Influence of infection on clinical picture of diabetic foot syndrome.

The aim of our study was to analyse the foot infections in diabetic patients. We analysed foot ulcerations in 124 diabetics who attended outpatient foot clinic, or were hospitalized in the period from 1996 to 2006. Basic neuropathy screening examination was made with cotton wisp, pin-prick, tuning fork, and monofilament. For evaluation of leg ischemia, besides the evaluation of the presence of pedal pulses, the ankle-brachial pressure index was measured. If the infection of foot ulceration was clinically present, bacteriology examinations was performed. In the case of deep wound infection, x-ray examination was made. If bone destruction was present, osteomyelitis was diagnosed by technecium bone scanning and by technecium-labelled leukocyte scan. Deformation and destruction of the bone without infection was appoited as Charcot neuroarthropathy. Foot ulcer infection was found in 58 % diabetic patients, wounds were more often deep (80 %). Infection was not associated with special location of foot ulcer. Two-third of the total infected wounds were associated with leg ischemia and 30.6 % of infected ulcer ended with leg amputation. More foot ulcer infections were found in the diabetics with HbAlc over 8 %. Infection was coupled with diabetic retinopathy (in 63 % patients) (p=0.023), and also with diabetic nephropathy (in 66 % patients) (p=0.012). Bacteriology examination revealed most often Staphylococci (45.8 %), antibiotic therapy was made most often with chinolones. Osteomyelitis was present in 34.7 % of foot ulcer infections. In 14 diabetics (56 %) after antibiotic therapy it was not necessary to perform a leg amputation. HbAlc seems to be a significant predictor of osteomyelitis (p<0.02; OR=1.76). In conclusion, we confirmed that diabetic foot infections, especially on ischemic leg, in diabetics with poor metabolic control and chronic diabetic microvascular complications, are associated with a higher risk of leg amputations. Further, it is possible to cure osteomyelitis successfully without surgery in more than half the cases (Tab. 1, Ref. 24). Full Text in free PDF www.bmj.sk.

[Characteristics of foot ulcers in diabetic patients]. / Charakteristika ulcerácií na nohách u diabetikov.

INTRODUCTION: Diabetic foot syndrome is often presented as a skin lesion in diabetics. The aim of our study was to analyse foot ulcerations in diabetics, together with ethiopatogenesis, location and grade of impairment. METHODS: We analysed foot ulcerations in 124 diabetics who attended outpatient foot clinic, or were hospitalized in the period from 1996 to 2006. Basic neuropathy screening examination was made with cotton wisp, pin-prick, tuning fork, and monofilament. Beside the evaluation of the presence of pedal pulses, the ankle-brachial pressure index was measured. If the infection of foot ulceration was present, bacteriology examinations was performed. Wagner and University of Texas classifications of foot ulcerations were applied, moreover, location of ulcerations was analysed. RESULTS: Neuropathic ulcer was diagnosed in 46 patients of the total number of 124 (37%), neuroischemic in 76 patients (61%) and pure ischemic ulcer only in 2 patients (2%). Neuropathy was present in 122 (98%) patients with diabetic foot, limb ischemia in 78 patients (63%). Fifty four per cent of foot ulcers were located on toes and 43% ulcers on plantar surface. Foot ulcer infection was detected in 72 patients (58%). We found 48 superficial ulcers (38.7%) and 76 deep ulcers (61.3%). In diabetics without foot ischemia and infection 39% deep ulcers were present whereas in the group with ischemia and infection the proportion amounted to 80% (p < 0.05). CONCLUSION: Diabetic foot syndrom was present more often in type-2 diabetics with longer disease duration, in those on insulin treatment, in men of older age, further in the diabetics with pure glycemic control and/or with chronic microvascular diabetic complications.

Decreased fluidity of isolated erythrocyte membranes in type 1 and type 2 diabetes. The effect of resorcylidene aminoguanidine.

