner) on ankle pressure index (AP; ankle joint-to-upper extremity systolic pressure ratio), subjective symptoms, and intermittent claudication were investigated in diabetic patients with arteriosclerosis obliterans (ASO). Forty patients (25 men and 15 women), mean age 63.9 years, were enrolled in this study. ASO was grade I in 30 patients, grade II in seven, grade III in one, and grade IV in two according to the Fontaine classification. They were administered six tablets (20 microg/tablet) of beraprost sodium daily for 6 months. At 3 and 6 months, API had significantly increased and symptoms such as coldness, numbness, and lack of feeling in the lower extremities were significantly improved. Ten evaluable patients increased ambulatory distance by approximately threefold, suggesting an improvement in intermittent claudication. Adverse reactions were experienced by five (12.5%) of the 40 patients (one case each of headache, dull headache, pain in the posterior region of the neck, heartburn, stomach discomfort, and anemia), but all were mild and resolved without treatment. Beraprost sodium was shown to improve API and symptoms in the lower extremities in diabetic patients with ASO, suggesting that it is useful in treating peripheral circulatory disorders in such patients.

Serious hand sepsis and diabetes mellitus: specific tropical syndrome with western counterparts

Infection in the extremities of diabetic patients most commonly involves the feet and, at least in western societies, is often associated with chronic complications of diabetes. Severe hand infection, often culminating in amputation and even death, is, however, well-described in tropical countries, where it may not be associated with any evidence of neuropathy or arterial insufficiency. Similar cases are described in the western literature but are more often associated with more severe antecedent trauma. The literature describing hand sepsis in diabetic patients both in tropical and in western practice is reviewed and we draw some conclusions about pathogenesis and treatment from the literature and from original data documenting the varying experience of hand sepsis in diabetic practice throughout Africa.

Effects of beraprost sodium and prostaglandin E 1 on skin blood flow in diabetic rats and normal dogs

1. 1. The present study was undertaken to compare the effects of beraprost sodium (BPS), a stable prostaglandin I 2 analog, with prostaglandin E 1 (PGE 1) on the skin blood flow in anesthesized diabetic rats and anesthetized dogs. 2. 2. In anesthetized diabetic rats, BPS, but not PGE 1, caused a dose-dependent and significant increase in femoral skin blood flow. 3. 3. In anesthetized dogs, PGE 1 significantly increased femoral arterial blood flow than BPS. However, BPS significantly increased in-step skin blood flow than PGE 1. 4. 4. The above data suggest that BPS may be clinically useful for the treatment of circulatory insufficiency of lower extremities in diabetic patients.

Gangrene and ulcer of the lower extremities in diabetic patients

In diabetic patients in Japan, gangrene, and ulcers of the lower extremities were found in 2% of out-patients and in 4% of hospitalized patients. This prevalence in Japan is much less than in Western countries, as already shown by the Multinational Study on Vascular Diabetic Diseases. The ratio of ulcers due to neuropathy is 3 or 4 times more than that caused by ASO. But recent trends showed a gradual increase in ASO among diabetic patients. According to the API measured by the ultrasonic Doppler method, the prevalence of ASO is estimated as being 10% of diabetic patients, and about one tenth of ASO patients will develop gangrene in future.

Bacteremia in Adult Diabetic Patients

To compare the microbiology, sources, complications, and outcome of bacteremia in diabetic and nondiabetic patients. A prospective study was conducted of all episodes of bacteremia in hospitalized diabetic and nondiabetic patients. The study consisted of patients greater than or equal to 18 yr of age with bacteremia detected within a 19-mo interval. We compared 124 episodes of bacteremia in 119 diabetic patients to 508 episodes in 480 nondiabetic patients. Diabetic patients were older than nondiabetic patients (median age 74 vs. 68 yr, P = 0.0001). In patients with an indwelling urinary catheter and bacteremic urinary tract infection, the percentage of Klebsiella in diabetic patients was 60% (6 of 10) and in nondiabetic patients was 17% (4 of 23, P = 0.04). In patients without an obvious source of bacteremia, the percentage of staphylococcal isolates in diabetic patients was 29% (10 of 35) and in nondiabetic patients was 14% (24 of 176, P = 0.04). Staphylococci were a common cause of bacteremic infections of the extremities in diabetic patients (12 of 19, 63%) and nondiabetic patients (20 of 50, 40%). Septic shock was the only complication that was more common in diabetic patients. The mortality in diabetic and nondiabetic patients was 28 and 29%, respectively. Our results represent elderly patients with non-insulin-dependent diabetes mellitus. In this group, empirical treatment for suspected bacteremic urinary tract infection in patients with a urinary catheter should include coverage for Klebsiella. Empiric treatment for suspected bacteremia of unknown origin or caused by infection of the extremities should include an antistaphylococcal drug. The prognosis of bacteremia in diabetic and nondiabetic patients was similar.

Quantitation of skin vasomotor control in normal subjects and in diabetic patients with autonomic neuropathy

Peripheral autonomic neuropathy in diabetes has been difficult to evaluate. We have developed a test to quantitate sympathetic skin vasomotor function in the extremities. Skin vasomotor reflexes were investigated after warming and cooling the left arm and recording changes in skin temperature as a measure of skin blood flow in the right hand and both feet. Twenty-three diabetic patients with cardiac autonomic neuropathy and 28 healthy control subjects were examined. In contrast to the healthy subjects, the diabetic patients showed reduced or even absent responses in skin temperature to both warming and cooling. The rate of skin temperature decrease for the hand and feet during cooling, which was used as the actual parameter to quantitate skin vasomotor control, was significantly reduced in the diabetic group as compared with the healthy control subjects. We conclude that this technique provides a simple non-invasive method for quantitating skin vasomotor function in the extremities of diabetic patients.