Balneotherapy for chronic venous insufficiency.

BACKGROUND: Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction or a combination of these symptoms, with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It places a large financial burden on health systems. There is a wide variety of treatment options for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) may be a relatively cheap and efficient way to deliver physiotherapy to people with CVI. This is an update of a review first published in 2019. OBJECTIVES: To assess the effectiveness and safety of balneotherapy for the treatment of people with chronic venous insufficiency. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 28 June 2022. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials comparing balneotherapy to no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. disease severity, 2. health-related quality of life (HRQoL) and 3. ADVERSE EFFECTS: Our secondary outcomes were 1. pain, 2. oedema, 3. leg ulcer incidence and 4. skin pigmentation changes. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included nine randomised controlled trials involving 1126 participants with CVI. Seven studies evaluated balneotherapy versus no treatment, one study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis), and one study evaluated balneotherapy versus dryland exercises. We downgraded our certainty in the evidence due to a lack of blinding of participants and investigators, participant-reported outcomes and imprecision. Balneotherapy versus no treatment Balneotherapy compared to no treatment probably results in slightly improved disease severity signs and symptoms scores as assessed by the Venous Clinical Severity Score (VCSS; mean difference (MD) -1.75, 95% confidence interval (CI) -3.02 to -0.49; 3 studies, 671 participants; moderate-certainty evidence). Balneotherapy compared to no treatment may improve HRQoL as assessed by the Chronic Venous Insufficiency Quality of Life Questionnaire 2 (CIVIQ2) at three months, but we are very uncertain about the results (MD -10.46, 95% CI -19.21 to -1.71; 2 studies, 153 participants; very low-certainty evidence). The intervention may improve HRQoL at 12 months (MD -4.48, 95% CI -8.61 to -0.36; 2 studies, 417 participants; low-certainty evidence). It is unclear if the intervention has an effect at six months (MD -2.99, 95% CI -6.53 to 0.56; 2 studies, 436 participants; low-certainty evidence) or nine months (MD -6.40, 95% CI -13.84 to 1.04; 1 study, 59 participants; very low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on the occurrence of adverse effects. The main adverse effects were thromboembolic events (odds radio (OR) 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; low-certainty evidence), erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; low-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study, 59 participants; low-certainty evidence). No studies reported any serious adverse effects. Balneotherapy compared with no treatment may improve pain scores slightly at three months (MD -1.12, 95% CI -1.35 to -0.88; 2 studies, 354 participants; low-certainty evidence); and six months (MD -1.02, 95% CI -1.25 to -0.78; 2 studies, 352 participants; low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on oedema (measured by leg circumference) at 24 days to three months, but we are very uncertain about the results (standardised mean difference (SMD) 0.32 cm, 95% CI -0.70 to 1.34; 3 studies, 369 participants; very low-certainty evidence). Balneotherapy compared with no treatment may have little or no effect on the incidence of leg ulcers at 12 months, but we are very uncertain about the results (OR 1.06, 95% CI 0.27 to 4.14; 2 studies, 449 participants; very low-certainty evidence). Balneotherapy compared with no treatment may slightly reduce skin pigmentation changes as measured by the pigmentation index at 12 months (MD -3.60, 95% CI -5.95 to -1.25; 1 study, 59 participants; low-certainty evidence). Balneotherapy versus melilotus officinalis For the comparison balneotherapy versus a phlebotonic drug (melilotus officinalis), there was little or no difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study, 35 participants; very low-certainty evidence) or oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study, 35 participants; very low-certainty evidence), but we are very uncertain about the results. The study reported no other outcomes of interest. Balneotherapy versus dryland exercise For the comparison balneotherapy versus dryland exercise, evidence from one study showed that balneotherapy may improve HRQoL as assessed by the Varicose Vein Symptom Questionnaire (VVSymQ), but we are very uncertain about the results (MD -3.00, 95% CI -3.80 to -2.20; 34 participants, very low-certainty evidence). Balneotherapy compared with dryland exercises may reduce oedema (leg volume) after five sessions of treatment (right leg: MD -840.70, 95% CI -1053.26 to -628.14; left leg: MD -767.50, 95% CI -910.07 to -624.93; 1 study, 34 participants, low-certainty evidence). The study reported no other outcomes of interest. AUTHORS' CONCLUSIONS: For the comparison balneotherapy versus no treatment, we identified moderate-certainty evidence that the intervention improves disease severity signs and symptoms scores slightly, low-certainty evidence that it improves pain and skin pigmentation changes, and very low-certainty evidence that it improves HRQoL. Balneotherapy compared with no treatment made little or no difference to adverse effects, oedema or incidence of leg ulcers. Evidence comparing balneotherapy with other interventions was very limited. To ensure adequate comparison between trials, future trials should standardise measurements of outcomes (e.g. disease severity signs and symptoms score, HRQoL, pain and oedema) and follow-up time points.

Transcutaneous Electric Nerve Stimulation on ischemic rest pain in inpatients: randomised trial.