Changes in the physico-chemical properties of erythrocyte membranes induced by nonenzymatic glycation as well as the possible prevention of their rise were studied. Using the fluorescent probe 1,6-diphenyl-1,3,5-hexatriene (DPH), fluorescence anisotropy values were determined in erythrocyte membranes isolated from type 1 and type 2 diabetic patients with and without complications. The mean anisotropy values for the groups of diabetic patients were significantly higher than those for the control group (p < 0.01). This indicated pathologically decreased fluidity in cell membranes in the diabetics regardless of the type of diabetes or the presence of complications. The fluorescence anisotropy positively correlated (p < 0.01) with clinical parameters, such as glycohaemoglobin and plasma cholesterol content, which are important for the monitoring of the compensation status of the diabetic patient. Our results support the suggestion that protein crosslinking and oxidative stress induced by nonenzymatic glycation contribute to changes in the physico-chemical properties of erythrocyte membranes. In vitro testing of a new potential drug resorcylidene aminoguanidine (RAG) showed its ability to increase significantly (p < 0.001), to various extent (p < 0.01), the fluidity of both diabetic and control erythrocyte membranes. Upon the administration of RAG, reduced fluorescence anisotropy values for the groups of diabetic patients approached the normal values obtained for the controls. This may play an important role in the improvement of impaired cell functions found in diabetes that are controlled by the cell membrane.

Does diabetic autonomic neuropathy influence the clinical manifestations of reflux esophagitis?

Diabetic autonomic neuropathy is a common complication of diabetes mellitus and affects every segment of the gastrointestinal tract. Gastrointestinal problems tend to be more common and severe in diabetics compared with the nondiabetic population. In the literature, the prevalence of reflux esophagitis is not known. The aim of this study was to analyze esophagoscopic findings, compare them with esophageal symptoms, and evaluate reflux esophagitis in relationship with autonomic neuropathy. We examined 54 diabetics (15 type 1, 39 type II), 28 males and 26 females, average age 55.4 (95% confidence intervals 52.1-58.8), with duration of diabetes more than 5 (average 15.0; 12.4-17.6) years. All patients completed a structured questionnaire. After overnight fasting, gastroesophageal endoscopy was performed in the morning to establish the presence of reflux esophagitis, using the Los Angeles classification. Cardiovascular autonomic neuropathy was diagnosed with the help of cardiovascular autonomic reflexes (deep breathing, active orthostasis, Valsalva's maneuver) and spectral analysis of heart rate variation. Endoscopic esophagitis was present in 22 (40.7%) diabetics and 10 of them (45 %) also complained of reflux symptoms. Sensitivity of symptoms was 45.5% and specificity was 72%. We found the presence of symptoms of reflux esophagitis in 21 (38.9%) diabetics, but of this group only 10 (47.6%) had endoscopic changes. Autonomic neuropathy was present in 29 patients, 16 (55%) of them had reflux esophagitis and 18 (62%) were positive for reflux symptoms. In the diabetics without autonomic neuropathy, esophagitis was noted in 6 (24%), which reflects a significant difference (p < 0.05). Reflux symptoms were present in 10 (40%) diabetics without autonomic neuropathy, and in comparison with patients who had autonomic neuropathy, the difference was not statistically significant. Thus, reflux eosophagitis is common in diabetic patients, with a prevalence of 40.7%. Reflux symptoms do not have a great diagnostic value in establishing reflux esophagitis. We confirmed a relationship between autonomic neuropathy and the clinical manifestations of reflux esophagitis, but no association with accompanying reflux symptoms. (Tab. 2, Ref. 27.)

Effect of vitamin E supplementation on microalbuminuria, lipid peroxidation and blood prostaglandins in diabetic patients.

BACKGROUND: Oxidative stress is an important pathogenic factor in the development of diabetic vascular complications. AIMS: To study the effect of vitamin E supplementation on microalbuminuria, plasma levels of malondialdehyde (MLD) and metabolites of prostaglandins TXA2 (TXB2) and PGI2 (6-keto-PGF1alpha) and to evaluate the relation between plasma MLD and thromboxane B2 (TXB2) in diabetic patients. PATIENTS AND METHODS: Diabetic microalbuminuric patients were supplemented with vitamin E 1200 IU daily (EVIT, Rodisma, Germany) and measurements of microalbuminuria, MLD, TXB2 and 6-ketoPGF1alpha were repeated after 4 months of treatment. RESULTS: Vitamin E supplementation lowered microalbuminuria (93.8 +/- 45.6 vs 67.95 +/- 28.4 microg/min, p < 0.05), MLD (0.55 +/- 0.26 vs 0.32 +/- 0.16 micromol/l, p < 0.001) and also TXB2 level (115.14 +/- 22.7 vs 15.32 +/- 14.7 ng/l, p < 0.001) in diabetic microalbuminuric patients. The changes of 6-keto-PGF1alpha after treatment were not significant. CONCLUSIONS: Our results did not show any significant relationship between levels of MLD and TXB2. Vitamin E supplementation significantly lowered microalbuminuria, MLD and TXB2. (Tab. 2, Fig. 2, Ref. 35).

