| Diabetic Ulcer
I./ Ulcera Diabetica I. ***********************************
****** DATA-MEDICOS *********
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ULCERA DIABETICA (I) / DIABETIC ULCER (I)
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***** DERMAGIC-EXPRESS No 15 *********
****** 15 NOVIEMBRE 1.998 *******
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1.) EDITORIAL
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Saludos migos dermágicos, el DR. Marcelo Errico (Argentina) la semana pasada me pidio una puesta al dia sobre manifestaciones cutáneas de la Diabetes, el tema es bastante extenso en cuanto a BIBLIOGRAFIA, para hoy les tengo 22 REFERENCIAS sobre la ulcera diabética bastante interesantes, en la próxima edición libero los nuevos productos para este tipo de ulceras encontrados enla WEB.
Hasta una próxima edición de DERMAGIC,,,, saludos.
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DERMAGIC/EXPRESS(15)
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U L C E R A D I A B E T I C A (I) / DIABETIC ULCER I
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1.) Promotion and acceleration of diabetic ulcer healing by
arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group.
2.) Effects of electrical stimulation on wound healing in patients with
diabetic ulcers.
3.) The use and abuse of wound care materials in the treatment of diabetic
ulcerations.
4.) Relationship of microalbuminuria with the diabetic foot ulcers in type
II diabetes.
5.) Choosing a practical screening instrument to identify patients at risk
for diabetic foot ulceration.
6.) Effect of topical basic fibroblast growth factor on the healing of
chronic diabetic neuropathic ulcer of the foot. A pilot, randomized,
double-blind, placebo-controlled study.
7.) Prognostic value of the clinical examination of the diabetic foot ulcer.
8.) Wound healing. New modalities for a new millennium.
9.) Is hyperbaric oxygen a useful adjunct in the management of problem
lower extremity wounds?
10.) Adjunctive systemic hyperbaric oxygen therapy in treatment of severe
prevalently ischemic diabetic foot ulcer. A randomized study.
11.) [Mri and surgical indications in perforating ulcer in diabetic patients]
12.) 1995 William J. Stickel Gold Award. High strain rate tissue
deformation. A theory on the mechanical etiology of diabetic foot
ulcerations.
13.) A metabolically active human dermal replacement for the treatment of
diabetic foot ulcers.
14.) Cavity foot ulcers in diabetic patients: a comparative study of
cadexomer iodine ointment and standard treatment. An economic analysis
alongside a clinical trial.
15.) Power spectral analysis of heart rate variation in diabetic patients
with neuropathic foot ulceration.
16.) [Prognostic factors in treatment of diabetic foot ulcers]
17.) Total contact casting for diabetic neuropathic ulcers.
18.) Electron microscopic investigation of the effects of diabetes mellitus
on the Achilles tendon.
19.) New uses for benzoyl peroxide: a broad-spectrum antimicrobial agent.
20.) Topical therapy of leg ulcers with 20 percent benzoyl peroxide lotion.
21.) Treatment of cutaneous ulcers with benzoyl peroxide.
22.) Clinical evaluation of recombinant human platelet-derived growth
factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer
Study Group.
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1.) Promotion and acceleration of diabetic ulcer healing by
arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group.
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Author
Steed DL; Ricotta JJ; Prendergast JJ; Kaplan RJ; Webster MW; McGill
JB; Schwartz SL
Address
Department of Surgery, University of Pittsburg, Pennsylvania 15213.
Source
Diabetes Care, 18(1):39-46 1995 Jan
Abstract
OBJECTIVE--To determine the effectiveness and safety of
arginine-glycine-aspartic acid
(RGD) peptide matrix in the treatment of diabetic foot ulcers.
