Infrared thermography and ulcer prevention in the high-risk diabetic foot: data from a single-blind multicentre controlled clinical trial.

AIM: To assess the usefulness of monthly thermography and standard foot care to reduce diabetic foot ulcer recurrence. METHODS: People with diabetes (n = 110), neuropathy and history of ≥ 1 foot ulcer participated in a single-blind multicentre clinical trial. Feet were imaged with a novel thermal imaging device (Diabetic Foot Ulcer Prevention System). Participants were randomized to intervention (active thermography + standard foot care) or control (blinded thermography + standard foot care) and were followed up monthly until ulcer recurrence or for 12 months. Foot thermograms of participants from the intervention group were assessed for hot spots (areas with temperature ≥ 2.2°C higher than the corresponding contralateral site) and acted upon as per local standards. RESULTS: After 12 months, 62% of participants were ulcer-free in the intervention group and 56% in the control group. The odds ratios of ulcer recurrence (intervention vs control) were 0.82 (95% CI 0.38, 1.8; P = 0.62) and 0.55 (95% CI 0.21, 1.4; P = 0.22) in univariate and multivariate logistic regression analyses, respectively. The hazard ratios for the time to ulcer recurrence (intervention vs control) were 0.84 (95% CI 0.45, 1.6; P = 0.58) and 0.67 (95% CI 0.34, 1.3; P = 0.24) in univariate and multivariate Cox regression analyses, respectively. CONCLUSIONS: Monthly intervention with thermal imaging did not result in a significant reduction in ulcer recurrence rate or increased ulcer-free survival in this cohort at high risk of foot ulcers. This trial has, however, informed the design of a refined study with longer follow-up and group stratification, further aiming to assess the efficacy of thermography to reduce ulcer recurrence.

Reliability of a novel thermal imaging system for temperature assessment of healthy feet.

BACKGROUND: Thermal imaging is a useful modality for identifying preulcerative lesions ("hot spots") in diabetic foot patients. Despite its recognised potential, at present, there is no readily available instrument for routine podiatric assessment of patients at risk. To address this need, a novel thermal imaging system was recently developed. This paper reports the reliability of this device for temperature assessment of healthy feet. METHODS: Plantar skin foot temperatures were measured with the novel thermal imaging device (Diabetic Foot Ulcer Prevention System (DFUPS), constructed by Photometrix Imaging Ltd) and also with a hand-held infrared spot thermometer (Thermofocus® 01500A3, Tecnimed, Italy) after 20 min of barefoot resting with legs supported and extended in 105 subjects (52 males and 53 females; age range 18 to 69 years) as part of a multicentre clinical trial. The temperature differences between the right and left foot at five regions of interest (ROIs), including 1st and 4th toes, 1st, 3rd and 5th metatarsal heads were calculated. The intra-instrument agreement (three repeated measures) and the inter-instrument agreement (hand-held thermometer and thermal imaging device) were quantified using intra-class correlation coefficients (ICCs) and the 95% confidence intervals (CI). RESULTS: Both devices showed almost perfect agreement in replication by instrument. The intra-instrument ICCs for the thermal imaging device at all five ROIs ranged from 0.95 to 0.97 and the intra-instrument ICCs for the hand-held-thermometer ranged from 0.94 to 0.97. There was substantial to perfect inter-instrument agreement between the hand-held thermometer and the thermal imaging device and the ICCs at all five ROIs ranged between 0.94 and 0.97. CONCLUSIONS: This study reports the performance of a novel thermal imaging device in the assessment of foot temperatures in healthy volunteers in comparison with a hand-held infrared thermometer. The newly developed thermal imaging device showed very good agreement in repeated temperature assessments at defined ROIs as well as substantial to perfect agreement in temperature assessment with the hand-held infrared thermometer. In addition to the reported non-inferior performance in temperature assessment, the thermal imaging device holds the potential to provide an instantaneous thermal image of all sites of the feet (plantar, dorsal, lateral and medial views). TRIAL REGISTRATION: Diabetic Foot Ulcer Prevention System NCT02317835, registered December 10, 2014.

A medical thermal imaging device for the prevention of diabetic foot ulceration.

In this paper a description is given of the development, characterisation and first results of a thermal imaging device aimed at significantly reducing the incidence of diabetic foot ulceration (DFU). These devices will be used in three clinical centres and in two preliminary clinical trials. The first will be on healthy volunteers to set a robust baseline for the overall research aims and the second on >100 patients at high risk of DFU. In the second phase of the project the objective is to demonstrate significant reduction in the incidence of DFU through a comparison of the results of standard care of high risk feet with standard care plus thermal imaging.