[Comparison of insulin loss in treatment of diabetics using the classical syringe or the insulin pen (Novopen II)]. / Porovnanie strát inzulínu pri liecbe diabetikov klasickou striekackou alebo inzulínovým perom (NOVOPEN II).

The aim of the study was to investigate changes in insulin wastage when transferring patients from vial insulin to Actraphane HM Penfills and NovoPen II. Twenty four diabetic patients, were treated with Actraphane HM 40 IU/ml vial for 3 months, then transferred to Actraphane HM Penfill and NovoPen II for further 3 months. Wastage 1 (difference between insulin consumption and the total prescribed dose) was higher in vials than in Penfills (268.7 +/- 69.4 IU/3 months/patients vs. -7.6 +/- 30.2 IU/3 months/patient, p < 0.001 mean +/- SEM). Wastage 2 (insulin remaining in the container when discharged) was higher in the Penfills than in vials (214.1 +/- 22.04 IU/3 months/patient vs 45.2 +/- 11.2 IU/3 months/patient). Total wastage was 313.9 +/- 67.8 IU/3 months/patient (3.96 IU/day/patient) when using vials and 206.5 +/- 31.2 IU/3 months/patient (2.52 IU/day/patient) when using Penfills (NS). Higher wastage in vials may relate to a larger volume used for "airshot", and to a larger imprecision in the measured and injected dose when using vials. The latter may also be reflected in a significantly higher average incidence of weighted hypogiycemias in the vial period (15 +/- 4.28/3 months/patient) compared to the Penfill period (5.1 +/- 1.2/3 months/patient, p < 0.01). Total wastage was seen to be 29% smaller by using NovoPen II and therefore saving of insulin seems to be possible (approximately 1.44 IU/day/patient).

[Effect of vitamin E therapy on progression of diabetic nephropathy]. / Vplyv liecby vitamínom E na progresiu diabetickej nefropatie.

Pathogenesis of diabetic nephropathy, which belongs to most serious microangiopathic complications of diabetes, is still not completely clear. Thromboxan A2 and increased oxidation stress are new factors apparently associated with pathogenesis of diabetic nephropathy. It was the aim of the contribution to verify the participation of thromboxan A2 and oxidation stress in the pathogenesis of diabetic nephropathy, as well as to follow the effects of treatment with vitamin E on its progression. In 19 diabetic subjects with microalbuminemia (MA) (age 55.2 +/- 7.6 years), 10 diabetic subjects with normoalbuminemia (NA) (age 54.4 +/- 6.1 years) and in 10 healthy subjects (age 53.6 +/- 9.4) the authors examined the level of malondialdehyde (MLDA) in serum, metabolites of thromboxan A2 (thromboxan B2-TXB2) and prostacyclin PGI2 (6-keto-PGF1 alpha) in urine by means of an RIA method (Isotop, Hungary). The diabetic patients with microalbuminemia were subsequently administered natural vitamin E (EVIT, Rodisna, FRG) at the daily dose of 1200 IU for the period of four months. After two and four months, respectively, MA, MLDA, TXB2 and 6-keto-PGF1 alpha) were examined. The age of the subjects in the two groups was not significantly different. In diabetic subjects with MA, the authors observed significantly higher MLDA levels in serum than in the control individuals (0.55 +/- 0.26 vs. 0.22 +/- 0.02 mumol/l, P < 0.001) and a significant difference occurred also in TBX2 in urine (134.7 +/- 113.8 vs. 27.7 +/- 10.1 ng/12 h, P < 0.001). Increased levels of TXB2 in urine were already present in diabetic subjects with NA as compared with healthy individuals (69.1 +/- 38.8 vs. 27.7 +/- 10.1 ng/12 h, P < 0.05). The treatment with vitamin E caused a significant decrease of MA (93.8 +/- 45.6 vs. 67.95 +/- 28.4 micrograms/min, P < 0.05), MLDA in serum (0.55 +/- 0.26 vs. 0.32 +/- 0.16 mumol/l, P < 0.001). On the basis of our results it is possible to suppose the role of oxidation stress and increased level of thromboxan A2 in the pathogenesis of diabetic nephropathy. The authors also confirmed that the treatment with vitamin E favorably decreases microalbuminemia, while the nephroprotective effect is apparently mediated not only by the antioxidant action, but also the decrease of thromboxan A2 production.