Causas referidas para o desenvolvimento de úlceras em pés de pessoas com diabetes mellitus

OBJETIVO: Analisar as causas referidas na etiologia das úlceras em pés de pessoas com Diabetes mellitus (DM). MÉTODOS: Estudo seccional, quantitativo, realizado no Ambulatório de Diabetes de um Hospital Universitário em Ribeirão Preto - SP. Os dados foram coletados com instrumento estruturado e exame físico dos pés de amostra de 30 pacientes diabéticos. RESULTADOS: Amostra com idade média de 57,5 anos, predominância do sexo masculino e baixa escolaridade; 90% possuíam DM tipo 2, de longa duração e mal controlado; obesidade/sobrepeso em 77% e insensibilidade plantar em 93,3%. A região metatarsiana foi o local de úlcera referido com maior frequência, e a causa foi a calosidade. CONCLUSÃO: as causas referidas envolvidas na etiologia das úlceras correspondem, de forma direta ou indireta, a fatores extrínsecos que podem ser prevenidos com cuidados básicos e de baixo custo. A insensibilidade plantar, fator fundamental desencadeador das úlceras, no entanto não foi reconhecida pelas pessoas.

Einfluss einer pharmazeutischen Betreuung auf den klinischen Verlauf und die Behandlungsergebnisse von Diabetikern mit Diabetischem Fußsyndrom (DFS)

Einfluss einer Pharmazeutischen Betreuung auf den klinischen Verlauf und die Behandlungsergebnisse von Diabetikern mit Diabetischem Fußsyndrom (DFS) Hintergrund/Rationale: In Deutschland gibt es etwa 6 Millionen Diabetiker und die Tendenz ist steigend. Das Diabetische Fußsyndrom (DFS) stellt eine häufige und besonders gravierende Folgeerkrankung des Diabetes mellitus dar. Jährlich werden in Deutschland ca. 45.000 Amputationen aufgrund des DFS bei Diabetikern durchgeführt. Es verursacht bei den Patienten physische und psychische Beeinträchtigungen und produziert hohe Krankheitskosten. Der Prävention, der Behandlung und der Rezidivprophylaxe des DFS kommt daher ein hoher Stellenwert zu. Ziel dieser Arbeit war es, ein klinisch-pharmazeutisches Betreuungsprogramm für Patienten mit DFS zu erarbeiten und den Einfluss der Pharmazeutischen Betreuung, speziell einer intensivierten Patientenschulung, auf klinische und soziale Behandlungsergebnisse hin zu untersuchen. Es sollte geklärt werden, ob eine zusätzliche pharmazeutische Betreuung Einfluss auf den Wundheilungsverlauf und die Abheilungsrate der Fußläsionen von Diabetikern mit DFS nehmen kann. Methoden: 52 Patienten mit DFS wurden in eine randomisierte, kontrollierte Studie eingeschlossen und im Verhältnis 1:1 einer Interventions- oder Kontrollgruppe zugeteilt. Die Interventionsgruppe wurde kontinuierlich durch einen Apotheker zusätzlich individuell betreut (Anleitung zum sachgerechten Umgang mit Arzneimitteln, Medizinprodukten und Therapiemaßnahmen), die Kontrollgruppe erhielt die übliche medizinische Betreuung. Die Auswirkungen der Intervention auf den klinischen Verlauf der beobachteten Fußläsionen, die Rezidivfreiheit und Rehospitalisierungsrate, aber auch auf die Patientenzufriedenheit, das Patientenwissen und die Lebensqualität wurden untersucht. Jeder Patient wurde über einen Zeitraum von 12 Monaten beobachtet. Ergebnisse: Die Studienergebnisse belegen einen positiven Einfluss der Pharmazeutischen Betreuung auf die klinischen Endpunkte der Diabetiker mit DFS. Die Wundheilung der Läsionen in der Interventionsgruppe, bezogen auf Abheilungsdauer und -rate, konnte klinisch positiv beeinflusst werden. Des weiteren konnte in der Interventionsgruppe die Anzahl an neu aufgetretenen Läsionen, sowie weiterer Krankenhausaufenthalte um jeweils fast 50% verringert werden. Durch die Pharmazeutische Betreuung konnte die Patientenzufriedenheit mit der Behandlung deutlich gesteigert werden. Entsprechendes fand sich für das Patientenwissen und die Lebensqualität.

