Lower Limb Complications Research Articles

Role of Glyceraldehyde-Derived AGEs and Mitochondria in Superoxide Production in Femoral Artery of OLETF Rat and Effects of Pravastatin.

A complication of diabetes mellitus is the over-production of vascular superoxides, which contribute to the development of arteriosclerosis and peripheral arterial disease (PAD). Hyperglycemia induces the formation and accumulation of advanced glycation end-products (AGEs), which in turn stimulate vascular superoxide production. The mechanism underlying AGE-mediated vascular superoxide production remains to be clarified in lower limb complications associated with diabetes. In the present study, we investigated the role of AGEs and the mitochondrial respiratory complex in superoxide production in femoral arteries using the type 2 diabetes model Otsuka Long-Evans Tokushima Fatty (OLETF) rats [vs. non-diabetic Long-Evans Tokushima Otsuka (LETO) rats]. The effects of in vivo administration of pravastatin on superoxide production in femoral arteries were also examined. Using chemiluminescent assays, luminescence microscopy, and competitive enzyme-linked immunosorbent assay (ELISA), we determined that vascular superoxide production and serum glyceraldehyde-derived AGEs (Glycer-AGEs) increased in OLETF rats. Pravastatin inhibited these responses without changing serum total cholesterol concentrations. The mitochondrial complex II inhibitor thenoyltrifluoroacetone (TTFA) also inhibited vascular superoxide production. Application of Glycer-AGEs in situ increased superoxide production in the vascular wall of femoral arteries from pravastatin-treated OLETF rats, which was then inhibited by TTFA. These results suggest that hyperglycemia increases serum Glycer-AGEs, which subsequently induce superoxide production in the femoral artery of OLETF rats in a mitochondrial complex II-dependent manner. Collectively, our results have partially elucidated the pathological mechanisms leading to diabetes-related PAD, and indicate dual beneficial actions of pravastatin for the prevention of oxidative damage to the vascular wall.

Effect of Ayurvedic therapy in the management of Lower Limb Complications related to Diabetes Mellitus - A Case Study

According to data presented by WHO, The global prevalence of diabetes among adults is projected to be 7.7% of (439 million) adults by 2030. Study estimated that 47% of patients with diabetes have some peripheral neuropathy and is estimated to be present in 7.5% of patients at the time of diabetes diagnosis. Diabetes is the leading cause of Non traumatic lower extremity amputations in India, with approximately 5% of diabetics developing foot ulcers each year and 1% requiring amputation . Various oral hypoglycaemic agents, insulin formulations, life style modification plans consisting of dietary management and exercise, are some of the important efforts towards the management of diabetes. In spite of fascinating advances in pharmaco-therapeutic agents, world is seeking for safer and effective remedies. Increased side effects, lack of effective treatment for complications, high cost of new drugs and resistance to the drugs are some reasons for renewed public interest in Ayurvedic medicines. Now the primary goal is not merely to achieve normoglycemia, but also to minimize its complications. Basti karma is one among the Panchakarma in Ayurveda. Panchakarma intervenes at the systemic level regardless of the tissue or organ involved in the pathology. Here the case study with diabetic peripheral neuropathy and vasculopathy has shown beneficial immediate and mid-term improvement after Ayurvedic treatments. The study provides early basis for larger studies regarding role of Ayurvedic treatment in management and prevention of DM related complications.