OBJECTIVE: To investigate the efficacy of a short-term application of Transcutaneous Electric Nerve Stimulation to relieve rest pain in patients with chronic limb-threatening ischemia. METHODS: In patients ³18 years old, with chronic limb-threatening ischemia and rest pain ³3 in the Visual Analogue Scale, without diabetic neuropathy were randomly assigned to 1) Transcutaneous Electric Nerve Stimulation (100 Hz, 200 µs) or 2) sham intervention, both during one or two 20 min treatment sessions. The primary outcome was pain intensity, assessed by the visual analogue scale (0-10 cm) and described by the McGill Pain Questionnaire. We used a t-test for difference of means. RESULTS: A total of 169 patients were assessed, 23 met the study criteria and were randomized. Thirty-four applications were performed in two days: in the 17 Transcutaneous Nerve Stimulation and 17 sham. The within-group analysis indicated a pain decrease in both groups (Transcutaneous Electric Nerve Stimulation, from 7-3.9 cm, p<0.0001, and sham from 5.8-3.2 cm, p<0.0001). No statistically significant difference was verified between-groups (p=0.5). CONCLUSIONS: Both groups showed a decrease in rest pain of 54 and 55%, respectively. However, there was no difference between short-term high-frequency Transcutaneous Electric Nerve Stimulation and sham intervention to relieve ischemic rest pain in chronic limb-threatening ischemia patients.

Brazilian Portuguese version of the Mediterranean diet scale: Translation procedures and measurement properties.

BACKGROUND AND AIM: The Mediterranean Diet Scale (MDS) is a questionnaire with characteristics which can contribute to the multidimensional assessment of patients with diabetes mellitus (DM) by the multidisciplinary team, as well as to evaluate the effect of specific educational and nutritional interventions. The aim of this study was to translate and perform a cross-cultural adaptation of a Canadian MDS and analyze the measurement properties of the Brazilian Portuguese version of the Mediterranean Diet Scale (MDS-Brazil) in individuals with DM in Brazil. METHODS: This was a cross-sectional study. The analyzed measurement properties were the internal consistency, floor and ceiling effects, reproducibility, and construct validity. The inclusion criteria were diagnosis of DM type 1 or type 2, literate, outpatients, and without eating restrictions. RESULTS: Of the 160 volunteers included in this study, 30 participated in pretesting, and another 130 (57.7% women, 74.6% DM type 2, 56.55 ± 14.88 years) agreed to participate in the evaluation stage of the measurement properties. All items were cross-culturally adapted. A factor analysis (KMO = 0.555 and X² = 137.22; p < 0.001) extracted five factors, with no floor or ceiling effects, Cronbach's alpha = 0.42, and reproducibility ICC = 0.75. CONCLUSIONS: The cross-cultural adaptation was performed maintaining the equivalences. The MDS-Brazil measurement properties showed substantial reproducibility, low internal consistency, and fair correlations of construct validity in patients with DM.

Patient education program for Brazilians living with diabetes and prediabetes: findings from a development study.

BACKGROUND: Globally, the incidence of diabetes is increasing and strategies to reach a comprehensive approach of care are needed, including education in self-management. This is particularly true in low and middle-income countries where the number of people living with diabetes is higher than in the high-income ones. This article describes the development of a structured patient education program for Brazilians living with diabetes or prediabetes. METHODS: These steps were undertaken: 1) a 4-phase needs assessment (literature search of local diabetes guidelines, environmental scan, evaluation of information needs of patients identified by diabetes experts, and patient focus groups); and, 2) the translation and cultural adaptation of the patient guide (preparation, translation, back-translation, back-translation review, harmonization, and proofreading). RESULTS: Four of the seven guidelines identified include educational aspects of diabetes management. No structured education program was reported from the environmental scan. Regarding the information needs, 15 diabetes experts identified their patients' needs, who referred that they have high information needs for topics related to their health condition. Finally, results from six patient focus groups were clustered into six themes (self-management, physical activity, eating habits, diabetes medication, psychosocial being, and sleep), all embedded into the new education program. Constructive theory, adult learning principles, and the Health Action Process Approach model were used in program development and will be used in delivery. The developed program consists of 18 educational sessions strategically mapped and sequenced to support the program learning outcomes and a patient guide with 17 chapters organized into five sections, matched with weekly lectures. CONCLUSIONS: This program is a sequential and theoretical strategic intervention that can reach programs in Brazil to support diabetes and prediabetes patient education.

Transcutaneous Electric Nerve Stimulation on ischemic rest pain in inpatients: randomised trial

SUMMARY OBJECTIVE: To investigate the efficacy of a short-term application of Transcutaneous Electric Nerve Stimulation to relieve rest pain in patients with chronic limb-threatening ischemia. METHODS: In patients ³18 years old, with chronic limb-threatening ischemia and rest pain ³3 in the Visual Analogue Scale, without diabetic neuropathy were randomly assigned to 1) Transcutaneous Electric Nerve Stimulation (100 Hz, 200 μs) or 2) sham intervention, both during one or two 20 min treatment sessions. The primary outcome was pain intensity, assessed by the visual analogue scale (0-10 cm) and described by the McGill Pain Questionnaire. We used a t-test for difference of means. RESULTS: A total of 169 patients were assessed, 23 met the study criteria and were randomized. Thirty-four applications were performed in two days: in the 17 Transcutaneous Nerve Stimulation and 17 sham. The within-group analysis indicated a pain decrease in both groups (Transcutaneous Electric Nerve Stimulation, from 7-3.9 cm, p<0.0001, and sham from 5.8-3.2 cm, p<0.0001). No statistically significant difference was verified between-groups (p=0.5). CONCLUSIONS: Both groups showed a decrease in rest pain of 54 and 55%, respectively. However, there was no difference between short-term high-frequency Transcutaneous Electric Nerve Stimulation and sham intervention to relieve ischemic rest pain in chronic limb-threatening ischemia patients.