RESEARCH DESIGN AND
METHODS--This randomized placebo-controlled investigator- and
patient-blinded
prospective multicenter investigation was conducted at three
institutional and three private
U.S. clinics providing ambulatory care. Sixty-five diabetic patients
with chronic full-thickness
neurotrophic foot ulcers were enrolled. Six discontinued the study
because of adverse
events. RGD peptide matrix (Argidene Gel; formerly Telio-Derm Gel) was
applied topically
twice weekly for up to 10 weeks in patients who otherwise received
standard care. Control
group patients received topical saline as a placebo plus standard
care. The primary method
of assessment was the incidence and rate of ulcer closure. All
patients enrolled were
included in the data analysis. RESULTS--The percentage of patients
whose ulcers healed
completely in the RGD peptide matrix group (35%; 14 of 40 patients)
was over fourfold
greater (P = 0.02) than that in the placebo group (8%; 2 of 25
patients). By the study end
point (either day of healing or week 10), 30 of 40 (75%) RGD peptide
matrix patients had
achieved > 50% ulcer closure compared with 12 of 25 (48%) placebo
patients (P = 0.03).
RGD peptide matrix also significantly (P = 0.03) increased the rate of
ulcer closure over the
10 weeks of the study. CONCLUSIONS--RGD peptide matrix treatment
promoted and
accelerated the healing of chronic diabetic foot ulcers to a significant
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2.) Effects of electrical stimulation on wound healing in patients with
diabetic ulcers.
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Author
Baker LL; Chambers R; DeMuth SK; Villar F
Address
Department of Biokinesiology and Physical Therapy, University of
Southern California, Los
Angeles 90033, USA. [email protected]
Source
Diabetes Care, 20(3):405-12 1997 Mar
Abstract
OBJECTIVE: To evaluate the effects of two stimulation waveforms on
healing rates in
patients with diabetes and open ulcers. The hypothesis was that
stimulus waveforms with
minimal polar characteristics would provide significant healing for
this patient sample.
RESEARCH DESIGN AND METHODS: This was a prospective study that
enrolled 80
patients with open ulcers. Patients received stimulation with either
an asymmetric biphasic
(A) or symmetric biphasic (B) square-wave pulse. Amplitudes were set
to activate intact
peripheral nerves in the skin. Two other groups received either very
low levels of stimulation
current (MC), or no electrical stimulation (C). When combined these
groups were referred to
as the control group. Treatment was carried out daily until the wound
healed, the patient
withdrew from the study, or the physician changed the overall wound
management program.
Average healing rates were calculated from weekly measures of the
wound perimeter and
were used for statistical comparison through a one-way analysis of
variance. RESULTS:
Stimulation with the A protocol significantly increased the healing
rate, enhancing healing by
nearly 60% over the control rate of healing. Stimulation with the B
protocol did not increase
the healing rate when compared with control subjects. CONCLUSIONS:
Electrical
stimulation, given daily with a short pulsed, asymmetric biphasic
waveform, was effective for
enhancement of healing rates for patients with diabetes and open ulcers.
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3.) The use and abuse of wound care materials in the treatment of diabetic
ulcerations.
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Author
Day MR; Fish SE; Day RD
Address
Nashville Family Foot Care, TN 37203, USA.
Source
Clin Podiatr Med Surg, 15(1):139-50 1998 Jan
Abstract
With the ever-increasing availability of wound care materials for use
in diabetic foot
ulcerations, a thorough understanding of the indications and
applications of these materials
is important for wound-management success. The coupling of a lack of
understanding of the
interaction of wound care materials and the dynamic nature of
wound-healing physiology may
lead to a protracted healing course that may constitute an abuse of an
otherwise useful
adjunct to wound healing protocols. This article provides an overview
of wound care
products, their indications, and possible complications of
inappropriate use.
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4.) Relationship of microalbuminuria with the diabetic foot ulcers in type
II diabetes.
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Author
Guerrero-Romero F; Rodr´iguez-Mor´an M
Address
Research Group on Diabetes and Chronic Illnesses, Mexican Social
Security Institute,
Durango.
