RESUMO
BACKGROUND: Health-related quality of life (HRQoL) is poor in patients with persistent diabetic foot ulcers and poor HRQoL predicts worse outcomes in these patients. Amputation is often considered a treatment failure, which is why conservative treatment is generally preferred over amputation. However, it is unclear whether minor amputation negatively affects HRQoL compared with conservative treatment in patients with diabetic foot ulcers. METHODS: In the cohort of the multicenter, prospective, observational Eurodiale study, we determined difference in change of HRQoL measured by EQ-5D between patients with a diabetic foot ulcers that healed after conservative treatment (n = 676) and after minor amputation (n = 145). Propensity score was used to adjust for known confounders, attempting to overcome lack of randomization. RESULTS: Baseline HRQoL was not significantly different between patients treated conservatively and undergoing minor amputation. In addition, there was no difference in the change of HRQoL between these groups. In patients who healed 6 to 12 months after the first visit, HRQoL on the anxiety/depression subscale even appeared to improve more in those who underwent minor amputation. CONCLUSIONS: Minor amputation was not associated with a negative impact on HRQoL in patients with a diabetic foot ulcers. It may therefore not be considered treatment failure in terms of HRQoL but rather a viable treatment option. A randomized controlled trial is warranted to further examine the influence of minor amputations on health-related quality of life.
Assuntos
Amputação Cirúrgica , Diabetes Mellitus Tipo 2/complicações , Pé Diabético/terapia , Qualidade de Vida , Idoso , Tratamento Conservador , Pé Diabético/etiologia , Feminino , Seguimentos , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To test the efficacy and safety of therapeutic magnetic resonance (TMR) in the management of diabetic foot ulcers (DFU), the authors designed a prospective randomised controlled trial in three highly specialised diabetic foot clinics. METHOD: All the patients consecutively visited in a period of 18 months were screened according to the inclusion (presence of an ulcer >1 cm2 in the foot lasting at least 6 weeks; ABPI>0.6; consent to participate in the study) and exclusion (Charcot's foot; local or systemic infections; chronic renal failure; any wearable electrically-driven life-supporting device) criteria. Patients, who were treated according to international guideline protocols, were randomised into two groups: group A received for four weeks the sham application of TMR, while group B received the active TMR for the same period. People were followed-up to 10 weeks and healing rate (HR), healing time (HT), rate of granulation tissue on wound bed (% GT), reduction of the area of the lesion (∆AL) and a score (0-3) evaluating erythema, oedema, pain and tenderness, respectively, were measured. Adverse events (AE) were registered and monitored throughout the study. RESULTS: No differences were observed in HR, HT and ∆AL between the two groups during follow-up, while % GT and the scores for erythema, oedema and pain at 10 weeks showed significant (p<0.05) improvements in group B compared with group A and versus baseline. When restricted to non-ischaemic patients (ABPI>0.8), ∆AL was significantly (p<0.05) more pronounced in group B than in group A. No difference in AE occurrence was observed between the two groups. CONCLUSION: Our study, despite not being able to demonstrate the effectiveness of TMR on healing rate at 10 weeks, with 4 weeks of active treatment in neuro-ischaemic DFUs, shows positive effects on clinical aspects of the DFU and is associated with a significant increase of GT in the wound bed. DECLARATION OF INTEREST: The study has been fully sponsored by Thereson S.p.A., manufacturer of TMR devices.
Assuntos
Pé Diabético/terapia , Espectroscopia de Ressonância Magnética/uso terapêutico , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do TratamentoRESUMO
AIM: To identify the factors responsible for the low health-related quality of life associated with foot ulcers and the relative importance of these factors. METHODS: A total of 1232 patients with a new foot ulcer, who presented at one of the 14 centres in 10 European countries participating in the Eurodiale study, were included in this cross-sectional study. Patient and ulcer characteristics were obtained as well as results from the Euro-Qol-5D questionnaire, a health-related quality of life instrument with five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression). To analyse the relative importance of comorbidities and ulcer- and patient-related factors for health-related quality of life, linear regression models were used to calculate the relative contributions of each factor to the fit (R(2) ) of the model. RESULTS: Patients reported poor overall health-related quality of life, with problems primarily in the mobility and pain/discomfort domains. Among the comorbidities, the inability to stand or walk without help was the most important determinant of decreased health-related quality of life in all five domains. Among ulcer-related factors, ulcer size, limb-threatening ischaemia and elevated C-reactive protein concentration also had high importance in all domains. The clinical diagnosis of infection, peripheral arterial disease and polyneuropathy were only important in the pain/discomfort domain. CONCLUSIONS: The factors that determine health-related quality of life are diverse and to an extent not disease-specific. To improve health-related quality of life, treatment should not only be focused on ulcer healing but a multifactorial approach by a specialized multidisciplinary team is also important.