116 Results of a National Foot Health Survey of Patients with Systemic Lupus Erythematosus

Background: SLE can affect many tissues throughout the body. Anecdotally, it is suggested that people with SLE experience a range of complications in the foot and lower limb, including vascular impairment (e.g. RP), neurological impairment, poor tissue viability (e.g. ulceration), infection and foot pain. However, to date, the precise prevalence of foot complications experienced by people with SLE has not been described. The aim of this survey was to determine self-reported foot and lower limb complications experienced by people with SLE. Methods: The survey was developed via patient and practitioner focus groups. A consensus approach was used to generate items and to formulate themes, categories, question format and survey structure. The survey was checked for face and content validity prior to cognitive debriefing to ensure usability and understanding. Consecutive patients with a confirmed diagnosis of SLE meeting the inclusion criteria attending any of seven UK clinical sites or members of Lupus UK were invited to participate. Ethical approval and participant informed consent was obtained. Results: A total of 182 survey responses were completed. For all responders, the most frequent age range was 40–49 years, mean BMI was 27 (S.D. 7) and mean disease duration was 15 years (S.D. 10). A number of vascular complications were reported, including intermittent claudication [n ¼ 100 (55%)], RP [n ¼ 94 (52%)] and splinter haemorrhage [n ¼ 39 (21%)]. Overall, 164 patients (90%) reported experiencing symptoms of peripheral vascular complications. Symptoms of peripheral neuropathy were reported by 30 patients (16%), while a fall as a consequence of neuropathic symptoms was reported by 45 patients (25%). A range of skin and nail complications were reported, including callus or corns [n ¼ 130 (71%)], onychocryptosis [n ¼ 69 (38%)], rashes or blistering [n ¼ 62 (34%)] and ulceration [n ¼ 45 (25%)]. A high prevalence of infection was reported; a history of viral infection (verrucae pedis) or fungal infection (tinea pedis) was reported by 77 patients (42%), bacterial infection by 28 patients (15%) and onychomycosis by 65 patients (36%). Overall, 170 patients (93%) reported having experienced some form of tissue viability complication. Foot joint pain, stiffness and swelling was reported by 145 (80%), 136 (75%) and 94 (52%) patients, respectively. Foot-related walking impairment was reported by 67 patients (37%). Only 60 patients (33%) reported having ever been asked about their feet by a medical professional. Seventy-seven patients (42%) reported that they would benefit from the provision of general foot health care advice. Conclusion: A large number of people with SLE report vascular complications, impaired tissue viability, musculoskeletal problems and foot pain, as well as a range of infections and conditions of the skin and nails. Despite this, foot health assessment by professionals was infrequent. These results highlight the need to undertake clinical studies investigating lower limb pathologies in SLE.

Cross-sectional correlations between the toe brachial index and lower limb complications in older people.

The aim of the study was to investigate the relationship between the toe brachial index (TBI) and foot ulceration and amputation in older people. Two hundred and sixty-one participants meeting guidelines for lower limb vascular assessment had their toe and brachial blood pressure measured, medical records audited and signs and symptoms of peripheral arterial disease (PAD) recorded. Pearson's correlation and linear regression analyses were performed to determine the strength of relationships between variables. Significant correlations were found between the TBI and painful symptoms (r = -0·35, P < 0·05) and foot complications (r = -0·31, P < 0·05). After adjusting for traditional risk factors for foot complications, participants with a TBI <0·70 were 19 times more likely to have a history of foot wounds or amputation (odds ratio = 19·20, 95% confidence interval (CI): 2·36-155·96, P < 0·001) than those with higher TBI values (>0·70). This preliminary study supports a TBI threshold of 0·70 for PAD diagnosis and indicates that lower values are associated with painful symptoms, history of ulceration and amputation. Future longitudinal investigation of the predictive capacity is now warranted.

Physical and Mechanical Therapies for Lower Limb Problems in Juvenile Idiopathic Arthritis: A Systematic Review (Protocol)

Background: Juvenile Idiopathic Arthritis is the most common chronic, autoimmune, inflammatory joint disease affecting children under 16 years of age. Children with juvenile idiopathic arthritis may present with severe lower limb joint disability and dysfunction. The evidence base for treating lower limb problems in juvenile idiopathic arthritis is growing, however is currently uncoordinated and difficult for clinicians to access. This paper reports a protocol to systematically review the evidence for physical and mechanical interventions for lower limb problems in juvenile idiopathic arthritis. Methods/Design: The following electronic databases will be searched for eligible studies: MEDLINE, EMBASE, Cochrane Central Registar of Controlled Trials, PUBMED and CINAHL. Randomised control trials and quasi randomised control trials of physical and mechanical interventions for lower limb problems in children with juvenile idiopathic arthritis will be included. Two authors will independently screen studies for eligibility for inclusion and assess the risk of bias. One author will extract and analyse statistical data, which will be checked by a second author. Discussion: This systematic review aims to establish a best-practice pathway of non-invasive and non-drug interventions for lower limb complications of juvenile idiopathic arthritis and to highlight the areas of greatest need for future research. Keywords: Children, foot orthoses, foot, juvenile idiopathic arthritis, lower limb.

Lower limb complications of diabetes mellitus: a comprehensive review with clinicopathological insights from a dedicated high-risk diabetic foot multidisciplinary team

Diabetic complications in the lower extremity are associated with significant morbidity and mortality, and impact heavily upon the public health system. Early and accurate recognition of these abnormalities is crucial, enabling the early initiation of treatments and thus avoiding or minimizing deformity, dysfunction and amputation. Following careful clinical assessment, radiological imaging is central to the diagnostic and follow-up process. We aim to provide a comprehensive review of diabetic lower limb complications designed to assist radiologists and to contribute to better outcomes for these patients.

