RESUMO
Hyperbaric oxygen (HBO2) therapy is an adjunct treatment for diabetic foot ulcers. Since plausible mechanisms of action for this treatment include increased angiogenesis and high tissue oxygen concentrations, concerns about deterioration of retinopathy have been raised. The aim of this study was to evaluate the effects of HBO2 on visual acuity (VA) and retinopathy in patients with chronic diabetic foot ulcers during a two-year follow-up period. This is a randomized, single-center, double-blinded and placebo-controlled clinical trial evaluating the effects of HBO2 in patients with diabetes mellitus and chronic foot ulcers. All study participants underwent an ophthalmological examination before the first study treatment and then at three, six, 12 and 24 months. Fifty patients with a median age of 67 years were included. Visual acuity was similar between groups and did not change during the two-year observation period. No differences in retinopathy were seen between groups; neither were any differences found in numbers or areas of bleedings, hard exudates, microaneurysms or edemas, nor between groups or visits. New clinically significant macular edema was identified in four eyes in the HBO2 group and in three eyes in the placebo group. In this population of diabetic foot ulcer patients HBO2 seems to be neutral in an ophthalmological perspective. From a retinal point of view, we could not identify any indication of harmful effects of HBO2 on the microvascular bed in the placebo group.
Assuntos
Pé Diabético/complicações , Retinopatia Diabética/terapia , Oxigenoterapia Hiperbárica , Acuidade Visual , Idoso , Doença Crônica , Retinopatia Diabética/classificação , Retinopatia Diabética/diagnóstico , Método Duplo-Cego , Feminino , Humanos , Oxigenoterapia Hiperbárica/efeitos adversos , Oxigenoterapia Hiperbárica/métodos , Edema Macular/diagnóstico , Masculino , Pessoa de Meia-Idade , Placebos/uso terapêutico , Estatísticas não Paramétricas , Fatores de TempoRESUMO
OBJECTIVE: Charcot foot (CF) requires prolonged offloading of the affected foot to decrease the risk of deformity. The earliest phase in active CF (stage 0) is characterized by inflammatory signs without established fractures or skeletal deformity. We investigated whether offloading in stage 0 influences duration of total contact casting (TCC), risk of recurrence, and future need for surgery. RESEARCH DESIGN AND METHODS: All patients treated for active CF at Skåne University Hospital (Lund, Sweden) between 2006 and 2019 were screened for participation in a retrospective cohort study. CF events of included patients were classified as stage 0 or 1 according to X-ray and MRI reports. RESULTS: A total of 183 individuals (median age 61 [interquartile range (IQR) 52-68] years, 37% type 1 diabetes, 62% men) were followed for a median of 7.0 (IQR 3.9-11) years. In 198 analyzed CF events, 74 were treated with offloading in stage 0 and 124 in stage 1. Individuals offloading in stage 0 had significantly shorter TCC duration (median 75 [IQR 51-136] vs. 111.5 [72-158] days; P = 0.001). The difference was sustained when including only MRI-confirmed CF. The risk of developing new ipsilateral CF events >1 year after introduced definitive footwear was lower in those treated with offloading in stage 0 (2.7% vs. 9.7%; P < 0.05). No individual treated with offloading in stage 0 underwent reconstructive surgery, compared with 11 (8.9%) treated with offloading in stage 1 (P < 0.01). Amputation rates were similar. CONCLUSIONS: Offloading in stage 0 CF was associated with shorter TCC treatment, lower risk of a new CF event, and diminished need for reconstructive surgery. Future amputation risk was not affected.
Assuntos
Pé Diabético , Cirurgia Plástica , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Pé Diabético/cirurgia , Projetos Piloto , Estudos Retrospectivos , Pé/cirurgiaRESUMO
A young man presented unconscious with severe hyponatraemia, hypokalaemia, hypomagnesaemia and metabolic alkalosis. After 4 months of treatment in hospital, the hypomagnesaemia persisted. The patient had no signs of diabetes mellitus, and radiology showed no abnormalities of the kidneys, pancreas or genitourinary tract. A parenteral magnesium load demonstrated renal wasting with increased fractional urinary excretion of magnesium. Genetic tests for Gitelman as well as Bartter syndromes were negative. However, a wider genetic panel revealed that the patient was heterozygous for a deletion on chromosome band 17q12, encompassing the whole HNF1B gene.This case highlights the importance of considering pathogenic HNF1B variants in isolated profound hypomagnesaemia caused by renal wasting. Pathogenic HNF1B variants may partly mimic hypomagnesaemia found in Gitelman and Bartter syndromes and may be present without other features linked to HNF1B variants, including diabetes mellitus.