Assuntos
Pé Diabético/psicologia , Qualidade de Vida , Idoso , Estudos Transversais , Pé Diabético/epidemiologia , Pé Diabético/terapia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Estudos Prospectivos , Autocuidado/estatística & dados numéricosRESUMO
Routine care of non-healing acute and chronic wounds often comprises either cleaning or debridement. Consequently, debridement is a basic necessity to induce the functional process of tissue repair, which makes it a central medical intervention in the management of acute and chronic, non-healing wounds.
Assuntos
Desbridamento , Cicatrização , Gerenciamento Clínico , Humanos , Ferimentos e LesõesRESUMO
OBJECTIVES: The incidence of minor amputation may vary significantly, and determinants of minor amputation have not been studied systematically. We evaluated minor amputation rate, the determinants of minor amputation and differences in amputation rate between European centres. METHODS: In the Eurodiale study, a prospective cohort study of 1232 patients (1088 followed until end-point) with a new diabetic foot ulcer were followed on a monthly basis until healing, death, major amputation or up to a maximum of 1 year. Ulcers were treated according to international guidelines. Baseline characteristics independently associated with minor amputation were examined using multiple logistic regression modelling. Based on the results of the multivariable analysis, a disease severity score was calculated for each patient. RESULTS: One hundred and ninety-four (18%) patients underwent a minor amputation. Predictors of minor amputation were depth of the ulcer (odds ratio 6.08, confidence interval 4.10-9.03), peripheral arterial disease (odds ratio 1.84, confidence interval 1.30-2.60), infection (odds ratio 1.56, confidence interval 1.05-2.30) and male sex (odds ratio 1.42, confidence interval 0.99-2.04). Minor amputation rate varied between 2.4 and 34% in the centres. Minor amputation rate in centres correlated strongly with disease severity score at the moment of presentation to the foot clinic (r=0.75). CONCLUSIONS: Minor amputation is performed frequently in diabetic foot centres throughout Europe and is determined by depth of the ulcer, peripheral arterial disease, infection and male sex. There are important differences in amputation rate between the European centres, which can be explained in part by severity of disease at presentation. This may suggest that early referral to foot clinics can prevent minor amputations.
Assuntos
Amputação Cirúrgica/estatística & dados numéricos , Pé Diabético/cirurgia , Neuropatias Diabéticas/cirurgia , Idoso , Intervalos de Confiança , Pé Diabético/epidemiologia , Pé Diabético/fisiopatologia , Neuropatias Diabéticas/epidemiologia , Neuropatias Diabéticas/fisiopatologia , Europa (Continente)/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Índice de Gravidade de DoençaRESUMO
Diabetic complications in the lower extremities, especially those secondary to diabetic macroangiopathy, have increasingly become a clinical emergency, given the high prevalence and progression of the disease. Until recently, the only approach to treating advanced stage disease was medical therapy and major amputation; however, the advent of revascularization procedures has radically improved the prognosis of patients with critical lower limb ischemia. In this setting, iloprost holds a dual position: as first-choice therapy in patients ineligible for revascularization and as complementary therapy in candidates for surgical or endovascular revascularization.