Balneotherapy for chronic venous insufficiency.

BACKGROUND: Chronic venous insufficiency (CVI) is a progressive and common disease that affects the superficial and deep venous systems of the lower limbs. CVI is characterised by valvular incompetence, reflux, venous obstruction, or a combination of these with consequent distal venous hypertension. Clinical manifestations of CVI include oedema, pain, skin changes, ulcerations and dilated skin veins in the lower limbs. It can result in a large financial burden on health systems. There is a wide variety of treatment options or therapies for CVI, ranging from surgery and medication to compression and physiotherapy. Balneotherapy (treatments involving water) is a relatively cheap option and potentially efficient way to deliver physical therapy for people with CVI. OBJECTIVES: To assess the efficacy and safety of balneotherapy for the treatment of people with chronic venous insufficiency (CVI). SEARCH METHODS: The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, AMED and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and the Clinical Trials.gov trials register to August 2018. We searched the LILACS and IBECS databases. We also checked references, searched citations and contacted study authors to identify additional studies. SELECTION CRITERIA: We included randomised and quasi-randomised controlled trials comparing balneotherapy with no treatment or other types of treatment for CVI. We also included studies that used a combination of treatments. DATA COLLECTION AND ANALYSIS: Two review authors independently reviewed studies retrieved by the search strategies. Both review authors independently assessed selected studies for complete analysis. We resolved conflicts through discussion. We attempted to contact trial authors for missing data, obtaining additional information. For binary outcomes (leg ulcer incidence and adverse events), we presented the results using odds ratio (OR) with 95% confidence intervals (CI). For continuous outcomes (disease severity, health-related quality of life (HRQoL), pain, oedema, skin pigmentation), we presented the results as a mean difference (MD) with 95% CI. MAIN RESULTS: We included seven randomised controlled trials with 891 participants (outpatients in secondary care). We found no quasi-randomised controlled trials. Six studies (836 participants) evaluated balneotherapy versus no treatment. One study evaluated balneotherapy versus a phlebotonic drug (melilotus officinalis) (55 participants). There was a lack of blinding of participants and investigators, imprecision and inconsistency, which downgraded the certainty of the evidence.For the balneotherapy versus no treatment comparison, there probably was no improvement in favour of balneotherapy in disease severity signs and symptom score as assessed using the Venous Clinical Severity Score (VCSS) (MD -1.66, 95% CI -4.14 to 0.83; 2 studies, 484 participants; moderate-certainty evidence). Balneotherapy probably resulted in a moderate improvement in HRQoL as assessed by the Chronic Venous Insufficiency Questionnaire 2 (CVIQ2) at three months (MD -9.38, 95% CI -18.18 to -0.57; 2 studies, 149 participants; moderate-certainty evidence), nine months (MD -10.46, 95% CI -11.81 to -9.11; 1 study; 55 participants; moderate-certainty evidence), and 12 months (MD -4.99, 95% CI -9.19 to -0.78; 2 studies, 455 participants; moderate-certainty evidence). There was no clear difference in HRQoL between balneotherapy and no treatment at six months (MD -1.64, 95% CI -9.18 to 5.89; 2 studies, 445 participants; moderate-certainty evidence). Balneotherapy probably slightly improved pain compared with no treatment (MD -1.23, 95% CI -1.33 to -1.13; 1 study; 390 participants; moderate-certainty evidence). There was no clear effect related to oedema between the two groups at 24 days (MD 43.28 mL, 95% CI -102.74 to 189.30; 2 studies, 153 participants; very-low certainty evidence). There probably was no improvement in favour of balneotherapy in the incidence of leg ulcers (OR 1.69, 95% CI 0.82 to 3.48; 2 studies, 449 participants; moderate-certainty evidence). There was probably a reduction in incidence of skin pigmentation changes in favour of balneotherapy at 12 months (pigmentation index: MD -3.59, 95% CI -4.02 to -3.16; 1 study; 59 participants; low-certainty evidence). The main complications reported included erysipelas (OR 2.58, 95% CI 0.65 to 10.22; 2 studies, 519 participants; moderate-certainty evidence), thromboembolic events (OR 0.35, 95% CI 0.09 to 1.42; 3 studies, 584 participants; moderate-certainty evidence) and palpitations (OR 0.33, 95% CI 0.01 to 8.52; 1 study; 59 participants; low-certainty evidence), with no clear evidence of an increase in reported adverse effects with balneotherapy. There were no serious adverse events reported in any of the studies.For the balneotherapy versus a phlebotonic drug (melilotus officinalis) comparison, we observed no clear difference in pain symptoms (OR 0.29, 95% CI 0.03 to 2.87; 1 study; 35 participants; very low-certainty evidence) and oedema (OR 0.21, 95% CI 0.02 to 2.27; 1 study; 35 participants; very low-certainty evidence). This single study did not report on the other outcomes of interest. AUTHORS' CONCLUSIONS: We identified moderate- to low-certainty evidence that suggests that balneotherapy may result in a moderate improvement in pain, quality of life and skin pigmentation changes and has no clear effect on disease severity signs and symptoms score, adverse effects, leg ulcers and oedema when compared with no treatment. For future studies, measurements of outcomes such as disease severity sign and symptom score, quality of life, pain and oedema and choice of time points during follow-up must be standardised for adequate comparison between trials.

