Lower Limbs Of Diabetic Patients Research Articles

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.

Routine MRI findings of the asymptomatic foot in diabetic patients with unilateral Charcot foot

BackgroundImaging studies of bones in patients with sensory deficits are scarce.AimTo investigate bone MR images of the lower limb in diabetic patients with severe sensory polyneuropathy, and in control subjects without sensory deficits.MethodsRoutine T1 weighted and T2-fat-suppressed-STIR-sequences without contrast media were performed of the asymptomatic foot in 10 diabetic patients with polyneuropathy and unilateral inactive Charcot foot, and in 10 matched and 10 younger, non-obese unmatched control subjects. Simultaneously, a Gadolinium containing phantom was also assessed for reference. T1 weighted signal intensity (SI) was recorded at representative regions of interest at the peritendineal soft tissue, the tibia, the calcaneus, and at the phantom. Any abnormal skeletal morphology was also recorded.ResultsMean SI at the soft tissue, the calcaneus, and the tibia, respectively, was 105%, 105% and 84% of that at the phantom in the matched and unmatched control subjects, compared to 102% (soft tissue), 112% (calcaneus) and 64% (tibia) in the patients; differences of tibia vs. calcaneus or soft tissue were highly significant (p < 0.005). SI at the tibia was lower in the patients than in control subjects (p < 0.05). Occult traumatic skeletal lesions were found in 8 of the 10 asymptomatic diabetic feet (none in the control feet).ConclusionMR imaging did not reveal grossly abnormal bone marrow signalling in the limbs with severe sensory polyneuropathy, but occult sequelae of previous traumatic injuries.

Below the knee angioplasty for limb salvage in diabetic patients with critical lower limb ischemia

Introduction: It is well known that atherosclerotic involvement in diabetic patients with critical limb ischemia (CLI) mainly affects below-the-knee (BTK) arteries. But the therapeutic efficacy of percutaneous transluminal angioplasty (PTA) in such patients has not been clearly defined. Aim: This study aims to assess the clinical success and the limb-salvage rates for infragenicular angioplasty as the initial treatment of critically ischemic lower limbs in diabetic patients. Materials and methods: From December 2006 to October 2008, a consecutive series of 64 limbs in 54 diabetic patients with critical limb ischemia (Rutherford categories 4,5,6) were treated by primary infragenicular angioplasty. Our primary end points were immediate technical success, sustained clinical improvement, haemodynamic outcome, and limb salvage rate. Secondary end points were periprocedural complications and 30-day all cause mortality. Results: The mean age of our 54 patients was 62 years (48-70 years). The initial technical success was achieved in 94% of procedures, with limb salvage rate of 100%, 95%, 89%, and 84% at 1, 3, 6, and 12 months respectively, haemodynamic improvement of 96%, 89%, 79%, and 60% at 1, 3, 6, and 12 months respectively, and sustained clinical improvement of 100%,95%, 89%, and 84% at 1, 3, 6, and 12 months respectively,. The periprocedural adverse events occurred in 5 (7.8%) procedures, and the 30-day all cause mortality was 1/54 (1.85%). Conclusion: Primary infragenicular angioplasty for limb salvage in the diabetic patient population represents an efficacious method to improve wound healing in critically ischemic limbs, taking into consideration the fragile nature and co-morbidities in such selected patient population.

Negative pressure therapy (vacuum) for wound bed preparation among diabetic patients: case series.

Complications from diabetes mellitus affecting the lower limbs occur in 40 to 70% of such patients. Neuropathy is the main cause of ulceration and may be associated with vascular impairment. The wound evolves with necrosis and infection, and if not properly treated, amputation may be the end result. Surgical treatment is preferred in complex wounds without spontaneous healing. After debridement of the necrotic tissue, the wound bed needs to be prepared to receive a transplant of either a graft or a flap. Dressings can be used to prepare the wound bed, but this usually leads to longer duration of hospitalization. Negative pressure using a vacuum system has been proposed for speeding up the treatment. This paper had the objective of analyzing the effects of this therapy on wound bed preparation among diabetic patients. Eighty-four diabetic patients with wounds in their lower limbs were studied. A commercially available vacuum system was used for all patients after adequate debridement of necrotic tissues. For 65 patients, skin grafts completed the treatment and for the other 19, skin flaps were used. Wound bed preparation was achieved over an average time of 7.51 days for 65 patients and 10 days for 12 patients, and in only one case was not achieved. This experience suggests that negative pressure therapy may have an important role in wound bed preparation and as part of the treatment for wounds in the lower limbs of diabetic patients.