Assuntos
Angiopatias Diabéticas/tratamento farmacológico , Iloprosta/uso terapêutico , Doença Arterial Periférica/tratamento farmacológico , Inibidores da Agregação Plaquetária/uso terapêutico , Interações Medicamentosas , Humanos , Prostaglandinas/uso terapêuticoRESUMO
AIMS: To evaluate the patients' perceptions of telemedicine visits during COVID-19 lockdown and their level of anxiety about COVID and diabetic foot (DF). METHODS: In May 2020, we contacted by phone all the patients who underwent in March and April to remote monitoring visits for DF during the lockdown for COVID-19, with a structured interview, focusing on their perceptions about telemedicine service for DF and on the anxiety toward COVID and DF. RESULTS: We analyzed 257 remote monitoring visits in 211 patients. Two hundred and six patients answered the follow-up interview; 177 patients (85.9%) remembered the monitoring visit, 140 (67.9%) the health care professional and 181 patients (87.9%) the reason of contact; 169 patients were alone during the visit, 37 with a relative. Patients judged useful both the monitoring during pandemic (4.35 ± 0.28 on a maximum of five) and the possibility to continue after the lockdown (4.34 ± 0.23 on a maximum of five). Eventually, we observed that DF patients were more worried by DF than by COVID on a scale from 0 (not fear at all) to 5 (terrified) (4.79 ± 0.05 vs. 3.27 ± 1.03, p < 0.05). This difference was higher in previously ulcerated patients (4.84 ± 0.03 vs. 3.03 ± 1.13, p < 0.05) and even more in amputees (4.93 ± 0.03 vs. 2.73 ± 1.21, p < 0.05). CONCLUSIONS: DF patients appreciated televisits during lockdown and the continuation of this service after its end. In this context DF prevails on COVID in the worries of patients, especially if they are recurrent ones.
Assuntos
Atitude , COVID-19/psicologia , Pé Diabético/psicologia , Telemedicina , Pé Diabético/terapia , Medo , Feminino , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
Neuropathic leg ulcers (NLUs) affect more than 10% of diabetic patients with peripheral neuropathy and represent the most common cause of ulceration of the leg in these patients. Though their pathogenesis is well known, related to the chronic neuropathic edema, the management of NLUs, mainly based on elastocompression, is still controversial, with lower healing rates than nondiabetic venous leg ulcers. The authors tested if a novel gel formulation, containing amino acids and hyaluronic acid (Vulnamin)gel; Errekappa, Milan, Italy), will improve the outcomes of NLUs when used together with elastocompression. Thirty patients affected by NLU were randomized into 2 groups, both treated with 4-layer elastocompressive bandaging: patients in group A were topically treated with the application of Vulnamin) gel, whereas patients in group B received only the inert gel vehicle. The healing rate at 3 months was evaluated as the primary endpoint, whereas the secondary endpoints were healing time, reduction in ulcer area and ulceration score in 4 weeks, number of infective complications, and overall satisfaction of patients. Healing rate was significantly (P < .05) higher in patients in group A when compared with those in group B; healing time, patients' satisfaction, and reduction in ulcer area and ulceration score in 4 weeks were also higher in patients in group A. However, no significant differences were found in the prevalence of infections and other adverse events. The use of Vulnamin) gel with elastocompression is safe and effective in the management of NLUs of diabetic patients.
Assuntos
Aminoácidos/administração & dosagem , Bandagens , Neuropatias Diabéticas/complicações , Ácido Hialurônico/administração & dosagem , Úlcera da Perna/tratamento farmacológico , Administração Tópica , Método Duplo-Cego , Combinação de Medicamentos , Seguimentos , Géis , Humanos , Úlcera da Perna/etiologia , Úlcera da Perna/patologia , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Cicatrização/efeitos dos fármacosRESUMO
AIMS: To determine current management and to identify patient-related factors and barriers that influence management strategies in diabetic foot disease. METHODS: The Eurodiale Study is a prospective cohort study of 1232 consecutive individuals presenting with a new diabetic foot ulcer in 14 centres across Europe. We determined the use of management strategies: referral, use of offloading, vascular imaging and revascularization. RESULTS: Twenty-seven percent of the patients had been treated for > 3 months before referral to a foot clinic. This varied considerably between countries (6-55%). At study entry, 77% of the patients had no or inadequate offloading. During follow-up, casting was used in 35% (0-68%) of the plantar fore- or midfoot ulcers. Predictors of use of casting were male gender, large ulcer size and being employed. Vascular imaging was performed in 56% (14-86%) of patients with severe limb ischaemia; revascularization was performed in 43%. Predictors of use of vascular imaging were the presence of infection and ischaemic rest pain. CONCLUSION: Treatment of many patients is not in line with current guidelines and there are large differences between countries and centres. Our data suggest that current guidelines are too general and that healthcare organizational barriers and personal beliefs result in underuse of recommended therapies. Action should be undertaken to overcome these barriers and to guarantee the delivery of optimal care for the many individuals with diabetic foot disease.