Fisioterapia intra-hospitalar para pacientes com isquemia crítica de membro inferior: consenso de especialistas / Fisioterapia intrahospitalaria para pacientes con isquemia crítica de miembro inferior: consenso de especialistas / Intra-hospital physical therapy for patients with critical lower limb ischaemia: an expert consensus

RESUMO A isquemia crítica de membro inferior (ICMI) gera impacto nos sistemas de saúde, na qualidade de vida e funcionalidade dos indivíduos diagnosticados. Entretanto, há pouca evidência científica que permita fundamentar a intervenção fisioterapêutica para pacientes internados por ICMI. O objetivo desse estudo foi elaborar um consenso de especialistas sobre a fisioterapia intra-hospitalar para pacientes com ICMI. Para tal, foi utilizado o método Delphi. Um painel de especialistas foi formado por 18 fisioterapeutas que representavam 85,7% da equipe de um hospital de referência em cirurgia vascular. Foram consideradas, para o consenso, as respostas com valor mínimo de concordância de 70% e média ou mediana ≥3,1 na escala Likert. Os questionários abordaram itens da avaliação, objetivos e condutas fisioterapêuticas nas fases pré e pós-cirurgia de revascularização. Definiram-se como itens essenciais a avaliação de sintomas, função cognitiva, musculoesquelética e cardiorrespiratória. Controle da dor, redução de edemas, ganho de amplitude de movimento, deambulação e educação em saúde são objetivos no pré-operatório e o ganho de força muscular na fase pós-operatória. Exercícios passivo, assistido, ativo livre e circulatório, incluindo os membros superiores, estão indicados antes e após as cirurgias. Educação em saúde e deambulação com redução de peso em área de lesão plantar são essenciais em todo o período de internação. A eletroanalgesia foi preconizada no pré-operatório e a elevação do membro inferior e exercícios resistidos no pós-operatório.

RESUMEN La isquemia crítica de miembro inferior (ICMI) afecta a los sistemas de salud y la calidad de vida y funcionalidad de los individuos diagnosticados. Sin embargo, hay poca evidencia científica que fundamente la intervención fisioterapéutica para pacientes internados por ICMI. El objetivo de este estudio fue elaborar un consenso de especialistas sobre la fisioterapia intrahospitalaria para pacientes con ICMI. Para ello, se utilizó el método Delphi. Se formó un panel de expertos con 18 fisioterapeutas que representaban el 85,7% del equipo de un hospital de referencia en cirugía vascular. Se consideraron, para el consenso, las respuestas con un valor mínimo de concordancia del 70% y media o mediana ≥3,1 en la escala Likert. Los cuestionarios abordaron ítems de evaluación, objetivos y conductas fisioterapéuticas en las fases pre y poscirugía de revascularización. Se definieron como elementos esenciales la evaluación de síntomas y las funciones cognitiva, musculoesquelética y cardiorrespiratoria. En el preoperatorio, control del dolor, reducción de edemas, ganancia de amplitud de movimiento, deambulación y educación en salud son los objetivos; en la fase posoperatoria, la ganancia de fuerza muscular. Los ejercicios pasivos, asistidos, activos libres y circulatorios, incluidos los miembros superiores, se indican antes y después de las cirugías. La educación en salud y la deambulación con reducción de peso en el área de lesión plantar son esenciales en todo el período de internación. La electroanalgesia fue preconizada en el preoperatorio; y, en el postoperatorio, elevación del miembro inferior y ejercicios resistidos.

ABSTRACT Critical limb ischemia (CLI) is a disease with a great burden for the healthcare system, patient's functionality and quality of life. However, there is little evidence to guide intrahospital physical therapy programs for patients with CLI. Thus, this study aimed to provide an expert consensus on intrahospital physiotherapeutic care for CLI patients. An expert panel was made up with 18 experienced physical therapists, which represented 85.7% of physical therapists from a reference vascular surgery team in a university hospital. The Delphi method was used to produce a consensus, considering a minimum agreement of 70% and a mean or median score in the Likert scale ≥3.1. The questionnaires included items related to assessment, goals and physiotherapeutic interventions prior and after revascularization. A consensus was reached on assessing symptoms, cognitive, articular, musculoskeletal and cardiorespiratory functions. Pain control, edema drainage, range of motion gain, walking incentive and health education are goals in the pre-operatory and the muscular strengthening in postoperatory phase. In both phases there was a consensus on the use of passive, active-assisted and active exercises, including upper limb exercises. Walking and therapeutic education are essential during the hospitalization period with offloading practices in area of plantar ulcer. Electroanalgesia should be used in preoperative phase and resisted exercises and lower limb elevation at postoperatory.