Source
J Diabetes Complications, 12(4):193-6 1998 Jul-Aug
Abstract
Microalbuminuria is a significant risk factor associated with
nephropathy, retinopathy, and
cardiovascular disease; however, there are no previous reports on the
relationship of
microalbuminuria with diabetic foot ulcers or stroke, despite the fact
that microalbuminuria
is a marker of vascular damage. The purpose of this study was to
determine the relationship
of microalbuminuria with diabetic foot ulcers in type II diabetes
patients. In this,
cross-sectional clinical study, outpatients of the offices at first
level medical care in Durango,
Mexico, were included in one of two groups; (a) patients with diabetic
foot ulcers and (b)
control of group patients without diabetic foot ulcers. Diabetic foot
diagnosis was
established on the basis of clinical criteria and pletismography.
Patients diagnosed with renal
disease, urinary tract infection, acute febrile illness, or heart
failure and those receiving
angiotensin-converting enzyme inhibitors were excluded from the study.
Microalbuminuria
was measured, on a 24-h urine collection, by precipitation with
sulfasalicylic acid, and
turbidity was determined by measuring absorbance with a
spectrophotometer. The study
included 670 diabetic patients. Using both odds ratio and logistic
regression analyses,
diabetes duration, cigarette smoking, aging, and microalbuminuria
showed a strong
relationship with diabetic foot ulcers. Microalbuminuria should be
considered as an
independent risk factor for diabetic foot ulcers.
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5.) Choosing a practical screening instrument to identify patients at risk
for diabetic foot ulceration.
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Author
Armstrong DG; Lavery LA; Vela SA; Quebedeaux TL; Fleischli JG
Address
Department of Orthopaedics, University of Texas Health Science Center,
San Antonio, Tex.,
USA.
Source
Arch Intern Med, 158(3):289-92 1998 Feb 9
Abstract
OBJECTIVE: To evaluate the sensitivity and specificity of 3 sensory
perception testing
instruments to screen for risk of diabetic foot ulceration. METHODS:
This case-control
study prospectively measured the degree of peripheral sensory
neuropathy in diabetic
patients with and without foot ulcers. We enrolled 115 age-matched
diabetic patients (40%
male) with a case-control ratio of approximately 1:3 (30 cases and 85
controls) from a
tertiary care diabetic foot specialty clinic. Cases were defined as
individuals who had an
existing foot ulceration or a history of a recently (< 4 weeks) healed
foot ulceration.
Controls were defined as subjects with no foot ulceration history.
Using receiver operating
characteristic analysis, we evaluated the sensitivity and specificity
of 2 commonly used
nephropathy assessment tools (vibration perception threshold testing
and the
Semmes-Weinstein 10-g monofilament wire system) and a 4-question
verbal neuropathy
score to evaluate for presence of foot ulceration. RESULTS: A
vibration perception
threshold testing using 25 V and lack of perception at 4 or more sites
using the
Semmes-Weinstein 10-g monofilament wire system had a significantly
higher specificity than
neuropathy score used. The neuropathy score was most sensitive when 1
or more answers
were affirmative. When modalities were combined, particularly the
monofilament wire system
plus vibration perception threshold testing and the neuropathy score
plus the monofilament
wire system, there was a substantial increase in specificity with
little or no diminution in
sensitivity. CONCLUSIONS: The early detection of peripheral neuropathy
or loss of
"protective sensation" is paramount to instituting a structured
treatment plan to prevent lower
extremity amputation. The results of our study suggest that all 3
sensory perception testing
instruments are sensitive in identifying patients at risk for
ulceration. Combining modalities
appears to increase specificity with very little or no diminution in
sensitivity.
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6.) Effect of topical basic fibroblast growth factor on the healing of
chronic diabetic neuropathic
ulcer of the foot. A pilot, randomized, double-blind,
placebo-controlled study.