(179) - Functional Outcomes and Quality of Life in Heart Transplant Patients Requiring Extracorporeal Membrane Oxygenation

Extracorporeal Membrane Oxygenation (ECMO) has been increasingly used as a rescue therapy for patients in cardiogenic shock both pre and post heart transplantation (HTx). This study aimed to describe early physical function, health-related quality of life (HRQOL) and lower limb complications in patients that received ECMO either pre or post HTx.

Lower limb malperfusion in type B aortic dissection: a systematic review.

Lower limb malperfusion (LLM) syndrome occurs in up to 40% of complicated type B aortic dissections (TBAD) and in up to 71% of TBAD with malperfusion syndrome. This syndrome is associated with higher 30-day mortality. The aim of this systematic review was to provide clinical and procedural data of patients with LLM syndrome secondary to TBAD. The PubMed database was systematically searched from January 2000 to June 2014 for English-language publications reporting on demographic data of patients with LLM secondary to TBAD. A total of 29 papers were included (10 original articles and 19 case reports), reporting on a total of 138 patients (mean age =58±12 years; male =87%). Lower limb complications developed in acute and chronic TBAD in 134 (97%) and 4 (3%) cases, respectively. LLM presented with acute limb ischemia in 120 (87%) patients. Bilateral clinical presentation occurred in 56% (40/72) of cases. LLM was the only clinically detected malperfusion in 52% of cases (44/84). In 40% (35/84) and 25% (21/84) of cases, LLM was clinically associated with renal and visceral malperfusion, respectively. Radiological imaging showed renal, celiac trunk and superior mesenteric artery involvement in 53% (47/88), 31% (27/88) and 34% (30/88) of cases, respectively. Medical, surgical and endovascular treatments were performed in 22 (16%), 51 (37%) and 65 (47%) patients, respectively. Thirty-day morbidity was 31% (13/42) and 46% (6/13) following surgical and endovascular treatment, respectively. Thirty-day mortality was 14% (5/36) and 8% (2/26) following surgical and endovascular treatment, respectively. LLM syndrome secondary to TBAD usually developed during the acute phase and, in most cases, presented with acute limb ischemia. Bilateral clinical presentation occurred in more than half of cases. Renal and visceral malperfusion were frequently associated with lower limb flow reduction but LLM was the only clinically detected malperfusion in more than half of patients. Surgical fenestration was burdened with significant complication rates and 30-day mortality. Endovascular procedures showed lower mortality but complication rates remained high.

Current concepts related to limb salvage in diabetes

SUMMARY: Limb salvage provides an alternative to amputation in patients with limb-threatening conditions. A majority of amputations occur secondary to lower limb complications, especially from diabetes such as diabetic foot ulcerations, infections and Charcot neuroarthropathy. Limb salvage techniques have been described in the literature with new advances in wound care, revascularization techniques and the introduction of a team approach to lower limb amputation prevention programs. Understanding risk factors for limb loss and treatment options for limb salvage is essential in treating patients with complications of diabetes.

Diabetic Foot Education and a Diabetic Foot Screening Tool

People with diabetes mellitus develop lower-limb complications such as diabetic neuropathy, peripheral vascular disease, foot ulcers, and lower-leg amputations. Widespread failure to carry out diabetic foot screening can lead to risk of ulceration and amputation. We hope to enhance competence and knowledge concerning high-risk diabetic foot screening. This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. (J Korean Diabetes 2014;15:221-226)

A randomized controlled pilot trial comparing the impact of access to clinical endocrinology video demonstrations with access to usual revision resources on medical student performance of clinical endocrinology skills

BackgroundDemonstrating competence in clinical skills is key to course completion for medical students. Methods of providing clinical instruction that foster immediate learning and potentially serve as longer-term repositories for on-demand revision, such as online videos demonstrating competent performance of clinical skills, are increasingly being used. However, their impact on learning has been little studied. The aim of this study was to determine the value of adjunctive on-demand video-based training for clinical skills acquisition by medical students in endocrinology.MethodsFollowing an endocrinology clinical tutorial program, 2nd year medical students in the pre-assessment revision period were recruited and randomized to either a set of bespoke on-line clinical skills training videos (TV), or to revision as usual (RAU). The skills demonstrated on video were history taking in diabetes mellitus (DMH), examination for diabetes lower limb complications (LLE), and examination for signs of thyroid disease (TE). Students were assessed on these clinical skills in an observed structured clinical examination two weeks after randomization. Assessors were blinded to student randomization status.ResultsFor both diabetes related clinical skills assessment tasks, students in the TV group performed significantly better than those in the RAU group. There were no between group differences in thyroid examination performance. For the LLE, 91.7% (n = 11/12) of students randomized to the video were rated globally as competent at the skill compared with 40% (n = 4/10) of students not randomized to the video (p = 0.024). For the DMH, 83.3% (n = 10/12) of students randomized to the video were rated globally as competent at the skill compared with 20% (n = 2/10) of students not randomized to the video (p = 0.007).ConclusionExposure to high quality videos demonstrating clinical skills can significantly improve medical student skill performance in an observed structured clinical examination of these skills, when used as an adjunct to clinical skills face-to-face tutorials and deliberate practice of skills in a blended learning format. Video demonstrations can provide an enduring, on-demand, portable resource for revision, which can even be used at the bedside by learners. Such resources are cost-effectively scalable for large numbers of learners.