Fatores de risco para mortalidade em pacientes submetidos a amputações maiores por pé diabético infectado / Risk factors for mortality among patients undergoing major amputations due to infected diabetic feet

A lesão no pé de pacientes com diabetes é um importante problema de saúde pública que frequentemente está associado a amputações em membros inferiores e mortalidade nessa população. Objetivos: Investigar os fatores de risco associados a mortalidade em pacientes com pé diabético infectado submetidos a amputação maior. Métodos: Estudo observacional, retrospectivo e caso-controle. Amostra composta por 78 pacientes com pé diabético e úlcera infectada submetidos a amputação maior em um serviço de cirurgia vascular em um hospital universitário no período de 5 anos. Resultados: A média de idade da amostra estudada foi de 63,8 ± 10,5 anos, com 54 (69,2%) pacientes do sexo masculino, com creatinina sérica média de 2,49 ± 2,4 mg/dL e hemoglobina sérica média de 7,36 ± 1,7 g/dL. Houve 47,4% de reinternação. Foi realizada amputação transtibial em 59,0% e transfemoral em 39,7% da amostra estudada. Nesta amostra, 87,2% dos pacientes apresentaram cultura positiva, predominantemente monomicrobiana (67,9%), e 30,8% presentaram infecção hospitalar da úlcera. Os gêneros de bactérias mais frequentes foram Acinetobacter spp. (24,4%), Morganella spp. (24,4%) e Proteus spp. (23,1%). Nenhum gênero bacteriano foi identificado como fator de risco para óbito. O nível de creatinina ≥ 1,3 mg/dL (OR 17,8; IC 2,1-150) e a amputação transfemoral (OR 4,5; C: 1,3-15,7) foram fatores de risco para o óbito. Conclusões: Os níveis séricos de creatinina ≥ 1,3 mg/dL e amputação transfemoral foram fatores de risco para óbito

Foot ulcers in patients with diabetes are a major public health problem and are often associated with lower limbs amputation and mortality in this population. Objectives: To investigate the risk factors associated with mortality in patients with infected diabetic foot ulcers and major lower limb amputations. Methods: This was an observational, retrospective, case-control study with a sample of 78 patients with infected diabetic foot ulcers who had major lower limb amputations at a Vascular Surgery Service at a university hospital. Results: The mean age of the study sample was 63.8 ± 10.5 years, 54 (69.2%) were male, mean serum creatinine was 2.49 ± 2.4 mg/dL and mean serum hemoglobin was 7.36 ± 1.7 g/dL.There was a 47.4% rate of readmissions to the same hospital.Transtibial amputation was performed in 59.0%; and transfemoral amputation in 39.7% of the sample. In this sample, 87.2% had a positive culture, predominantly (68.0%) monomicrobial and nosocomial infection of ulcers was observed in 30.8%. The most common bacterial genera were Acinetobacter spp. (24.4%), Morganella spp. (24.4%) and Proteus spp. (23.1%). No bacterial genus was identified as a predictor of death. Creatinine level ≥ 1.3 mg/dL (OR 17.8; IC 2.1-150) and transfemoral amputation (OR 4.5; IC: 1.3-15.7) were associated with death. Conclusions: Serum creatinine levels ≥ 1.3 mg/dL and transfemoral amputation were risk factors for death

Risk factors for mortality among patients undergoing major amputations due to infected diabetic feet.

BACKGROUND: Foot ulcers in patients with diabetes are a major public health problem and are often associated with lower limbs amputation and mortality in this population. OBJECTIVES: To investigate the risk factors associated with mortality in patients with infected diabetic foot ulcers and major lower limb amputations. METHODS: This was an observational, retrospective, case-control study with a sample of 78 patients with infected diabetic foot ulcers who had major lower limb amputations at a Vascular Surgery Service at a university hospital. RESULTS: The mean age of the study sample was 63.8 ± 10.5 years, 54 (69.2%) were male, mean serum creatinine was 2.49 ± 2.4 mg/dL and mean serum hemoglobin was 7.36 ± 1.7 g/dL. There was a 47.4% rate of readmissions to the same hospital. Transtibial amputation was performed in 59.0%; and transfemoral amputation in 39.7% of the sample. In this sample, 87.2% had a positive culture, predominantly (68.0%) monomicrobial and nosocomial infection of ulcers was observed in 30.8%. The most common bacterial genera were Acinetobacter spp. (24.4%), Morganella spp. (24.4%) and Proteus spp. (23.1%). No bacterial genus was identified as a predictor of death. Creatinine level ≥ 1.3 mg/dL (OR 17.8; IC 2.1-150) and transfemoral amputation (OR 4.5; IC: 1.3-15.7) were associated with death. CONCLUSIONS: Serum creatinine levels ≥ 1.3 mg/dL and transfemoral amputation were risk factors for death.

Hydrotherapy improves pain and function in older women with knee osteoarthritis: a randomized controlled trial.

BACKGROUND: Currently, there is poor evidence of the effect of hydrotherapy alone on patients with hip or knee osteoarthritis. OBJECTIVES: The study aimed to assess the impact of hydrotherapy on pain, function, and muscle function in older women with knee osteoarthritis. METHODS: A randomized controlled trial was conducted to evaluate the efficacy of hydrotherapy in women with knee osteoarthritis. Seventy-three women aged 65 and older were randomized to hydrotherapy (n=36) or a control group (n=37). The hydrotherapy group received the intervention program in a heated pool (twice per week for six weeks) and an educational protocol while the control group received an educational protocol only. Primary outcomes (before and post-treatment) were pain intensity (0-100) and function (0-100), assessed with the WOMAC questionnaire. Secondary outcomes (before and post-treatment) were knee extensor and knee flexor muscle performance (strength, power, and endurance), assessed by an isokinetic dynamometer. The magnitude of change between the groups for the outcomes was calculated using linear regression models adjusted by baseline outcome values. RESULTS: The hydrotherapy group had better outcomes for pain (adjusted mean difference=11 points, 95% CI: 3-18) and function (adjusted mean difference=12 points, 95% CI: 5-18). Patients receiving hydrotherapy had better performance for knee flexor and extensor strength, knee flexor power, and knee extensor endurance. CONCLUSION: Older women with knee osteoarthritis are likely to have benefits from a course of hydrotherapy exercises. Registry of clinical trials (Trial number RBR-8F57KR) - http://www.ensaiosclinicos.gov.br/rg/RBR-8f57kr/.