Systematic Monitoring of Wound Healing Using a Hand-held Near-Infrared Optical Scanner

According to the American Podiatric Medical Association, about 15 percent of the patients with diabetes would develop a diabetic foot ulcer. Furthermore, foot ulcerations leads to 85 percent of the diabetes-related amputations. Foot ulcers are caused due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities and the duration of the diabetes. To date, the wounds are inspected visually to monitor the wound healing, without any objective imaging approach to look before the wound’s surface. Herein, a non-contact, portable handheld optical device was developed at the Optical Imaging Laboratory as an objective approach to monitor wound healing in foot ulcer. This near-infrared optical technology is non-radiative, safe and fast in imaging large wounds on patients. The FIU IRB-approved study will involve subjects that have been diagnosed with diabetes by a physician and who have developed foot ulcers. Currently, in-vivo imaging studies are carried out every week on diabetic patients with foot ulcers at two clinical sites in Miami. Near-infrared images of the wound are captured on subjects every week and the data is processed using customdeveloped Matlab-based image processing tools. The optical contrast of the wound to its peripheries and the wound size are analyzed and compared from the NIR and white light images during the weekly systematic imaging of wound healing.

Evaluation of negative pressure vacuum-assisted system in acute and chronic wounds closure. Our experience

Negative-pressure therapy or vacuum-assisted closure (VAC) has been used in clinical applications since the 1940’s and has increased in popularity over the past decade. This dressing technique consists of an open cell foam dressing put into the wound cavity, a vacuum pump produces a negative pressure and an adhesive drape. A controlled sub atmospheric pressure from 75 to 150 mmHg is applied. The vacuum-assisted closure has been applied by many clinicians to chronic wounds in humans; however it cannot be used as a replacement for surgical debridement. The initial treatment for every contaminated wound should be the necrosectomy. The VAC therapy has a complementary function and the range of its indications includes pressure sores, stasis ulcers, chronic wounds such as diabetic foot ulcers, post traumatic and post operative wounds, infected wounds such as necrotizing fasciitis or sternal wounds, soft-tissue injuries, bone exposed injuries, abdominal open wounds and for securing a skin graft. We describe our experience with the VAC dressing used to manage acute and chronic wounds in a series of 135 patients, with excellent results together with satisfaction of the patients.

Prevalencia de las deformidades óseas y estructurales en pacientes con pie diabético que acuden al área de consulta externa de traumatología del Hospital Regional Vicente Corral Moscoso, Cuenca-Ecuador 2015

Objetivo general: Establecer la prevalencia de las deformidades óseas y estructurales en pacientes con pie diabético que acudieron al área de consulta externa de Traumatología del Hospital Regional Vicente Corral Moscoso durante el período de tres meses. Metodología: Estudio descriptivo llevado a cabo en 100 pacientes con pie diabético que acudieron a la consulta externa de Traumatología durante tres meses. El método de investigación fue la observación directa; las técnicas comprendieron entrevista, evaluación mediante plantoscopía y valoración radiográfica, los instrumentos usados fueron los formularios, los datos tras su validación fueron ingresados en una base en el programa SPSS V15; mediante el cual se realizó el análisis usando tablas simples con porcentajes y frecuencias relativas. Resultados: La media de edad fue de 64,09 años con el 84% de la población de sexo femenino; el cuadro clínico se caracterizó por presencia de callosidades 62%; metatarsalgia 57%; talalgia 48% y dolor en bunion de 21%. Tomando en consideración los parámetros radiográficos se diagnosticó hallux valgus 71%; deformidades de los dedos en garra 56%; pie plano 34%; dedos en martillo 31%; juanetillo de sastre 30%; hallux rigidus 16% y pie cavo 13%. La valoración mediante el uso de plantoscopía reveló 39% de pacientes pie plano y el 17% pie cavo

Développement d'instruments de mesure pour l'évaluation des facteurs influençant l'adoption des pratiques exemplaires pour le traitement de la mise en décharge de l'ulcère du pied diabétique