New perspectives on bone densitometry.

Methods of bone mineral density measurement are presented. Radiological photogrammetry, single photon absorptiometry, dual photon absorptiometry and dual energy X-ray absorptiometry are described. Mode of work of densitometers and their characteristics ares presented. Modern development of densitometric equipment and possible application in diagnosing of osteoporosis is discussed.

Childhood growth, physical activity, and peak bone mass in women.

Peak bone mass is an important determinant of the risk of osteoporotic fracture, and preventive strategies against osteoporosis require a clear understanding of the factors influencing bone gain in early life. We report a longitudinal study aiming to identify the relationships between childhood growth, lifestyle, and peak bone mass in women. One hundred and fifty-three women born in a British city during 1968-1969 were traced and studied in 1990. Data on their growth in childhood was obtained from linked birth and school health records; current bone mineral measurements were made by dual X-ray absorptiometry. There were statistically significant associations between weight at 1 year and BMC (but not BMD) at the lumbar spine (r = 0.32, p < 0.01) and femoral neck (r = 0.26, p < 0.01). These remained significant after adjusting for current weight. There were also strong relationships between childhood height measurements and adult BMC at the two skeletal sites. Physical activity was the major lifestyle determinant of BMD after allowing for body build. We conclude that infant growth and physical activity in childhood are important determinants of peak bone mass in women. Growth primarily determines the size of the skeletal envelope, and its trajectory is established by age 1 year. Activity, in contrast, modulates the mineral density within the skeletal envelope and may contribute to the consolidation of bone following the end of linear growth.

Bone mineral density in nonsteroid treated early rheumatoid arthritis.

OBJECTIVES: To determine whether significant reduction in bone mass is detectable in early disease in patients with rheumatoid arthritis (RA) and to examine the possible influences of disease activity and physical disability on bone mineral density (BMD) of the lumbar spine (LS) and femoral neck (FN). METHODS: LS and FN BMD values were measured and Z scores determined in a cross-sectional study of 104 patients with RA of less than five years duration. BMD values were also compared between a subgroup of 64 patients and a normal control group matched for age, sex, menopausal status and body mass. BMD values and Z scores were correlated with disease activity, measured by the Stoke Index, disability, measured by HAQ score, and disease duration. RESULTS: Premenopausal female patients with RA had significantly reduced mean FN Z scores (-0.62, 95% CI -0.30 to -0.94) which correlated with HAQ scores (Rs 0.358, p = 0.05) and age (Rs 0.397, p = 0.03). There were no significant changes of BMD in males or postmenopausal females. Disease duration and disease activity did not correlate with BMD changes. CONCLUSION: BMD is reduced in premenopausal female patients with early RA possibly related to the attainment of peak bone mass. No significant reduction of BMD was found in males or postmenopausal females with early disease. Physical disability but not disease activity appears to play a role in the reduction of FN bone mass.

Osteoporosis in early ankylosing spondylitis: a primary pathological event?

Patients with severe ankylosing spondylitis of long duration often have spinal osteoporosis secondary to ankylosis and immobility. Bone mineral density of defined regions of the lumbar spine, femoral neck, and carpus was measured in 25 men who met accepted diagnostic criteria for ankylosing spondylitis but had early disease, with normal mobility and no, or very minor, radiological evidence of lumbar spine involvement. Compared with age-matched male controls, patients with ankylosing spondylitis had a significantly lower hydroxyapatite density in the lumbar spine (mean [SD] 0.82 g/cm2 [0.12] vs 0.91 g/cm2 [0.11]) and in the femoral neck (0.83 g/cm2 [0.11] vs 0.92 g/cm2 [0.11]). There was no significant difference in carpal bone mineralisation density. The pattern of bone loss in these patients indicates early loss of trabecular bone in ankylosing spondylitis, possibly from a systemic cause, but biochemical indices of calcium turnover were similar in patients and controls.

Sulfasalazine-induced colitis complicating idiopathic ulcerative colitis.