Diabetic Foot Ulcer Complications and Its Management-a Medical College-Based Descriptive Study in Odisha, an Eastern State of India.

The aim of this study was to prepare a profile of diabetic foot ulcer (DFU) complications and its management and to assess the outcome of the surgical interventions. A prospective study was carried out in 60 patients with DFU during the period of January 2009 to October 2010 to categorize them based on Meggit-Wagner system and to find out the complications, management, below knee amputation rate, and mortality rate. Majority of the patients (30%, n = 18) presented with Wegner grade 3 DFU. Only three patients (5%) presented with grade 0 DFU. Split skin grafting was the most frequently done intervention, comprising 29% of the time. Below knee amputation was required in 10% of cases and mortality rate was 12%. Lack of awareness about diabetes mellitus and its lower limb complications, poor compliance to the treatment, poorly controlled blood sugar levels, delay in diagnosis, and late presentation to the tertiary care center are all factors which led to occurrence of DFU at an age earlier than that seen in other studies.

Population‐based screening for the prevention of lower extremity complications in diabetes

Diabetes-related foot disease is a major health problem leading to significant morbidity and cost. If high-risk populations could be identified and treated before they develop complications, a significant reduction in the burden of foot disease and number of amputations might be expected. We examined the evidence to support population-based screening programs. MEDLINE and EMBASE databases were searched from January 1970 to February 2012 to identify studies assessing the impact of screening on lower limb complications in diabetes. Foot screening was defined as combined risk stratification and intervention to prevent foot complications in a population of people with diabetes mellitus. Articles reporting singularly on stratification of risk factors to predict subsequent complications but not reporting effect on minor, major and/or combined major and minor (total) amputation were excluded. Two randomized control trials were identified. These demonstrated patient benefit from screening in the setting of a general secondary care diabetes clinic and renal dialysis unit. Four before and after studies suggested benefit from primary care or regional screening. One study tried to address confounding from general improvements in the provision of diabetes foot care separately from screening. All the observational studies were prone to confounding. The evidence base for formal national primary care-based foot screening of all patients with diabetes is weak. Focused research is needed to confirm that general population-based screening in the community is effective and cost-effective. Limited evidence suggests that screening of high-risk populations of patients may be justified.

Healthcare, self-care, and health status of immigrants and non-immigrants with type 2 diabetes in the Canadian Community Health Surveys

AimsTo identify healthcare, self-care, and health status disparities between immigrants and non-immigrants with type 2 diabetes mellitus (T2DM) in Canada. MethodsImmigrants and non-immigrants with T2DM were compared in the nationally representative 2005 and 2007 Canadian Community Health Surveys (N=7658 representing 1,205,000 in 2005; N=3605 representing 1,446,000 in 2007). ResultsNo significant differences existed between immigrants and non-immigrants with T2DM in annual glycated hemoglobin testing, foot examination by a physician, urine protein testing, or eye examinations. Among self-care measures, immigrants were less likely to perform foot self-examination at least weekly (OR=0.70 [0.50, 0.98] in 2005; OR=0.65 [0.47, 0.91] in 2007) or smoke (OR=0.63 [0.45, 0.87] in 2005; OR=0.44 [0.25, 0.77] in 2007), but there were no differences in self-monitoring of blood glucose or physical inactivity. With respect to health status, immigrants were less likely to have a chronic condition in addition to T2DM (OR=0.68 [0.54, 0.86] in 2005; OR=0.59 [0.41, 0.84] in 2007), but there were no differences in self-perceived general or mental health. ConclusionsHealthcare, self-care, and health status were similar in immigrants and non-immigrants with T2DM in Canada; however, immigrants were less likely to regularly examine their feet. Culturally appropriate footcare education should be considered to prevent lower limb complications.

Knowledge, Risk Factors and Behaviors Associated with Lower-Limb Complications in Patients with Diabetes on Hemodialysis

Identify risk factors for lower-limb complications, knowledge of diabetes self-management and foot care behaviors performed in patients with diabetes on hemodialysis.