L'ulcère du pied diabétique (UPD) affecte 15 à 25 % des personnes diabétiques. Le traitement recommandé de la mise en décharge de l'ulcère est peu appliqué, entraînant des délais de guérison excessifs et des coûts élevés pour le système de santé. Peu d'études abordent le sujet des facteurs responsables de la faible adoption des pratiques exemplaires pour le traitement de décharge de l'UPD en soins de première ligne. Les objectifs spécifiques de ce projet de maîtrise sont d'élaborer et de valider deux questionnaires, un dédié aux patients et un dédié aux professionnels de la santé, explorant les facteurs influençant l'adoption des pratiques exemplaires pour le traitement de la mise en décharge de l’UPD en soins de première ligne. En guise de référence à l'élaboration des questionnaires, un guide de développement d'instrument de mesure, inspiré de la théorie du comportement planifié, a été utilisé. L'analyse de deux types de validation a été entreprise, soit l'analyse de la validité de contenu et de la stabilité temporelle. Les résultats ont démontré des scores particulièrement élevés de validité de contenu et des scores de stabilité temporelle satisfaisants pour le questionnaire dédié aux patients. Le questionnaire dédié aux professionnels de la santé a aussi remporté des scores de validité de contenu particulièrement élevés, mais les items ont obtenu des scores de stabilité temporelle faibles. Le niveau de connaissance des participants sur le sujet exploré a eu une influence majeure sur les résultats de stabilité temporelle. Pour la version finale des questionnaires, seulement les items obtenant des scores élevés de validité de contenu et de stabilité temporelle ont été conservés. Cette étude a fait l'objet d'un article de recherche intitulé Development of Survey Tools to Explore Factors Influencing the Adoption of Best Practices for Diabetic Foot Ulcer Offloading et a été soumis à la revue Journal of Wound Ostomy & Continence Nursing. Les réponses obtenues aux items remportant des coefficients de validité forts sont brièvement examinées à la partie discussion. Les résultats de ce projet de maîtrise permettent de souligner la nécessité de recourir à une méthodologie rigoureuse pour l'obtention d'instruments de mesure valides; un élément trop souvent négligé dans les études sur les soins de santé.

The effect of diabetic neuropathy and previous foot ulceration in EMG and ground reaction forces during gait

Background. We aimed at investigating the influence of diabetic neuropathy and previous history of plantar ulcers on electromyography (EMG) of the thigh and calf and on vertical ground reaction forces during gait. Methods. This study involved 45 adults divided into three groups: a control group (n = 16), diabetic neuropathic group (n = 19) and diabetic neuropathic group with previous history of plantar ulceration (it = 10). EMG of the right vastus lateralis, lateral gastrocnemius and tibialis anterior were studied during the stance phase. The peaks and time of peak occurrence were determined and a co-activation index between tibialis anterior and lateral gastrocnemius. In order to represent the effect of the changes in EMG, the first and second peaks and the minimum value of the vertical ground reaction force were also determined. Inter-group comparisons of the electromyographical and ground reaction forces variables were made using three MANCOVA (peaks and times of EMG and peaks of force) and one ANCOVA (co-activation index). Findings. The ulcerated group presented a delayed in the time of the lateral gastrocnemius and vastus lateralis peak occurrence in comparison to control`s. The lateral gastrocnemius delay may be related to the lower second vertical peak in diabetic subjects. However, the delay of the vastus lateralis did not cause any significant change on the first vertical peak. Interpretations. The vastus lateralis and lateral gastrocnemius delay demonstrate that ulcerated diabetic neuropathic patients have a motor deficit that could compromise their ability to walk, which was partially confirmed by changes on ground reaction forces during the push-off phase. (c) 2007 Elsevier Ltd. All rights reserved.

Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy

Background: The purpose of this study was to investigate the ankle range of motion during neuropathic gait and its influence on plantar pressure distribution in two phases during stance: at heel-strike and at push-off. Methods: Thirty-one adults participated in this study (control group, n = 16; diabetic neuropathic group, n = 15). Dynamic ankle range of motion (electrogoniometer) and plantar pressures (PEDAR-X system) were acquired synchronously during walking. Plantar pressures were evaluated at rearfoot. midfoot and forefoot during the two phases of stance. General linear model repeated measures analysis of variance was applied to investigate relationships between groups, areas and stance phases. Findings: Diabetic neuropathy patients walked using a smaller ankle range of motion in stance phase and smaller ankle flexion at heel-strike (P = 0.0005). Peak pressure and pressure-time integral values were higher in the diabetic group in the midfoot at push-off phase when compared to heel-strike phase. On the other hand, the control group showed similar values of peak pressure in midfoot during both stance phases. Interpretation: The ankle mobility reduction observed could be associated to altered plantar pressure distribution observed in neuropathic subjects. Results demonstrated that midfoot and forefoot play a different role in subjects with neuropathy by receiving higher loads at push-off phase that are probably due to smaller ankle flexion at stance phase. This may explain the higher loads in anterior areas of the foot observed in diabetic neuropathy subjects and confirm an inadequate foot rollover associated to the smaller ankle range of motion at the heel-strike phase. (C) 2009 Elsevier Ltd. All rights reserved.