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Author
Richard JL; Parer-Richard C; Daures JP; Clouet S; Vannereau D; Bringer
J; Rodier M;
Jacob C; Comte-Bardonnet M
Address
Department of Dietetics and Diabetology, Centre Medical, Le Grau du
Roi, France.
Source
Diabetes Care, 18(1):64-9 1995 Jan
Abstract
OBJECTIVE--To assess the efficacy and safety of topical human
recombinant basic
fibroblast growth factor (bFGF) on the healing of diabetic
neurotrophic foot ulcers.
RESEARCH DESIGN AND METHODS--Seventeen diabetic patients suffering from
chronic neuropathic ulcer of the plantar surface of the foot entered a
pilot, randomized,
double-blind study comparing local application of bFGF with placebo.
Main inclusion criteria
were a typical neuropathic ulcer of Wagner grade I-III, more than 0.5
cm in the largest
diameter, with an abnormally high vibration perception threshold in
the absence of significant
peripheral vascular disease or wound infection. bFGF or placebo was
applied daily during
the 6 weeks as inpatients then twice a week for 12 weeks. Evolution of
ulcer size was
assessed through weekly clinical examination and computerized
photographs. RESULTS--In
the bFGF group, three of nine ulcers healed compared with five of
eight in the placebo
group (NS). The weekly reduction in ulcer perimeter and area was
identical in both groups,
as was the rate of linear advance from entry to the 6th week of
treatment (bFGF: 0.053 +/-
0.048 mm vs. placebo: 0.116 +/- 1.129 mm): the same result was
obtained at the 11th
week. Moreover, percent healed area at the end of the study did not
differ significantly. No
side effects were observed during bFGF application.
CONCLUSIONS--Topical application
of bFGF has no advantage over placebo for healing chronic neuropathic
diabetic ulcer of
the foot. Because diabetes causes significant wound-healing defects,
we hypothesized that
using a single growth factor might be insufficient to accelerate wound
closure of diabetic
ulcers.
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7.) Prognostic value of the clinical examination of the diabetic foot ulcer.
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Author
Edelman D; Hough DM; Glazebrook KN; Oddone EZ
Address
Center for Health Services Research in Primary Care, Durham Veterans
Affairs Medical
Center, NC 27705, USA.
Source
J Gen Intern Med, 12(9):537-43 1997 Sep
Abstract
OBJECTIVE: To determine the value of the history, physical
examination, and magnetic
resonance imaging (MRI) in predicting successful primary healing of a
foot ulcer in a
diabetic patient. DESIGN: Prospective cohort study. SETTING: Durham
(NC) Veterans
Affairs Medical Center. PATIENTS: Sixty-four consecutive diabetic
patients with 78
dermal ulcers through the full thickness of the skin and at or distal
to the malleoli of the ankle.
MEASUREMENTS AND MAIN RESULTS: A structured clinical history and physical
examination were performed by two examiners, a physician participating
in the study and the
referring physician. Fifty of these patients with 63 ulcers underwent
MRI. Patients were
followed prospectively for 6 months after enrollment to ascertain
healing of the ulcer,
amputation, and death. During the 6-month follow-up period, 8 (13%) of
the patients died.
Seventeen (22%) of the ulcers were amputated, 17 (22%) of the ulcers
failed to heal, and
36 (47%) healed primarily. Univariate predictors of healing at 6
months included age less
than 65 years, diagnosis of diabetes within the last 15 years,
painless ulcer, palpable ankle
pulse, anklebrachial index greater than 0.5, and the physician's
assessment of the overall
likelihood of osteomyelitis. In a multivariable logistic regression
model, predictors of healing
included the presence of an audible pulse on Doppler examination (p =
.01) and a painless
ulcer (p = .04). The diagnosis of osteomyelitis on MRI did not predict
healing in these
patients. CONCLUSIONS: Foot ulcers in patients with diabetes
frequently have poor
outcomes; fewer than half the patients in this study healed their
ulcers within 6 months. The
vascular components of the clinical examination are the best
predictors of healing in patients
with a diabetic foot ulcer.