Some historical aspects of diabetic foot disease

During the 19th century and for much of the 20th century, disease of the lower limb in diabetic patients was conceptualized not, as it is now, as 'the diabetic foot' or as 'a diabetic foot ulcer' but as 'gangrene in the diabetic foot' or as 'diabetic gangrene'. The prognostically and therapeutically important distinction between gangrene due to vascular insufficiency and gangrene due to infection in a limb with a normal or near normal blood supply was not made until about 1893. The advent of aseptic surgery improved the survival of amputation flaps, but surgery remained a hazardous undertaking until the discovery of insulin. Although insulin therapy reduced the risk of surgical intervention, diabetic foot disease now replaced hyperglycaemic coma as the major cause of diabetic mortality. The increasing workload attributable to diabetic foot disease after the introduction of insulin is reflected in the publications on diabetes in the 1920s. In some hospitals in North America this led to initiatives in prophylactic care and patient education, the importance of which were only more widely appreciated some 60 years later. A continuing emphasis on ischemia and infection as the major causes of diabetic foot disease led to a neglect of the role of neuropathy. In consequence, the management of diabetic neuropathic ulceration entered a prolonged period of therapeutic stagnation at a time when significant advances were being made in the management of lepromatous neuropathic ulceration. Reasons for the revival of progress in the management of diabetic neuropathic ulceration in the 1980s will be discussed.

Effects of Isoflurane and Sevoflurane Anesthesia on Arteriovenous Shunt Flow in the Lower Limb of Diabetic Patients without Autonomic Neuropathy

Failure of sympathetic nerve control caused by diabetic neuropathy results in vasodilation of arteriovenous shunts. The aim of this study was to test the hypothesis that the function of arteriovenous anastomoses was disordered in mild diabetic patients without apparent neuropathy, and that volatile anesthetics opened arteriovenous shunts more greatly in nondiabetic patients than diabetic patients. Autonomic system function was assessed by cardiovascular reflex tests. Arterial-venous oxygen content difference (A-VDeltaO2) and partial oxygen pressure index (Pvo2/Pao2, the ratio of oxygen tension in femoral vein blood to that in femoral artery blood) were measured before and during isoflurane or sevoflurane anesthesia in 16 diabetic and 22 nondiabetic patients. Skin temperatures of the foot and leg were measured in 14 diabetic and 15 nondiabetic patients using thermography before and during anesthesia. Pvo2/Pao2 before anesthesia was significantly higher in diabetic patients. In nondiabetics, venous oxygen content significantly increased and A-VDeltaO2 markedly decreased during anesthesia, but these parameters were unchanged in diabetics. Foot temperatures were higher in diabetics before anesthesia, and increased gradually and significantly in both groups during anesthesia, but with a greater increase in nondiabetic patients. Induction of anesthesia caused a larger decrease in leg temperature in diabetics than in nondiabetics. Diabetic patients have a higher Pvo2/Pao2 and a small core-to-peripheral temperature gradient before anesthesia, suggesting latent dysfunction of the autonomic nerve system, even in the absence of autonomic neuropathy. Volatile anesthesia opens the arteriovenous shunt in nondiabetics to a greater extent than in diabetic patients.

Investigation of perfusion reserve using 99Tc(m)-MIBI in the lower limbs of diabetic patients.