Poly-N-Acetyl Glucosamine Fibers Induce Angiogenesis in ADP Inhibitor-Treated Diabetic Mice

Background: It has been previously demonstrated that short-fiber poly-N-acetyl-glucosamine (sNAG) nanofibers specifically interact with platelets, are hemostatic, and stimulate diabetic wound healing by activating angiogenesis, cell proliferation, and reepithelialization. Platelets play a significant physiologic role in wound healing. The influence of altered platelet function by treatment with the ADP inhibitor Clopidogrel (CL) on wound healing and the ability of sNAG to repair wounds in diabetic mice treated with CL were studied.Methods: Dorsal 1 cm2 skin wounds were excised on genetically diabetic 8-week to 12-week-old, Lep/r-db/db male mice, and wound healing kinetics were determined. Microscopic analysis was performed for angiogenesis (PECAM-1) and cell proliferation (Ki67). Mice were either treated with CL (P2Y12 ADP receptor antagonist, CL) or saline solution (NT). CL wounds were also treated with either a single application of topical sNAG (CL-sNAG) or were left untreated (CL-NT).Results: CL treatment did not alter wound healing kinetics, while sNAG induced faster wound closure in CL-treated mice compared with controls. CL treatment of diabetic mice caused an augmentation of cell proliferation and reduced angiogenesis compared with nontreated wounds. However, sNAG reversed the effects of CL on angiogenesis and partially reversed the effect on cell proliferation in the wound beds. The sNAG-treated wounds in CL-treated mice showed higher levels of cell proliferation and not did inhibit angiogenesis.Conclusions: CL treatment of diabetic mice decreased angiogenesis and increased cell proliferation in wounds but did not influence macroscopic wound healing kinetics. sNAG treatment did not inhibit angiogenesis in CL-treated mice and induced faster wound closure; sNAG technology is a promising strategy to facilitate the healing of complex bleeding wounds in CL-treated diabetic patients.

Effect of lung resection and sham surgery on the frequency of infection in alloxan-diabetic rats

The present study was carried out in order to determine the effect of lung resection on the frequency of infections in alloxan-diabetic rats. Adult female Wistar rats were injected with alloxan (40 mg/kg, iv) to induce diabetes mellitus (group D; N = 45) or with vehicle (1.0 ml/kg, iv) to be used as controls (group C; N = 45). Thirty-six days after receiving alloxan both groups were randomly divided into three subgroups: no operation (NO; N = 15), sham operation (SO; N = 15), and left pneumonectomy (PE; N = 15). The rats were sacrificed 36 days after surgery and their lungs were examined microscopically and macroscopically. The occurrence of thoracic wall infection, thoracic wall abscess, lung abscess and pleural empyema was similar in groups D and C. In contrast, the overall infection rate was higher (P<0.05) in the diabetic rats (SO-D and PE-D subgroups, but not in the NO-D subgroup). Considering that the overall infection rate was similar in the SO-D and PE-D subgroups, we suggest that surgery but not pneumonectomy was related to the higher prevalence of infection in diabetic rats.

A comparison of lower limb EMG and ground reaction forces between barefoot and shod gait in participants with diabetic neuropathic and healthy controls

Background: It is known that when barefoot, gait biomechanics of diabetic neuropathic patients differ from nondiabetic individuals. However, it is still unknown whether these biomechanical changes are also present during shod gait which is clinically advised for these patients. This study investigated the effect of the participants own shoes on gait biomechanics in diabetic neuropathic individuals compared to barefoot gait patterns and healthy controls. Methods: Ground reaction forces and lower limb EMG activities were analyzed in 21 non-diabetic adults (50.9 +/- 7.3 yr, 24.3 +/- 2.6 kg/m(2)) and 24 diabetic neuropathic participants (55.2 +/- 7.9 yr, 27.0 +/- 4.4 kg/m(2)). EMG patterns of vastus lateralis, lateral gastrocnemius and tibialis anterior, along with the vertical and antero-posterior ground reaction forces were studied during shod and barefoot gait. Results: Regardless of the disease, walking with shoes promoted an increase in the first peak vertical force and the peak horizontal propulsive force. Diabetic individuals had a delay in the lateral gastrocnemius EMG activity with no delay in the vastus lateralis. They also demonstrated a higher peak horizontal braking force walking with shoes compared to barefoot. Diabetic participants also had a smaller second peak vertical force in shod gait and a delay in the vastus lateralis EMG activity in barefoot gait compared to controls. Conclusions: The change in plantar sensory information that occurs when wearing shoes revealed a different motor strategy in diabetic individuals. Walking with shoes did not attenuate vertical forces in either group. Though changes in motor strategy were apparent, the biomechanical did not support the argument that the use of shoes contributes to altered motor responses during gait.