Diabetic foot ulcer carries high amputation and mortality rates, particularly in the presence of advanced age, peripheral artery disease and anemia.

INTRODUCTION: Foot ulcer is also a clinical marker for limb amputation and for death in diabetic patients. The purpose of this study was to determine amputation and mortality rates and its associated factors in patients with diabetic foot ulcerations in a tertiary hospital in Brazil. METHODS: Retrospective medical records from 654 diabetic foot patients were reviewed. The risk factors were determined using the conditional logistic regression model analysis. RESULTS: The mean patient age was 63.1 years (SD 12.20). Peripheral arterial disease was present in 160 patients (24.5%). Major amputations were performed in 135 (21%). The in-hospital mortality rate was 12% and the mortality rate of the amputees was 22.2%. The lowest hemoglobin level, the median value was 9.50g/dL, (4.0-17.0). Anemia was detected in 89.6% of patients submitted to amputation and in 82,1% of those who died. Hemoglobin <11g/dL was the most significant risk factor for major amputation (odds ratio 5.57, p<0.0001). The presence of peripheral arterial disease and old age were also a risk for major amputation (odds ratio 1.84, p=0.007 and 1.02, p=0.028, respectively). Factors associated with increased risk for death were hemoglobin <11g/dL (odds ratio 4.04, p<0.001), major amputation (1.79, p=0.03) and old age (1.05, p<0,001). CONCLUSIONS: Diabetic foot ulcer is associated with high amputation and mortality rates. Old age, peripheral arterial disease and low hemoglobin level are risk factor for major amputation. Old age, major amputation and low hemoglobin level are risk factors for death.

Mapping the association between back pain and type 2 diabetes: A cross-sectional and longitudinal study of adult Spanish twins.

BACKGROUND: Back pain and type 2 diabetes often co-occur, resulting in greater impact on people's health and complexity in their care. Plausible causal mechanisms for this association have been proposed, yet the nature of the link remains unclear. We therefore explored the direction of the association between type 2 diabetes and chronic back pain in twins, controlling for genetics and early environmental confounding. METHODS: 2,096 and 1,098 twins were included in the cross-sectional and longitudinal analyses, respectively. Any or severe (≥ 9) low back pain (LBP), neck pain (NP), and spinal pain (concurrent LBP and NP) and type 2 diabetes were investigated. Sequential analyses were performed using logistic regression. Firstly, twins were analysed unpaired (adjusted age and gender): total sample analyses. Then, to control for genetic and shared environmental factors, a co-twin case-control analysis was performed including monozygotic and dizygotic twin pairs discordant for back pain (cross-sectional only). RESULTS: In the cross-sectional total sample analyses, type 2 diabetes was associated with chronic spinal pain (OR 1.61; 95%CI 1.12 to 2.31), severe chronic spinal pain (OR 3.33; 95%CI 1.47 to 7.53), chronic NP (OR 1.37; 95%CI 1.01 to 1.85), severe chronic NP (OR 2.28; 95%CI 1.24 to 4.21), and severe chronic LBP (OR 1.63; 95%CI 1.00 to 2.64). After further adjustment for genetic and shared environmental factors, none of the associations remained significant. The longitudinal analyses indicated that the presence of type 2 diabetes did not increase the risk of future back pain, or vice-versa, after two to four years. CONCLUSIONS: Chronic back pain (spinal pain, NP, or LBP) was associated with the prevalence of type 2 diabetes. Associations are stronger for severe cases of pain. Future research should investigate the temporal relationships between these conditions with longer follow up in twins.

The Brazilian Twin Registry.

The Brazilian Twin Registry (BTR) was established in 2013 and has impelled twin research in South America. The main aim of the initiative was to create a resource that would be accessible to the Brazilian scientific community as well as international researchers interested in the investigation of the contribution of genetic and environmental factors in the development of common diseases, phenotypes, and human behavior traits. The BTR is a joint effort between academic and governmental institutions from Brazil and Australia. The collaboration includes the Federal University of Minas Gerais (UFMG) in Brazil, the University of Sydney and University of Melbourne in Australia, the Australian Twin Registry, as well as the research foundations CNPq and CAPES in Brazil. The BTR is a member of the International Network of Twin Registries. Recruitment strategies used to register twins have been through participation in a longitudinal study investigating genetic and environmental factors for low back pain occurrence, and from a variety of sources including media campaigns and social networking. Currently, 291 twins are registered in the BTR, with data on demographics, zygosity, anthropometrics, and health history having been collected from 151 twins using a standardized self-reported questionnaire. Future BTR plans include the registration of thousands of Brazilian twins identified from different sources and collaborate nationally and internationally with other research groups interested on twin studies.