Assuntos
Atenção à Saúde/normas , Pé Diabético/terapia , Assistência Ambulatorial/normas , Assistência Ambulatorial/estatística & dados numéricos , Métodos Epidemiológicos , Europa (Continente) , Feminino , Humanos , Isquemia/terapia , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Reperfusão/estatística & dados numéricosRESUMO
We retrospectively evaluated the safety and effectiveness of colistin alone or in combination with other antimicrobials in eight diabetic patients with severe diabetic foot infections due to multidrug resistant (MDR) Pseudomonas aeruginosa, complicated in 4 cases by osteomyelitis. All patients received colistin after other ineffective antimicrobial treatment, when MDR P. aeruginosa strains were isolated by cultural examination and together with a multidisciplinary care approach including revascularization, surgical debridement and adequate offloading. The mean duration of therapy was 72 +/- 52.9 days. Six out of 8 patients (75%) successfully benefited from colistin therapy, while 2 patients failed and/or experienced side effects that led to discontinuation of therapy. Serious adverse events (i.e. acute renal failure and pulmonary edema) were observed in 1 patient. Our data allow us to conclude that colistin, alone or in combination with other antimicrobials, is safe and effective when administered as part of a multidisciplinary approach, to promote healing of diabetic foot infection due to MDR P. aeruginosa.
Assuntos
Colistina/uso terapêutico , Pé Diabético/terapia , Farmacorresistência Bacteriana Múltipla , Osteomielite/terapia , Infecções por Pseudomonas/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Colistina/administração & dosagem , Terapia Combinada , Desbridamento/métodos , Pé Diabético/complicações , Pé Diabético/microbiologia , Sinergismo Farmacológico , Quimioterapia Combinada , Feminino , Humanos , Imipenem/uso terapêutico , Masculino , Pessoa de Meia-Idade , Osteomielite/complicações , Osteomielite/microbiologia , Infecções por Pseudomonas/complicações , Infecções por Pseudomonas/microbiologia , Estudos Retrospectivos , Rifampina/uso terapêutico , Resultado do TratamentoRESUMO
The evaluation of the safety and effectiveness of colistin in association with rifampin and imipenem in 1 diabetic patient with severe diabetic foot infection (DFI) due to multidrug-resistant (MDR) Pseudomonas aeruginosa, complicated by osteomyelitis, is presented in this "Case Report". The patient received colistin after other ineffective antimicrobial treatment when an MDR P aeruginosa strain was isolated by cultural examination, together with a multidisciplinary care approach including surgical debridement and adequate offloading. The efficacy of combination colistin plus rifampin plus imipenem was observed with a checkerboard method and bactericidal activity of the serum. The patient received colistin combination therapy for 6 weeks with cure of the infection and without renal toxicity. These data suggest that colistin, in combination with rifampin and imipenem, is safe and effective, in promoting healing in DFI due to MDR P aeruginosa and suggest the need for controlled clinical studies.