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8.) Wound healing. New modalities for a new millennium.
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Author
Williams RL; Armstrong DG
Address
Department of Anesthesia, University of Texas Health Science Center,
San Antonio, USA.
Source
Clin Podiatr Med Surg, 15(1):117-28 1998 Jan
Abstract
Common to all studies of wound healing modalities is the need to
convert the chronic wound
into an acute wound and to maintain the wound in an acute state while
subsequently using
adjunctive therapy. Hence, precise control and documentation of wound
care is extremely
important in order to avoid contamination of the effects of a specific
modality with the effects
of good wound care. Falanga has noted that neuropathy of diabetes has
been given wide
support as the primary pathogenic component of diabetic ulcers,
whereas less recognition
has been made of the wound-healing failure component. The therapies
discussed in this article
considered the wound-healing failure component. Oxygen is a drug. The
use of oxygen under
normobaric conditions at higher than normal inspired partial pressures
is standard operating
procedure when clinicians are faced with patients with respiratory
embarrassment or heart
failure. The use of oxygen under hyperbaric conditions, however,
remains estranged from the
mainstream thoughts of most clinicians. Abnormally hypoxic wounds may
benefit from
specific oxygen therapy in hyperbaric dosage ranges. However,
correction of abnormal
wound oxygen tension alone does not guarantee healing. Hyperbaric
studies have been
criticized for the lack of well-defined wound care protocols, the
absence of precise wound
healing measures, and poorly defined wound healing endpoints. Studies
with growth factors
and human skin equivalents exclude patients typically referred for
hyperbaric therapy.
Patients referred for hyperbaric therapy often have larger wounds with
greater severity of
peripheral vascular disease with ABIs < 0.7 and TcPO2 < 30 to 40 mm
Hg, are often on
medications known to inhibit wound healing (e.g., steroids), or have
concomitant medical
disorders (collagen vascular disease, renal failure) associated with
poor healing. No
hyperbaric study has controlled stringently for all of these factors.
Nevertheless, HBO2 is
more specific and successful for the intended purpose of correction of
abnormal tissue
oxygen tensions than are growth factors for the intended purpose of
growth. Similarly, skin
substitutes are limited in their application and have not been tried
in patients with ABIs < 0.7
or TcPO2 values < 30 mm Hg. In our view, hyperbaric therapy probably
can be combined
successfully with allogenic grafts and human skin equivalents in this
group of patients.
Hyperbaric therapy can generate a sufficient granulation base in which
these products should
be able to close properly selected wounds successfully. No studies of
this combined modality
approach exist. Finally, regardless of the modality used to aid in
wound closure, long-term
outcomes probably depend more on neuropathy and large vessel disease
than on
microangiopathy and local wound-healing defects. The modalities
presented in this article
must prove to be both cost effective and practical before they are
widely disseminated.
Nevertheless, the ability to manipulate the local wound environment is
no longer inviolate as
was once presumed, and current investigations continue to advance
therapeutic options in this
most fascinating and challenging discipline.
Language
Eng
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9.) Is hyperbaric oxygen a useful adjunct in the management of problem
lower extremity wounds?
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Author
Ciaravino ME; Friedell ML; Kammerlocher TC
Address
Department of Surgical Education, Orlando Regional Medical Center, FL
32806, USA.