A diagnosis of idiopathic ulcerative colitis was made in a previously healthy 9-year-old boy. Symptoms persisted despite therapy with sulfasalazine, 50 mg/kg daily, but they eventually responded to treatment with parenteral nutrition and prednisone, 40 mg daily. Metronidazole was also given to eradicate persistent Dientamoeba fragilis from the stools. The symptoms resolved over 3 weeks, and the daily dose of prednisone was tapered. On two subsequent occasions a challenge with sulfasalazine caused an immediate recurrence of loose, blood-streaked stools and of nonspecific histologic features of ulcerative colitis, which resolved when the sulfasalazine was discontinued.

Benoxaprofen--dose-range studies using quantitative thermography.

Fifty-four hospitalized patients with rheumatoid arthritis participated in a dose-range study comparing benoxaprofen with placebo and in a further study comparing benoxaprofen with indomethacin. Assessments were made after a "washout period" weekly for 3 wk. There was clinical improvement with time in both the placebo and active drug groups which was attributable to bed rest and hospitalization. Assessments of pain, function, and analgesic consumption showed that benoxaprofen had analgesic activity at all dose levels. Computerized thermography showed that, at a dosage of 600 mg daily, benoxaprofen had a significant antiinflammatory effect; this observation was confirmed by the comparison with indomethacin. No side effects were noted in patients taking benoxaprofen.

[Monoclonal gammopathy and platelet function (author's transl)]. / Monoklonale Gammopathie und Thrombozytenfunktion.

This study of 20 patients with monoclonal gammopathy (17 patients with multiple myeloma and 3 patients with Waldenström's syndrome) showed a decreased platlet aggregation induced by ADP and collagen, a reduced platlet retention and a prolonged bleeding time in 25% of the cases in comparison with 30 age- and sex-matched healthy controls. Using Wu and Hoak's technique as increased number of reversible platelet aggregates was observed. There was no relationship between the parameters of primary haemostasis and protein analysis. A disturbed mechanism of primary haemostasis is the main factor responsible for the bleeding diathesis in patients with monoclonal gammopathy.

[Circulating platelet aggregates during haemodialysis]. / Zirkulierende Thrombozytenaggregate während Hämodialyse.

In eight chronically haemodialysed patients a significant increase of circulating platelet aggregates (method of Wu and Hoak) was observed immediately after starting haemodialysis. The number of aggregates decreased at the end of haemodialysis reaching the starting values after 360 min. The platelet interaction with the dialysis membrane surface might cause this phenomenon. Anticoagulation with heparin alone was insufficient in preventing aggregate formation during haemodialysis.

Prostacyclin-like activity of endothelium and subendothelium - important for atherosclerosis?

Morphological control of Moncada's bioassay for prostacyclin (PG I2) activity measurement shows that the activity depends not only on endothelium, but in important amounts on subendothelial tissue too. Therefore, it can be concluded that platelet thrombus formation after endothelial cell injury does not depend only on the PG I2-producing ability of the tissue.

[Platelet retention and hypothyroidism: an investigation in patients with thyroid carcinoma treated by total thyroidectomy (author's transl)]. / Thrombozytenretention und Hypothyreose. Untersuchung an total thyreoidektomierten Schilddrüsenkarzinompatienten.

Platelet retention was investigated using a standardized technique with a glass pearl column in 18 patients with malignant thyroid disease treated by thyroidectomy before and after high-dose radioiodine treatment (80 or 150 mCi). As compared with the normal controls platelet retention was significantly lower in 13 hypothyroid patients in whom thyroidectomy had been undertaken at least 6 months previously and hormone substitution therapy had been interrupted 3 weeks before the period of investigation. The remaining 5 patients, studied about 18 days following thyroidectomy, were euthyroid and displayed platelet retention values within the lower limits of the normal range except for one patient with markedly reduced values. Thyroid substitution therapy with synthetic preparations induced recovery of platelet retention in both groups examined over a 4 week period, the increase being highly significant in the group of hypothyroid patients. A transient increase in platelet retention was observed 24 hours after a therapeutic dose of radioiodine, and initial values being regained after a further 24-hour period. This phenomenon was found in both, the euthyroid and hypothyroid group, however, it was more pronounced in the latter patients. Our results indicate a dependence of platelet retention on thyroid hormone concentration. The observed transient increase after radioiodine may be due to a radiation effect.

Thermography and radiology complimentary methods for the study of inflammatory diseases.

The authors have correlated the findings of thermography and radiology in some inflammatory lesions. The two investigations are complementary. Thermography demonstrates changes of vascularity in the acute phase of a lesion whereas radiology is of value in showing structural changes.