Assuntos
Colistina/uso terapêutico , Pé Diabético/complicações , Imipenem/uso terapêutico , Osteomielite/complicações , Infecções por Pseudomonas/complicações , Pseudomonas aeruginosa/efeitos dos fármacos , Rifampina/uso terapêutico , Idoso , Antibacterianos/uso terapêutico , Farmacorresistência Bacteriana Múltipla , Quimioterapia Combinada , Seguimentos , Humanos , Masculino , Ossos do Metatarso , Osteomielite/tratamento farmacológico , Osteomielite/microbiologia , Infecções por Pseudomonas/tratamento farmacológico , Infecções por Pseudomonas/microbiologia , Pseudomonas aeruginosa/isolamento & purificaçãoRESUMO
To evaluate the relationship between carbapenemase-producing Klebsiella pneumoniae (KPC-Kp) gut colonization and mortality in diabetic patients with a foot infection (DFI) we performed a single-centre, retrospective, matched case-control study. In the study period, we identified 21 patients with DFI who had KPC-Kp gut colonization and 21 controls. The 90-day mortality rate was significantly higher in patients with colonized guts (47%) than the controls (4%) (p 0.013). A multivariate analysis demonstrated that gut colonization with KPC-Kp was the only independent predictor of mortality: odds ratio 13.33, 95% CI 1.90-272.80, p 0.024. In patients with DFI, KPC-Kp gut colonization appears to be an important risk factor for mortality.
Assuntos
Portador Sadio/microbiologia , Pé Diabético/mortalidade , Infecções por Klebsiella/microbiologia , Klebsiella pneumoniae/enzimologia , beta-Lactamases/metabolismo , Idoso , Idoso de 80 Anos ou mais , Portador Sadio/epidemiologia , Estudos de Casos e Controles , Feminino , Humanos , Infecções por Klebsiella/epidemiologia , Klebsiella pneumoniae/isolamento & purificação , Masculino , Fatores de Risco , Análise de SobrevidaRESUMO
Cardiovascular autonomic function tests were carried out on 22 men at varying stages of HIV infection. Thirteen were asymptomatic, seven had persistent generalized lymphadenopathy, and two had Kaposi's sarcoma. Pupil cycle times were also measured. Except for one subject with definite autonomic abnormalities, all the rest had almost normal test results. There were no correlations between individual tests of immune function and the autonomic test results. The tests were repeated 9-18 months later in 12 men, four of whom were taking zidovudine at that time. Although there was evidence of progression of HIV-associated immune dysfunction, there was no significant deterioration in autonomic function. In the single patient with abnormal autonomic function, these changes appeared to reverse on treatment with zidovudine.
Assuntos
Sistema Nervoso Autônomo/fisiopatologia , Infecções por HIV/fisiopatologia , Hemodinâmica , Adulto , Pressão Sanguínea , Linfócitos T CD4-Positivos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/imunologia , Testes de Função Cardíaca , Frequência Cardíaca , Humanos , Contagem de Leucócitos , Masculino , Pessoa de Meia-Idade , Zidovudina/uso terapêuticoRESUMO
Primary care of the diabetic patient with foot ulcer can be provided by medically or surgically trained practitioners. We have prospectively followed 90 sequential patients with newly developed foot ulcers from two major centers. One in the USA where the primary doctor was a podiatrist and one in Europe with a diabetologist. Thirty-four patients from Boston and 56 from Pisa (mean age, 55.6; range, 26-75 years; vs. 66.5; range, 35-94; P < 0.001), matched for sex, weight, type, duration of diabetes, renal impairment and retinopathy took part. Boston patients had more severe neuropathy, assessed with clinical examination utilizing a neuropathy disability score (NDS) (16 +/- 6 vs. 6 +/- 3 (mean +/- S.D.) P < 0.001) and vibration perception threshold (46 +/- 8 vs. 35 +/- 12 V: P < 0.001) while no difference existed in the number of patients with clinical infection, a history of lower extremity by-pass operation (6 (18%) vs. 3 (5%); P = NS) and in the size and the severity of the ulcer, according to the Wagner classification. Initial treatment was similar in both centers with emphasis on outpatient ulcer debridement, pressure relieving foot-wear and topical wound care. Hospitalization was needed in five (15%) Boston and 12 (21%) Pisa patients (P = NS) while surgery was performed on five (15%) Boston and 16 (29%) Pisa patients (P = NS). The in-hospital stay was similar in both centers (1.4 +/- 4.4 vs. 2.1 +/- 5.9 days; P = NS). The most common operations in both centers were incision, drainage and bone debridement. Ulcers healed in all patients but the amount of healing time was shorter in Boston patients (6.7 +/- 4.2 vs. 10.5 +/- 6.5 weeks; P < 0.02). We conclude that despite the differences in the two systems similar success rates were achieved in the two centers while a more surgically oriented strategy may have resulted in a slightly shorter healing time.