Source
Ann Vasc Surg, 10(6):558-62 1996 Nov
Abstract
Hyperbaric oxygen (HBO) is currently being used in the treatment of
nonhealing or "problem"
wounds of the lower extremities. In an attempt to evaluate the
efficacy of HBO in problem
wounds, a retrospective study of the HBO experience at Orlando
Regional Medical Center
was conducted. From 1989 to 1994, fifty-four patients with nonhealing
lower extremity
wounds resulting from underlying peripheral vascular disease and/or
diabetes mellitus were
treated with HBO. Wounds were grouped into the following five
categories: (1) diabetic
ulcers (n = 17 [31%]); (2) arterial insufficiency (n = 8 [15%]); (3)
gangrenous lesions (n = 6
[11%]); (4) nonhealing amputation stumps (n = 13 [24%]); and (5)
nonhealing operative
wounds (n = 10 [19%]). Each patient received an average of 30
treatments. Outcomes for all
54 patients treated with HBO in this study were dismal. None of the
patients experienced
complete healing, six (11%) showed some improvement, 43 (80%) showed
no improvement,
and in five cases (9%) results were inconclusive because these
patients underwent
concomitant revascularization or amputation. Thirty-eight of the 43
patients who showed no
improvement (88%) ultimately required at least one surgical procedure
to treat their wounds.
Thirty-four patients (63%) developed complications, most commonly
barotrauma to the ears,
which occurred in 23 patients (43%). The average cost of 30 HBO
treatments was $14,000
excluding daily inpatient charges. Based on the experience with HBO
therapy at Orlando
Regional Medical Center and the paucity of good supporting literature,
it is difficult to justify
such an expensive, ineffective complication-prone treatment modality
for problem extremity
wounds.
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10.) Adjunctive systemic hyperbaric oxygen therapy in treatment of severe
prevalently ischemic diabetic foot ulcer. A randomized study.
=====================================================================
Author
Faglia E; Favales F; Aldeghi A; Calia P; Quarantiello A; Oriani G;
Michael M; Campagnoli
P; Morabito A
Address
Diabetology Center, Niguarda Hospital, Milan, Italy.
Source
Diabetes Care, 19(12):1338-43 1996 Dec
Abstract
OBJECTIVE: To evaluate the effectiveness of systemic hyperbaric oxygen
therapy (s
HBOT) in addition to a comprehensive protocol in decreasing major
amputation rate in
diabetic patients hospitalized for severe foot ulcer. RESEARCH DESIGN AND
METHODS: From August 1993 to August 1995, 70 diabetic subjects were
consecutively
admitted into our diabetologic unit for foot ulcers. All the subjects
underwent our
diagnostic-therapeutic protocol and were randomized to undergo s-HBOT.
Two subjects,
one in the arm of the treated group and one in the arm of nontreated
group, did not complete
the protocol and were therefore excluded from the analysis of the
results. Finally, 35 subjects
received s-HBOT and another 33 did not. RESULTS: Of the treated group
(mean session =
38.8 +/- 8), three subjects (8.6%) underwent major amputation: two
below the knee and one
above the knee. In the nontreated group, 11 subjects (33.3%) underwent
major amputation:
7 below the knee and 4 above the knee. The difference is statistically
significant (P = 0.016).
The relative risk for the treated group was 0.26 (95% CI 0.08-0.84).
The transcutaneous
oxygen tension measured on the dorsum of the foot significantly
increased in subjects treated
with hyperbaric oxygen therapy: 14.0 +/- 11.8 mmHg in treated group,
5.0 +/- 5.4 mmHg in
nontreated group (P = 0.0002). Multivariate analysis of major
amputation on all the
considered variables confirmed the protective role of s-HBOT (odds
ratio 0.084, P = 0.033,
95% CI 0.008-0.821) and indicated as negative prognostic determinants
low ankle-brachial
index values (odds ratio 1.715, P = 0.013, 95% CI 1.121-2.626) and
high Wagner grade
(odds ratio 11.199, P = 0.022, 95% CI 1.406-89.146). CONCLUSIONS:
s-HBOT, in
conjunction with an aggressive multidisciplinary therapeutic protocol,
is effective in decreasing
major amputations in diabetic patients with severe prevalently
ischemic foot ulcers.