Does cerclage improve neonatal outcomes in a molar pregnancy and a coexistent fetus? A case report.

BACKGROUND: Complete hydatiform mole and coexistent viable fetus is very rare. The use of a cervical cerclage for cervical indications in the presence of this condition has never been reported. Although the diagnosis was made postnatal, the objective is to present a case with good neonatal outcome. CASE PRESENTATION: A patient presented with vaginal spotting around 23 weeks. She has a history of four preterm deliveries. Her cervix was dilated and a cerclage was placed. She presented again with PPROM around 25 weeks. She went into spontaneous preterm labor and delivered a viable fetus that is a healthy girl today. Eventually the pathology of the placenta showed a complete hydatidiform mole. CONCLUSION: It is necessary to inform patients about the potential risks and poor outcomes of this condition. For those who desire all potential interventions, cerclage placement could be considered.

Morbilidad oftalmológica en escolares de comunidades rurales en Venezuela / Ophthalmologic morbidity in schoolchildren of rural communities in Venezuela

Introducción: el deterioro de la función visual limita el desarrollo adecuado de los niños y repercute en el rendimiento escolar. Objetivo: determinar la frecuencia de morbilidad oftálmica en escolares que asisten a las escuelas ubicadas en las comunidades rurales de Puerto Cabello, Venezuela. Métodos: estudio descriptivo de tipo transversal en 1 183 escolares mediante un cuestionario elaborado para tal fin. Resultados: se registraron 1 183 diagnósticos, de los cuales 981 (82,94 %) no mostraron ninguna enfermedad oftálmica, y los restantes 202 (17,06 %) se evaluaron como patológicos. Las ametropías constituyeron la enfermedad más frecuentemente encontrada, 10,65 %, seguido por conjuntivitis en el 4,05 % de los casos. Conclusiones: hay una alta incidencia de enfermedades oftalmológicas que repercuten en el desarrollo integral del niño y su adaptación al medio escolar. Se recomienda la implementación de programas de detección o pesquisa de enfermedades oftalmológicas en escolares y profundizar en las acciones de educación y orientación a las familias y a la población en general.

Introduction: the deterioration of visual function limits the appropriate development of children and affects school performance. Objective: to determine the prevalence of ophthalmic morbidity in students attending schools in rural communities of Puerto Cabello, Venezuela. Methods: a descriptive cross-sectional study performed on 1183 schoolchildren through a customized questionnaire for this purpose. Result: there were 1183 diagnoses, of which 981 (82.94%) did not show any ophthalmologic disease, and the remaining 202 (17.06%) were evaluated as pathological. Ametropia was the most frequent pathology found in 10.65%, followed by conjunctivitis in 4.05% of cases. Conclusions: high incidence of ophthalmologic diseases that affect the comprehensive development of children and their adaptation to the school environment was found. Finally, it was recommended to implement programs of detection or screening of ophthalmologic diseases in schoolchildren, and to delve into the educational and orientation actions aimed at families and general population.

Prevención de parasitosis intestinal mediante técnicas de educación a distancia / Prevention of intestinal parasitosis based on the distance learning techniques

Introducción La parasitosis es una enfermedad propia de los países subdesarrollados. Según la OMS, una de las seis enfermedades más frecuente en poblaciones de países subdesarrollados. Objetivo Desarrollar una técnica a distancia en el área de la salud, mediante la producción de un video digital educativo para la enseñanza de las medidas de prevención sobre parasitosis intestinal. Métodos Diseño de campo con la aplicación de la metodología del College of Public Health de la Universidad del Sur de la Florida. La producción del video se concibió en cinco etapas: 1. Tema a tratar y objetivos del video digital, a quien va dirigido, duración, fecha de realización: desde el 1 de noviembre de 2008 hasta el 31 de marzo de 2009, recursos humanos, financieros e institucionales, elaboración del guión técnico, lista de escenas, descripción del tiempo de inicio y finalización de las escenas. 2. Etapa de pre-producción del video, tomas, encuadres y filmación. 3. Edición del video con el apoyo del software Pínnacle. 4. Posproducción del video, que se realizó en formato de DVD, el cuál puede ser observado en la televisión y en la computadora, facilitado por la colaboración del programa satelital "Simón Bolívar" que intercomunica a los pueblos de Suramérica. 5. Validación por expertos del producto terminado. Se utilizaron como instrumentos las entrevistas y la observación participante. Resultados El video tiene cinco escenas con las medidas de prevención. Incluye un ponente que explica el texto correspondiente. La presentación de cada escena tiene un tiempo de duración de 5 minutos. Conclusiones El desarrollo de la técnica de educación a distancia permite una instrucción de calidad y proporciona mayor adquisición de información educativa a mayor número de personas, en menor tiempo y a menores costos.