This study aimed to investigate the microvascular pathology in the lower limbs of diabetic patients without symptoms or findings of peripheral ischaemia by measuring perfusion reserve scintigraphically. It was carried out in 47 female subjects who had no evidence of peripheral arterial disease in their history, physical examination or Doppler ultrasonography. The diabetic group consisted of 25 women (mean age 54.2 +/- 3.54 years) with type II diabetes mellitus of more than 10 years' duration. A control group consisted of 22 healthy non-diabetic women (mean age 50.14 +/- 6.75 years). Each subject flexed their right foot maximally both dorsally and plantar 60 times. In the middle of this exercise, 370 MBq technetium-99m-methoxyisobutylisonitrile (99Tc(m)-MIBI) was injected intravenously. Ten minutes after the injection, a posterior image of both calves was obtained using a gamma camera. Rectangular regions of interest were symmetrically drawn over both calves. The total count in the resting calf was subtracted from the total count in the exercising calf, and the percentage increase, termed the perfusion reserve, was determined. A significant difference was found between the perfusion reserves of the diabetic and control groups (76.04 +/- 12.96% and 95.91 +/- 12.83%, respectively; P<0.001). In conclusion, microvascular pathology may be determined scintigraphically by measuring the perfusion reserve in the lower limb muscles in diabetic patients. This method may also be used to evaluate perfusion abnormalities in other circulatory disorders.

Manifestation of internal organs malfunction by laser Doppler study on microcirculation.

Monitoring of microvascular blood perfusion provides very specific information on the proper function or malfunction of some internal organs, e.g. the pancreas and kidney. The laser Doppler method was used to measure microperfusion in the skin of the lower limb of diabetic patients and patients undergoing hemodialysis. This method offers non-invasive, real-time monitoring and is already accepted in many clinical experiments. The method and the laser Doppler instruments used are described. Special attention is paid to the investigation of microvascular abnormality in diabetes by using a multichannel laser Doppler system during postocclusive reactive hyperemia. The study group consisted of 41 diabetes and 24 healthy subjects with no history of family diabetes. The most valuable data were obtained from the probe located on the most distal part of the foot. Some hyperemic parameters (maximum of hyperemic response, time to peak flow) were significantly different for the diabetic group as comparing to the norm. In the microcirculation study during hemodialysis, three patients with kidney dysfunction were investigated. Increase in red blood cell velocity was observed, probably caused by better distribution of blood to the peripheral circulation.

Diabetes Mellitus and Vascular Surgery

In order to accurately describe the role diabetes plays in the pathogenesis of arteriosclerosis and its relationship to clinical practice, one must not only compare diabetics to nondiabetics of similar age and sex but also attempt to identify those factors unique to diabetics. Of the approximately six million Americans with diabetes mellitus, 90% have type-I1 (noninsulin dependent) diabetes. The remaining lo%, the type-I patients, must take insulin for survival. There are clearly profound differences between type-I and type-II diabetics which have a direct bearing both on how we perceive the disease and approach its management. Of all amputations done in America, one-half are done in diabetics for reasons other than trauma. The reasons for such a high incidence of limb loss have been attributed to a variety of factors, which include extensive atherosclerosis, peripheral neuropathy , increased susceptibility to infection, Monckeberg’s medial sclerosis, and microvascular disease. This section will delineate the important factors based on current information. It is important to realize that much more is unknown than known. The one factor that needs to be dispelled is the myth of the role of the microcirculation in the promotion of tissue ischemia and death. The commonly held ideas about a specific diabetic microangiopathy pertains only to the eye, the kidneys, and perhaps the heart. Evidence for the presence of microcirculatory lesions other than a thickening of the capillary basement membrane in the lower limbs of diabetic patients is unconvincing at present.

Gangrene of the lower limbs in diabetic patients: A malignant complication

Diabetic foot lesions are a common medical problem with major socioeconomic impact. Gangrene is usually a late and sometimes fatal complication. A series of 118 diabetic patients who underwent amputation of the lower limb at our institution over a 10 year period has been presented. Forty-two patients underwent amputation of the toes or part of the foot, 48 underwent below-knee amputation, and 18 underwent above-knee amputation. In 24 (20.3 percent), the necrotic process advanced postoperatively and necessitated additional amputation. The average hospital stay was 33.6 days. Twenty-eight patients (23.7 percent) died during the postoperative period, and the main cause of death was sepsis. Patients who presented with extensive gangrene had a higher mortality rate. There was no correlation between mortality and the duration of conservative treatment, number of repeated operations, the treatment of diabetes before hospitalization, onset of symptoms, or status of the peripheral pulses. The solution to the problem is early and vigorous preventive treatment. This could be accomplished through highly specialized clinics within the community.