Assuntos
Pé Diabético/terapia , Úlcera do Pé/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Boston/epidemiologia , Estudos de Coortes , Diabetes Mellitus Tipo 2/complicações , Pé Diabético/etiologia , Pé Diabético/cirurgia , Neuropatias Diabéticas/patologia , Neuropatias Diabéticas/fisiopatologia , Feminino , Úlcera do Pé/etiologia , Úlcera do Pé/cirurgia , Hospitalização , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , CicatrizaçãoRESUMO
OBJECTIVES: To test the effectiveness of a combined approach to an early diagnosis of neuro-osteoarthropathy (NOA) of the diabetic foot, we studied a group of outpatients with active NOA, presenting for the first time to our Diabetic Foot Clinic in 1998, by means of an integrated approach designed to assess bone turnover. PATIENTS AND METHODS: Fifteen consecutive diabetic patients (five Type 1 and ten Type 2 diabetic individuals, age 61.9+/-12.2 years, diabetes duration 18.7+/-8.9 years, HbA(1c) 8.4+/-1.5%) with active NOA (Group 1) were compared to nine diabetic patients with chronic stable NOA (Group 2), 14 neuropathic diabetic patients without NOA (Group 3), 13 non-neuropathic diabetic patients (Group 4) and 15 healthy controls (Group 5). Determination of serum carboxy-terminal collagen telopeptide (ICTP), bone alkaline phosphatase isoenzyme (B-ALP), osteocalcin (BGP) concentrations, as well as urinary excretion of deoxypyridinoline (DPD) were obtained in all individuals for assessment of bone reabsorption and new bone formation. Moreover in all individuals quantitative ultrasound (QUS) of the calcaneal bone was performed and mass density of lumbar spine and femur bone was determined by dual-energy X-ray absorptiometry (DEXA). RESULTS: QUS was significantly lower in the active NOA patients as compared with other groups (P<0.01), while ICTP was higher in both NOA groups (P<0.01). Urinary DPD was higher in the neuropathic non-NOA group (P<0.01) than the other groups, and osteocalcin was higher in healthy controls compared to diabetic patients without NOA. QUS and ICTP were inversely correlated (r=0.44, P=0.000). QUS in the active NOA group was significantly (P<0.01) lower in the affected compared to the unaffected foot. CONCLUSION: Our results indicate a possible role for an integrated approach to the diagnosis and monitoring of NOA involving the diabetic foot. DPD may identify patients at-risk for NOA, ICTP could be tested as a marker for NOA in asymptomatic cases. Finally, QUS of the calcaneal bone may be useful in discriminating active versus quiescent phases.
Assuntos
Osso e Ossos/metabolismo , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 2/fisiopatologia , Pé Diabético/diagnóstico , Neuropatias Diabéticas/diagnóstico , Osteoartrite/diagnóstico , Idade de Início , Idoso , Índice de Massa Corporal , Neuropatias Diabéticas/diagnóstico por imagem , Hemoglobinas Glicadas/metabolismo , Humanos , Pessoa de Meia-Idade , Osteoartrite/diagnóstico por imagem , Pacientes Ambulatoriais , Reprodutibilidade dos Testes , UltrassonografiaRESUMO
In a group of 46 consecutive outpatients attending the diabetic clinic of our Metabolic Department, 30 insulin-dependent and 16 non-insulin-dependent diabetic patients in stable metabolic control, and in 38 age-matched controls, we measured vibration perception threshold with biothesiometer and autonomic function, by means of the five classical cardiovascular tests: R-R interval variations during deep breathing, Valsalva ratio, lying-to-standing, postural hypotension, and sustained handgrip. None of the patients complained of symptoms related to diabetic autonomic neuropathy (DAN) or sensory polyneuropathy. Vibration perception threshold positively