Assuntos
Síndrome de Bartter , Hiperglicemia , Hipopotassemia , Masculino , Humanos , Magnésio , Hiperglicemia/genética , Hiperglicemia/complicações , Hipopotassemia/diagnóstico , Síndrome de Bartter/diagnóstico , Testes Genéticos , Fator 1-beta Nuclear de Hepatócito/genéticaRESUMO
Systemic hyperbaric oxygen (HBO) is accomplished when a patient is breathing 100% oxygen in an environment with increased barometric pressure. A typical HBO treatment protocol of diabetic foot ulcer involves 20 to 40 sessions. Treatment is usually given as daily 90- to 120-minute HBO sessions at pressures between 2.0 and 2.5 absolute atmospheres. The wide use of HBO as treatment of diabetic foot ulcers over the past decades has been founded on weak scientific ground (ie, few and small prospective studies with methodologic limitations on top of case series). However, the consistency in positive outcome in these trials evaluating HBO on ulcer healing is noteworthy because these findings are in concert with data from in vitro and physiologic studies supporting the theoretic framework of HBO reversing hypoxia-induced pathology. Two well-designed randomized double-blinded placebo-controlled studies have in recent years put HBO on firmer ground as treatment of a selection of diabetic patients with chronic foot. Some evidence indicates that microvascular parameters such as transcutaneous (partial) oxygen pressure (TcPO(2)) could be useful in predicting which patients will benefit from therapy. Health economic studies suggest potential cost-effectiveness of HBO. But because these analyses are limited by their deficient primary clinical data, they should be interpreted with caution. Thus, HBO is only indicated in a selected group of patients with chronic diabetic foot ulcers. Several key issues remain to be addressed such as developing robust criteria to determine which patients are likely to benefit and when to start and stop treatment.
Assuntos
Pé Diabético/terapia , Oxigenoterapia Hiperbárica/métodos , Pé Diabético/fisiopatologia , Humanos , Oxigenoterapia Hiperbárica/economia , Microcirculação/fisiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do TratamentoRESUMO
Deformities such as hammer and claw toes are common in people with diabetes and neuropathy. These deformities increase pressure on the tip of toes, leading to callosity and subsequent pressure ulcers. Conventional flexor tenotomy has been shown to decrease the risk of pressure ulcers. During the first decade of the 21 century, a less traumatizing percutaneous method was introduced, and more recently a needle-based minimal flexor tenotomy method. In this paper, based on the outcome of 164 consecutive needle-based flexor tenotomies performed by diabetologists in routine clinics, we verify the simplicity and safety of this inexpensive method.
Assuntos
Pé Diabético , Tenotomia , Pé Diabético/cirurgia , Humanos , Agulhas , Dedos do PéRESUMO
OBJECTIVE: Postmenopausal phase expresses many unfavourable physiological changes that lead to increased risk for cardiovascular disease. We compared the effect of two sympatholytic antihypertensive drug treatments, the centrally acting imidazoline receptor-1 agonist moxonidine and peripherally acting beta-blocking agent atenolol on sensitive inflammatory markers in overweight postmenopausal women with diastolic hypertension. METHODS: This was a multicentre, multinational double-blinded, prospective study comparing moxonidine (0.3 mg twice daily) with atenolol (50 mg once daily) in 87 hypertensive postmenopausal overweight women who were not taking hormone therapy. Sensitive C-reactive protein, IL-6, TNFalpha, TNFalpha-RII and adiponectin were determined in the beginning of the study and after 8 weeks of medical treatment. RESULTS: TNFalpha increased in atenolol and decreased in moxonidine group (P = 0.0004 between the groups). Adiponectin concentration decreased dramatically in atenonol but did not change in moxonidine treatment group (P < 0.0001 between the groups). In logistic regression analysis only treatment group showed an independent effect on changes in adiponectin and TNFalpha concentrations. CONCLUSION: We believe that centrally acting sympatholytic agent moxonidine is beneficial in the treatment of postmenopausal women with hypertension by reducing inflammatory cytokine TNFalpha without changing protective adiponectin level.