Introduction Parasitosis is a disease inherent to the underdeveloped countries. According to the WHO, it is one of the six most frequent illnesses in underdeveloped country populations. Objective To create a distance learning technique in the healthcare area on the basis of educational digital video for teaching preventive measures for intestinal parasitosis. Methods Field design using the methodology of the College of Public Health in South Florida University. The production of the video was organized in five phases: 1st-Topic and objectives of the digital video, audience to be addressed, duration, date of filming (November 1st 2008 to March 31st 2009); human, financial and institutional resources; preparation of the technical script; listing of scenes, and description of the length of start and ending of the scenes. 2nd- Pre-production of the video including shots, framing and filming. 3rd- Pinacle software-aided video edition. 4th- Video post-production in DVD format, which can be accessed by TV and computer thanks to Simón Bolívar satellite program-based cooperation linking the South America nations. 5th- Validation of the final product by experts. Interviews and participating observations were the instruments used for this end. Results A five-scene video, taking 5 minutes each, with the preventive measures. It includes a presenter who explains all about the respective texts. Conclusions The creation of this distance learning technique allows giving quality teaching aimed at the public and at greater acquisition of educational information by a higher number of persons in less time and at lower costs.

[Therapeutic education for diabetics: foot care in the reality of patients and family members]. / Educação terapêutica para diabéticos: os cuidados com os pés na realidade de pacientes e familiares.

Knowing the reality of foot care practice taught in educational programs for diabetics can enhance the therapeutic education success. This study presents the perceptions of diabetics and their family members about primary cares to prevent complications on foot. A qualitative exploratory study was conducted in an intentional sample of 30 diabetic with neuropathic risk of foot injuries as well as 11 of their family members, participants of a preventive program offered in a public health center in the city of Porto Alegre, Rio Grande do Sul State, Brazil. A semi-structured interview with open-ended questions about experiences of foot care was conducted. The material transcribed was submitted to qualitative content analyses. Patients need assistance to foot care practice. A cooperative and interactive network is formed behind patients, perceived as a support or a threat to freedom. The importance of preventive measures becomes evident from their personal experiences of a complication or those of others'. Therapeutic education to prevent diabetic foot complications must consider the relations of assistance formed around the patient. It is necessary to break the silence of the evolution of the disease in order to motivate the patient to the adoption of preventive measures.

Educação terapêutica para diabéticos: os cuidados com os pés na realidade de pacientes e familiares / Therapeutic education for diabetics: foot care in the reality of patients and family members

Conhecer a realidade da prática dos cuidados com os pés ensinados nos programas educativos para diabéticos pode contribuir para um melhor resultado da educação terapêutica. Este estudo apresenta significados atribuídos por pacientes diabéticos e seus familiares aos cuidados primários que visam prevenir complicações nos pés. Foi realizada uma pesquisa qualitativa exploratória sobre amostra intencional de trinta diabéticos, neuropatas, com risco de lesão nos pés e familiares de onze deles, que participaram de um programa de prevenção em uma unidade de saúde pública do município de Porto Alegre (RS). Foi aplicada uma entrevista semidirigida com questões abertas sobre a experiência dos cuidados com os pés. O material transcrito foi submetido à análise qualitativa de conteúdo. Os pacientes precisam de ajuda para realizar os cuidados com os pés. Uma rede de solidariedade e interações é formada por trás dos pacientes, percebida como um apoio ou uma ameaça à liberdade. É a experiência própria ou alheia de uma complicação que evidencia a importância da prevenção. A educação terapêutica para prevenção de complicações nos pés de diabéticos deve levar em conta as relações de assistência formadas em torno do doente. É preciso romper o silêncio da evolução da doença para motivar o paciente à adoção das medidas preventivas.

Knowing the reality of foot care practice taught in educational programs for diabetics can enhance the therapeutic education success. This study presents the perceptions of diabetics and their family members about primary cares to prevent complications on foot. A qualitative exploratory study was conducted in an intentional sample of 30 diabetic with neuropathic risk of foot injuries as well as 11 of their family members, participants of a preventive program offered in a public health center in the city of Porto Alegre, Rio Grande do Sul State, Brazil. A semi-structured interview with open-ended questions about experiences of foot care was conducted. The material transcribed was submitted to qualitative content analyses. Patients need assistance to foot care practice. A cooperative and interactive network is formed behind patients, perceived as a support or a threat to freedom. The importance of preventive measures becomes evident from their personal experiences of a complication or those of others'. Therapeutic education to prevent diabetic foot complications must consider the relations of assistance formed around the patient. It is necessary to break the silence of the evolution of the disease in order to motivate the patient to the adoption of preventive measures.

Inter- and intra-examiner reliability of footprint pattern analysis obtained from diabetics using the Harris mat.

INTRODUCTION: High plantar pressure is a proven risk factor for ulceration among individuals with diabetes mellitus. The Harris and Beath footprinting mat is one of the tools used in screening for foot ulceration risk among these subjects. There are no reports in the literature on the reliability of footprint analysis using print pattern criteria. OBJECTIVE: The aim of this study was to evaluate the inter- and intra-examiner reliability of the analysis of footprint patterns obtained using the Harris and Beath footprinting mat. METHODS: Footprints were taken from 41 subjects using the footprinting mat. The images were subjected to analysis by three independent examiners. To investigate the intra-examiner reliability, the analysis was repeated by one of the examiners one week later. RESULTS: The weighted kappa coefficient was excellent (K(w) > 0.80) for the inter- and intra-examiner analyses for most of the points studied on both feet. CONCLUSIONS: The criteria for analyzing footprint patterns obtained using the Harris and Beath footprinting mat presented good reliability and high to excellent inter- and intra-examiner agreement. This method is reliable for analyses involving one or more examiners. Article registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) under the number ACTRN12609000693224.