Screening for the High-Risk Diabetic Foot

People with diabetes mellitus will develop lower-limb complications, such as neuropathy, peripheral vascular disease, foot ulcers, and lower-leg amputations. Resources to control elevated hemoglobin A1c and blood pressure, along with the standardized approach using the 60-second tool (2012), can detect the high-risk diabetic foot and help prevent complications.

Factores de riesgo de complicaciones vasculares en extremidades inferiores en los pacientes con diabetes

Background and Objetive To evaluate the risk factors of complications in lower limbs in diabetic patients. Patients and methods We evaluated 270 patients with diabetes followed in Hospital la Paz from 2000 to 2008.We measured the ankle-brachial index (ABI), toe-brachial index (TBII), and toe blood pressure (BP). We defined vascular complications in lower limbs. We compared some epidemiological and clinical variables between patients with and without a vascular event. We analyzed which variables have an independent association with the later appearance of a vascular event with Cox regression model. Results The mean value of ITB, IDB and toe blood pressure were significantly lower in patients who had a vascular event compared to those who had not presented it (ITB mean 0.92 ± 0.30 vs 0.78 ± 0.46, P = .007; IDB mean 0.86 ± 4.40 vs 0.42 ± 0.22, P = .001; PA mean 72.08 ± 30.62 vs 56.25 ± 29.51, P = .014).The association of vascular event and biomechanical abnormalities ( P = .022), active and old ulcers ( P = .000), and insensivity ( P = .023) were significantly. In the Cox regression model the toe brachial index (HR 0.05; IC:0.00-0.52; P = .013), the active (HR 3.26; IC:1.37-7.79; P = .008) and old ulcers (HR 5.55; IC:1.85-16.59; P = .002). and the biomechanical abnormalities (HR 4.92; IC:1.13-18.75; P = .019) had an independent value. Conclusions Toe brachial index, biomechanical abnormalities and ulcers have an independent value to predict the later appearance of vascular events. In addition, they are independent of the age, type of diabetes and others diabetic complications.

The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds: A retrospective review of 16 patients

The authors present their experience with the use of sural fasciocutaneous flaps for the treatment of various soft tissue defects in the lower limb. This paper is a review of these flaps carried out between 2003 and 2008. The series consists of 16 patients, 11 men and 5 women with an average age of 41 years (17-81) and with a follow-up period between 2 and 7 years. The etiology was major velocity accident in six cases, diabetes mellitus with osteomyelitis after ORIF for fractures (2), work accident in five, and another two cases with complications of lower limb injuries. The defect areas were located on calcaneus, malleolar area, tarsal area and lower tibia. Associated risk factors in the patients for the flap performance were diabetes (five patients) and cigarette smoking (ten patients).The technique is based on the use of a reverse-flow island sural flap combined with other flaps in three cases (cross-leg, peroneal, gastrocnemius). The anatomical structures which constituted the pedicle were the superficial and deep fascia, the sural nerve, the lesser saphenous vein and skin.The flap was viable in all 15 patients. On 8 cases was achieved direct closure, on three cases occurred a superficial necrosis and was skin grafted, on one case was observed partial necrosis which was treated with a second flap (posterior tibial perforator flap) and another one occurred delayed skin healing.The sural fasciocutaneous flap is useful for the treatment of severe and complex injuries and their complications in diabetic and non diabetic lower limbs. Its technical advantages are easy dissection, preservation of more important vascular structures in the limb and complete coverage of the soft tissue defects in just one operation without the need of microsurgical anastomosis. Thus this flap offers excellent donor sites for repairing soft tissue defects in foot and ankle.

Establishing and reviewing podiatry service to the haemodialysis ward at Caulfield Hospital

Background Podiatry services for patients attending haemodialysis at Caulfield Hospital (CH) began in June 2009 due to emerging evidence indicating people with chronic kidney disease and end stage renal failure are at an increased risk of developing lower limb complications such as ulceration and amputation. Risk factors become more frequent with progression of the disease, some research also suggests 95% of people with diabetes who receive haemodialysis treatment have at least one risk factor for foot ulceration.

Is there a relationship between static and dynamic ankle joint dorsiflexion during gait in people with a history of neuropathic ulceration?

Background The inclusion of limited joint mobility (LJM) as a risk factor for plantar neuropathic foot ulceration in diabetes is interspersed throughout the literature. This is commonly believed to occur through connective tissue thickening and stiffening, thereby reducing available static and dynamic motion below that required for normal foot function. High underfoot pressures are postulated to result, leading to increased ulcer risk. This project investigated this theory as it relates to ankle joint dorsiflexion in people with a range of lower limb complications due to diabetes.