Assuntos
Anti-Hipertensivos/uso terapêutico , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Inflamação/prevenção & controle , Pós-Menopausa/fisiologia , Sistema Nervoso Simpático/fisiopatologia , Adiponectina/metabolismo , Anti-Hipertensivos/farmacologia , Atenolol/farmacologia , Atenolol/uso terapêutico , Proteína C-Reativa/metabolismo , Método Duplo-Cego , Feminino , Finlândia , Humanos , Hipertensão/complicações , Imidazóis/farmacologia , Imidazóis/uso terapêutico , Inflamação/sangue , Inflamação/etiologia , Resistência à Insulina/fisiologia , Interleucina-6/sangue , Lituânia , Pessoa de Meia-Idade , Sobrepeso/metabolismo , Sobrepeso/fisiopatologia , Estudos Prospectivos , Receptores Tipo II do Fator de Necrose Tumoral/sangue , Suécia , Sistema Nervoso Simpático/efeitos dos fármacos , Fator de Necrose Tumoral alfa/sangueRESUMO
AIMS: Heart rate corrected QT (QTc) interval prolongation is a risk factor associated with increased mortality. Hyperbaric oxygen therapy (HBO) has previously been shown to have acute beneficial effects on QTc dispersion. The aim of this study was to evaluate long-term effects of HBO on QTc time in diabetic patients with hard-to-heal foot ulcers. METHODS: In a prospective, double-blinded placebo-controlled study, patients were randomized to 40 treatment sessions with either HBO or air (placebo), at 2.5 ATA. Patients fulfilling >35 completed treatment sessions were included in the evaluation. RESULTS: Of the initial 75 patients (38 HBO/37 placebo), two were excluded due to pacemaker use. Baseline characteristics were similar between groups. At the 2-year follow-up, QTc time was significantly shorter in the HBO compared to the placebo group (438 vs. 453ms, p<0.05). Further, fewer HBO treated patients had a QTc time >450ms (22 vs. 53 %, p<0.02). This difference seemed to be caused by a significant prolongation of the QTc interval in the placebo group (427 (419-459) at baseline vs. 456ms (424-469) after 2years), whereas no significant change was seen in HBO treated patients. CONCLUSIONS: HBO treatment might protect against QTc prolongation in this high-risk diabetic population.
Assuntos
Diabetes Mellitus Tipo 1/complicações , Diabetes Mellitus Tipo 2/complicações , Cardiomiopatias Diabéticas/prevenção & controle , Pé Diabético/terapia , Oxigenoterapia Hiperbárica , Síndrome do QT Longo/prevenção & controle , Idoso , Assistência Ambulatorial , Índice Tornozelo-Braço , Terapia Combinada , Cardiomiopatias Diabéticas/complicações , Cardiomiopatias Diabéticas/epidemiologia , Pé Diabético/complicações , Pé Diabético/fisiopatologia , Método Duplo-Cego , Feminino , Seguimentos , Humanos , Síndrome do QT Longo/complicações , Síndrome do QT Longo/epidemiologia , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Índice de Gravidade de Doença , Suécia/epidemiologia , CicatrizaçãoAssuntos
Hipoglicemiantes/administração & dosagem , Insulina/análogos & derivados , Diabetes Mellitus Tipo 1/sangue , Diabetes Mellitus Tipo 1/tratamento farmacológico , Diabetes Mellitus Tipo 2/sangue , Diabetes Mellitus Tipo 2/tratamento farmacológico , Hemoglobinas Glicadas/análise , Humanos , Insulina/administração & dosagem , Insulina Glargina , Insulina de Ação Prolongada , Satisfação do Paciente , Estudos RetrospectivosRESUMO
OBJECTIVE: Chronic diabetic foot ulcers are a source of major concern for both patients and health care systems. The aim of this study was to evaluate the effect of hyperbaric oxygen therapy (HBOT) in the management of chronic diabetic foot ulcers. RESEARCH DESIGN AND METHODS: The Hyperbaric Oxygen Therapy in Diabetics with Chronic Foot Ulcers (HODFU) study was a randomized, single-center, double-blinded, placebo-controlled clinical trial. The outcomes for the group receiving HBOT were compared with those of the group receiving treatment with hyperbaric air. Treatments were given in a multi-place hyperbaric chamber for 85-min daily (session duration 95 min), five days a week for eight weeks (40 treatment sessions). The study was performed in an ambulatory setting. RESULTS: Ninety-four patients with Wagner grade 2, 3, or 4 ulcers, which had been present for >3 months, were studied. In the intention-to-treat analysis, complete healing of the index ulcer was achieved in 37 patients at 1-year of follow-up: 25/48 (52%) in the HBOT group and 12/42 (29%) in the placebo group (P = 0.03). In a sub-analysis of those patients completing >35 HBOT sessions, healing of the index ulcer occurred in 23/38 (61%) in the HBOT group and 10/37 (27%) in the placebo group (P = 0.009). The frequency of adverse events was low. CONCLUSIONS: The HODFU study showed that adjunctive treatment with HBOT facilitates healing of chronic foot ulcers in selected patients with diabetes.