Plantar Pressures During Shod Gait in Diabetic Neuropathic Patients with and without a History of Plantar Ulceration

Background: Diabetic neuropathy leads to progressive loss of sensation, lower-limb distal muscle atrophy, autonomic impairment, and gait alterations that overload feet. This overload has been associated with plantar ulcers even with consistent daily use of shoes. We sought to investigate and compare the influence of diabetic neuropathy and plantar ulcers in the clinical history of diabetic neuropathic patients on plantar sensitivity, symptoms, and plantar pressure distribution during gait while patients wore their everyday shoes. Methods: Patients were categorized into three groups: a control group (CG; n = 15), diabetic patients with a history of neuropathic ulceration (DUG; n = 8), and diabetic patients without a history of ulceration (DG; n = 10). Plantar pressure variables were measured by Pedar System shoe insoles in five plantar regions during gait while patients wore their own shoes. Results: No statistical difference between neuropathic patients with and without a history of plantar ulcers was found in relation to symptoms, tactile sensitivity, and duration of diabetes. Diabetic patients without ulceration presented the lowest pressure-time integral under the heel (72.1 +/- 16.1 kPa x sec; P=.0456). Diabetic patients with a history of ulceration presented a higher pressure-time integral at the midfoot compared to patients in the control group (59.6 +/- 23.6 kPa x sec x 45.8 +/- 10.4 kPa x sec; P = .099), and at the lateral forefoot compared to diabetic patients without ulceration (70.9 +/- 17.7 kPa sec x 113.2 +/- 61.1 kPa x sec, P = .0193). Diabetic patients with ulceration also presented the lowest weight load under the hallux (0.06 +/- 0.02%, P = .0042). Conclusions: Although presenting a larger midfoot area, diabetic neuropathic patients presented greater pressure-time integrals and relative loads over this region. Diabetic patients with ulceration presented an altered dynamic plantar pressure pattern characterized by overload even when wearing daily shoes. Overload associated with a clinical history of plantar ulcers indicates future appearance of plantar ulcers. (J Am Podiatr Med Assoc 99(4): 285-294, 2009)

Treatment of Osteomyelitis in the Feet of Diabetic Patients by Photodynamic Antimicrobial Chemotherapy

Objective: This article describes two inexpensive photodynamic antimicrobial chemotherapy (PACT) protocols to provide intensive local care on ulcerated feet of diabetic patients with osteomyelitis. Background Data: Patients with this condition generally have poor quality of life. The usual treatment consists of the administration of a cocktail of drugs including anti-inflammatories, promoters of blood circulation, and systemic antibiotics. However, depending on the conditions of the tissues, amputation may be required. Consequently, it is important to develop PACT protocols that can help avoid amputation. Materials and Methods: Two PACT protocols were applied to two diabetic patients with osteomyelitis. These protocols were based on several PACT sessions that consisted of: (1) local injection of mixtures of phenothiazines (2% in water) and Hypericum perforatum extract (10% in propylene glycol), and (2) illumination, lasting 10 min, applied to the lesion's interior and exterior using, respectively, an optical fiber and a non-coherent light source. The frequency of PACT was daily or every other day in the beginning, and weekly after tissue recovery begun. The patients were followed clinically and by radiographic testing. Results: Both PACT protocols helped cure these patients who were about to have amputation of their feet. Radiograms showed that bone had healed and that the bone's texture had improved. Conclusion: Here we have described efficient and affordable PACT protocols to treat osteomyelitis in the feet of diabetic patients. This treatment modality should be considered by vascular surgeons and by orthopedists to treat osteomyelitis that is resistant to conventional treatments.

ELECTROMYOGRAPHY AND KINEMATIC CHANGES OF GAIT CYCLE AT DIFFERENT CADENCES IN DIABETIC NEUROPATHIC INDIVIDUALS

Introduction: Changes in gait cadence caused by challenging situations in daily life might induce higher demand for strength and propulsion in diabetic neuropathic (DN) subjects. Methods: Forty-six subjects (healthy and DN) walked at two cadences (self-selected and 25% higher). Kinematic and electromyographic data were obtained from lower limbs and compared across the gait cycle. Results: DN subjects showed a delayed peak in plantarflexor activity along the whole cycle (irrespective of cadence) compared with healthy subjects. However, during the imposed cadence, DN individuals showed reduced ankle range of motion along the entire cycle compared with the self-selected condition and healthy individuals walking at both cadences (P = 0.002). Conclusions: These findings suggest that when diabetic individuals face a new challenging situation that induces a higher demand for muscle strength and propulsion, the necessary range of motion and neuromuscular control around distal joints are insufficient. Muscle Nerve 44: 258-268, 2011