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11.) [Mri and surgical indications in perforating ulcer in diabetic patients]
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Author
Jarde O; Filloux V; Filloux JF; Remond A; Vives P
Address
Service d'orthop´edie-taumatologie, H^opital Nord, AMIENS, France.
Source
Acta Orthop Belg, 63(3):156-64 1997 Sep
Abstract
The authors report a series of thirty-six perforating ulcers of the
foot in diabetic patients,
evaluated using M.R.I. M.R.I. showed osteomyelitis in 16 cases,
cellulitis in 15 cases,
osteoarthropathies in 21 cases, tenosynovitis of flexor tendons in 2
cases, oedema in 2 cases
and abscess in one case. In 19 cases, M.R.I. was used to improve
diagnostic accuracy. The
medical treatment made use of thermo-moulded soles allowing for the
recovery of walking,
with a hole facing the perforating ulcer of the foot. The application
of insulin-soaked sponges
in the event of clean perforating ulcer of the foot and iodized
solution in the event of infected
perforating ulcer of the foot promoted healing. The treatment was only
conservative, when
the lesions were limited to the soft tissues. Surgical treatment was
performed in 19 cases due
to a global involvement of soft and osteoarticular tissues. In
fourteen cases the surgical
treatment was limited and was performed through the perforating ulcer.
Resection of
metatarsal heads or metatarso-phalangeal joints was performed in 10
cases, with resection of
surrounding pathologic tissue. The surgical treatment was limited to
the soft tissues in 6 cases.
In 4 cases, M.R.I. findings resulted into a transmetatarsal amputation
because the vascular
plexus was of poor quality and infection spread from the perforating
ulcer to the dorsal
aspect of the foot. In our opinion, dorsal infectious involvement in a
perforating ulcer of the
foot, is a factor of poor prognosis. A below-knee amputation has been
performed in one
patient.
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12.) 1995 William J. Stickel Gold Award. High strain rate tissue
deformation. A theory on the mechanical etiology of diabetic foot
ulcerations.
=====================================================================
Author
Landsman AS; Meaney DF; Cargill RS 2nd; Macarak EJ; Thibault LE
Address
Dr. William M. Scholl College of Podiatric Medicine, Chicago, IL
60610, USA.
Source
J Am Podiatr Med Assoc, 85(10):519-27 1995 Oct
Abstract
Foot ulcerations are one of the most common and dangerous
complications associated with
chronic diabetes mellitus. Many studies have focused on neuropathy, in
conjunction with
elevated ground reactive forces, as the principal cause of these
ulcerations. The authors
discuss the mechanical cause of diabetic ulcerations at the cellular
level. It is hypothesized
that increased rate of tissue deformation associated with foot slap
secondary to progressive
motor neuropathy is the actual culprit, and not the magnitude of local
pressure applied. The
authors present a cellular model that shows that high rates of tissue
deformation may result in
elevated intracellular calcium concentrations, which may lead to
cellular death, while
comparable loads gradually applied do not. Furthermore, there is no
significant difference in
the response observed at 5 psi and 10 psi. Based on these findings, it
is hypothesized that
techniques such as ankle foot orthoses, which control the velocity of
foot strike, may be
useful in treating diabetic foot ulcerations.
=====================================================================
13.) A metabolically active human dermal replacement for the treatment of
diabetic foot ulcers.
=====================================================================
Author
Naughton G; Mansbridge J; Gentzkow G
Address
Advanced Tissue Sciences, Inc., La Jolla, California 92037, U.S.A.
Source
Artif Organs, 21(11):1203-10 1997 Nov
Abstract
Tissue engineering, the science of growing living human tissues for
transplantation, promises
to revolutionize aspects of medical care. Ulcers of the skin of the
feet of diabetic patients
are a serious health problem and a major cause of amputations.