Assuntos
Pé Diabético/terapia , Oxigenoterapia Hiperbárica/métodos , Cicatrização , Adulto , Idoso , Idoso de 80 Anos ou mais , Ar , Amputação Cirúrgica , Doença Crônica , Pé Diabético/mortalidade , Pé Diabético/cirurgia , Feminino , Seguimentos , Humanos , Oxigenoterapia Hiperbárica/efeitos adversos , Masculino , Pessoa de Meia-Idade , Placebos , Resultado do TratamentoRESUMO
OBJECTIVE: Treatment with dopamine agonists has been associated with cardiopulmonary fibrotic reactions, predominantly in patients treated for Parkinson's disease. To our knowledge, these reactions have previously not been associated with low-dose cabergoline treatment for hyperprolactinaemia. METHOD: A case of constrictive pericarditis in a patient treated with cabergoline for hyperprolactinaemia is presented. The patient has been treated at a county hospital and a university hospital in southern Sweden. RESULTS: A 20-year-old woman with a 3-year history of amenorrhoea was referred to the department in 1992. From 2001 to 2005, she was given cabergoline, 0.5-1.5 mg/week. In 2005 a pericardectomy was performed due to fibrotic, constrictive pericarditis. CONCLUSIONS: Our present case suggests that constrictive pericarditis may develop even on low-dose cabergoline, which might indicate that this reaction, as opposed to valvular fibrosis, is not mediated by a 5-HT(2B) agonistic mechanism.
Assuntos
Ergolinas/efeitos adversos , Ergolinas/uso terapêutico , Hiperprolactinemia/tratamento farmacológico , Pericardite Constritiva/etiologia , Adulto , Cabergolina , Agonistas de Dopamina/efeitos adversos , Agonistas de Dopamina/uso terapêutico , Relação Dose-Resposta a Droga , Ergolinas/administração & dosagem , Feminino , Humanos , Pericardiectomia , Pericardite Constritiva/cirurgiaRESUMO
With the aim of identifying hypertension susceptibility loci, we performed a genome wide scan in Scandinavian sib-pairs with early onset primary hypertension. To be classified as affected, a diagnosis of primary hypertension at age =50 years was required. Two hundred and forty three patients with onset of primary hypertension at 40.0+/-7.7 (mean+/-SD) years from 91 families (91 sib-ships with a mean of 2.7 and a range of 2-6 affected members per sib-ship) were genotyped with 362 microsatellite markers with a density of approximately 10 cM. Loci obtaining nominal P=0.016 (LOD score >/= 1.0) were fine mapped with additional markers. Multipoint non-parametric linkage analysis was performed using GENEHUNTER v 2.0. Using simulations, a nominal P=0.0002 was determined to be a genome wide significant evidence of linkage. In the 10 cM genome wide scan, nominal P=0.016 were found on chromosomes 1 at 81 cM (P=0.007), 2 at 115 cM (P=0.006), 3 at 108 cM (P=0.006), 14 at 45 cM (P=0.0002) and at 99 cM (P=0.001), 17 at 42 cM (P=0.015) and 19 at 89 cM (P=0.007). After fine mapping of these loci, one of the chromosome 14 loci just obtained the level of genome wide significance (P=0.0002 at 41 cM) and the chromosome 2 locus reached suggestive evidence of linkage (P=0.002 at 118 cM). Our data suggest a hypertension susceptibility locus on chromosome 14 around 41 cM. The locus on chromosome 2 is also promising as it has been implicated in hypertension and blood pressure regulation in earlier genome scans.