correlated with Valsalva ratio (p < 0.05) and deep breathing (p < 0.01), and all of them correlated with age (p < 0.001), but not with duration of diabetes and metabolic control. Patients scored significantly lower than controls in vibration perception threshold and all of the autonomic function tests. According to the outcomes of cardiovascular tests ["Autonomic Score" (AS)] patients were divided into two different groups: presence (DAN+ = AS > or = 3) or absence (DAN- = AS < 3) of autonomic neuropathy. The DAN- group (n = 28, 60.9%) showed no significant differences from the DAN+ group (n = 18, 39.1%) in age, duration of diabetes, glycated hemoglobin, or body mass index. DAN+ patients had vibration perception threshold measured at the first toe tip and at external malleolus significantly higher than DAN- patients (p < 0.01 and p < 0.001, respectively) and controls (p < 0.005), as well as all the other cardiovascular tests except sustained handgrip. No difference in any of these items was observed between DAN- patients and controls.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Sistema Nervoso Autônomo/fisiopatologia , Sistema Cardiovascular/fisiopatologia , Diabetes Mellitus Tipo 1/fisiopatologia , Diabetes Mellitus Tipo 2/fisiopatologia , Neuropatias Diabéticas/fisiopatologia , Neurônios Aferentes/fisiologia , Adulto , Índice de Massa Corporal , Neuropatias Diabéticas/diagnóstico , Feminino , Hemoglobinas Glicadas/análise , Humanos , Masculino , Pessoa de Meia-Idade , Respiração , Limiar Sensorial , Manobra de Valsalva , VibraçãoRESUMO
To evaluate if skin hardness in diabetic neuropathic feet was increased and if its eventual modifications could be correlated to the severity of neuropathy, we studied a group of diabetic outpatients with and without neuropathy. Patients, selected among those who were attending their routine screening for diabetic neuropathy at our diabetologic clinic, were divided into two groups according to the presence (ND+) or absence (ND-) of diabetic neuropathy with the criteria of the S. Antonio Consensus Conference on Diabetic Neuropathy. Patients then underwent an evaluation of vibration perception threshold (VPT) by means of a biotesiometer, measurement of skin hardness (DMT) by means of a durometer, and transcutaneous oxygen tension (TcPO2) determination. VPT was determined at allux (VPT-A) and external malleolus (VPT-M), DMT was measured at heel (DMT-H), at medial (DMT-M) and lateral (DMT-L) midfoot, and at posterior midcalf (DTM-C) as a control site; TcPO2 was evaluated at dorsum (TcPO2-D) and at medial midfoot (TcPO2-M), respectively. All measurements were performed on the nondominant side with the patients supine. Patients were compared with age and gender-matched healthy volunteers (Controls), who underwent the same evaluations in the same order. ND+ patients showed higher values of VPT than ND- and Controls, both at first toe and at malleolus analysis of variance (ANOVA) p<0.01), as well of DMT in all the three sites explored (ANOVA, p<0.01). Moreover, ND+ showed no difference in DMT among the sites, while both in ND- and in controls DMT-M was significantly (p<0.05) lower than DMT-H and DMT-L. No difference among the three groups were observed in TcPO2 measurements, and no difference in DMT-C was observed either. A significant correlation was observed between DMT-H and VPT-M (r2 = 0.516) and between DMT-M and VPT-A (r2 = 0.624) in ND+ patients. Skin hardness was diffusely increased in ND+ patients, and this increase strongly correlates with the severity of neuropathy. Simple, noninvasive determination of skin hardness could identify patient at potential risk to develop neuropathic foot ulcers.
Assuntos
Pé Diabético/fisiopatologia , Neuropatias Diabéticas/fisiopatologia , Pele/fisiopatologia , Adulto , Monitorização Transcutânea dos Gases Sanguíneos , Pé Diabético/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Percepção , VibraçãoRESUMO
We tested the level of knowledge on diabetes and professional skills in a group of 60 non-diabetological health care professionals at the Policlinic of Pisa regarding the recognition and treatment of hypoglycaemia, the storage, mixing and administration of insulin, blood glucose stick monitoring, and the prevention and treatment of diabetic foot. The evaluation was carried out using a multiple-choice questionnaire and observation of the subjects, performance by means of pre-defined observation schedules, during the preparation and administration of a blend of rapid-intermediate insulin, the use of blood glucose sticks and the management of a simulated hypoglycaemic crisis. As regards hypoglycaemia, 90% of subjects did not give a correct definition, 88.3% were unaware of the existence of asymptomatic hypoglycaemia, and 96.6% did not give a complete answer as to the treatment of hypoglycaemia. For insulin, 51.7% did not know the standards for correct storage of insulin, 88.3% did not know the difference between "clear" and "opaque" insulins, and 91.7% ignored the required interval between administration of regular insulin and meals. For foot care, 45% admitted that the problems with diabetics' feet were frequently not controlled, and between 21.7% and 63.3% did not known the hygiene rules for feet. Assessment of the performance of the subjects using schedules revealed incorrect use of sticks and administration of insulin (80.2% mixed and 92.4% injected the insulin incorrectly). There is clearly a need for education of non-diabetological health professionals regarding the disease. This is supported by the health professionals themselves, 94.5% of whom wished to participate in a course on diabetes.
Assuntos
Diabetes Mellitus , Conhecimentos, Atitudes e Prática em Saúde , Recursos Humanos de Enfermagem Hospitalar , Glicemia/análise , Diabetes Mellitus/enfermagem , Hospitais com mais de 500 Leitos , Hospitais de Ensino , Humanos , Hipoglicemia , Insulina/administração & dosagem , Itália , Tocologia , Monitorização Fisiológica , Inquéritos e QuestionáriosRESUMO
In order to test whether or not an in-service requalification course on diabetes care for health professionals (HP) of nondiabetological departments can enhance their level of knowledge about diabetes and the quality of care for diabetic inpatients admitted for reasons other than diabetes, we carried out a requalification course involving 171 HP (161 nurses and 10 midwives) from nondiabetological departments of our hospital. Areas of intervention were: general knowledge of diabetes (GKD), bedside monitoring of blood glucose (BMG), insulin preparation and administration (IPA), diagnosis and treatment of hypoglycemic crises (DTH), and hospitalization-related problems (HRP). HP, divided into groups of about 20 each, completed a basal evaluation by means of a 25-item multiple choice questionnaire, and then attended six separate educative sessions, each of focusing on one topic, consisting of a theory lesson and an interactive exercise of equivalent length. At the end of the course, HP were re-evaluated with the same questionnaire, and their skills in BMG, IPA and DTH were tested by means of specific operational checklists, which divided each complex operation into a sequence of single operations, and then compared them with those of a control group of untrained colleagues (CG). The global knowledge of diabetes after the courses significantly improved, as gathered from the percentages of correct answers in each questionnaire (61.82% +/- 23.64% vs 31.18% +/- 20.00%; P < 0.001); separate analysis of different areas evidenced improvements in GKD (72.28% +/- 12.47% vs 31.46% +/- 20.56%; P < 0.01), BMG (68.77% +/- 15.75% vs 37.50% +/- 27.75%; P < 0.01), IPA (72.02% +/- 11.72% vs 33.45% +/- 21.22%; P < 0.05), and DTH (90.76% +/- 6.86% vs 49.82% +/- 26.68%; P < 0.05), but not in HRP. Professional skills profiles of HP, evaluated by measuring the number of errors done performing each task, were significantly (P < 0.001) better than those of CG, for BMG (1.09 +/- 0.73 vs 4.91 +/- 2.01), IPA (2.36 +/- 1.64 vs 5.64 +/- 2.25), and DHT (1.27 +/- 0.94 vs 3.82 +/- 1.12). Linear regression showed a significant (P < 0.001) correlation of skills and knowledge after the course for BMG (r2 = .49), IPA (r2 = .53), and DTH (r2 = .61). Positive although nonspecific indicators of outcomes of the course were the increase (of about 100%) of requests to our metabolic unit for diabetological consultations from other departments as well as the mentioning of diabetes in the diagnosis of discharge, and the 20% increase in the consumption of sticks for BMG. The course produced a significant improvement of knowledge and skills on specific diabetological items among participants.