Dermagraft, a
tissue-engineered, living human dermal tissue, which provides normal
growth factors and
matrix proteins, has been implanted to replace a patients' destroyed
dermises and heal these
ulcers. Large-scale clinical studies and in vitro experiments have
demonstrated the
importance of controlling specific product parameters, especially the
metabolic activity of the
tissue, to provide, upon implantation into the wound bed, a living
tissue that facilitates healing.
Implanting tissue within a defined therapeutic range of metabolic
activity dramatically
improves healing of diabetic foot ulcers, with significantly more
ulcers healed completely in
a shorter time. In this new, rapidly moving science, such elucidation
of the mechanism of
action is vital to ensure that tissues will provide their intended
benefit.
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14.) Cavity foot ulcers in diabetic patients: a comparative study of
cadexomer iodine ointment and standard treatment. An economic analysis
alongside a clinical trial.
=====================================================================
Author
Apelqvist J; Ragnarson Tennvall G
Address
Department of Internal Medicine, University Hospital of Lund, Sweden.
Source
Acta Derm Venereol, 76(3):231-5 1996 May
Abstract
Diabetic foot ulcers with exposure of tendon, muscle, or bone imply a
high probability for
deep infections and amputations. Delayed healing times are often
described. The aim of this
study was to compare the clinical effect and economic cost of
cadexomer iodine with
standard treatment in diabetic feet with cavity ulcers. Patients with
deep, exudative foot
ulcers were included in a 12-week open, randomised, comparative study.
When ulcers
stopped exudating, vaseline gauze was used in both groups until the
end of the study. Costs
were estimated for dressing material, staff and transportation.
Clinically relevant improvement
was seen in 12 patients treated with cadexomer iodine and in 13
patients treated with
standard treatment. The average weekly cost was SEK 903 and SEK 1,421,
respectively, of
which the major part was costs for staff and transportation related to
frequency of dressing
changes. Treatment with cadexomer iodine ointment (Iodosorb) showed no
clinical difference
compared to topical treatment consisting of gentamicin solution,
streptodornase/streptokinase, or dry saline gauze but was associated
with considerably lower
weekly treatment costs.
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15.) Power spectral analysis of heart rate variation in diabetic patients
with neuropathic foot ulceration.
=====================================================================
Author
Aso Y; Fujiwara Y; Inukai T; Takemura Y
Address
Department of Medicine, Koshigaya Hospital, Dokkyo University School
of Medicine,
Saitama, Japan.
Source
Diabetes Care, 21(7):1173-7 1998 Jul
Abstract
OBJECTIVE: To evaluate the relationship between diabetic autonomic
neuropathy and
diabetic neuropathic foot ulceration, we used power spectral analysis
(PSA) of heart rate
variation, which provides the accurate simultaneous quantification of
parasympathetic and
sympathetic activities, to assess autonomic function in diabetic
patients. RESEARCH
DESIGN AND METHODS: We studied 55 NIDDM patients including 10 diabetic
patients
without neuropathy, 23 diabetic patients with neuropathy and no
history of foot ulceration,
and 22 diabetic patients with neuropathic foot ulceration. We
performed PSA of 100 R-R
intervals at rest and analyzed the results by fast Fourier
transformation. RESULTS: The low
frequency (LF) power, which reflects sympathetic activity, and the
high frequency (HF)
power, which reflects parasympathetic (vagal) activity, were inversely
correlated with the
duration of diabetes and the fasting plasma glucose (FPG) levels. By
multiple regression
analysis, the FPG remained with significant influence on both LF and
HF powers. The LF
and HF powers were positively correlated with motor nerve conduction
velocity (MCV) and
sensory nerve conduction velocity (SCV) in the upper and lower limbs
and the coefficient of
variation of R-R intervals. The LF and HF powers were significantly
reduced in patients with
neuropathy and patients with foot ulceration compared with patients
without neuropathy.
Although the median MCV and SCV were similar between diabetic patients
with
neuropathy and patients with foot ulceration, both the LF and HF
powers were significantly
decreased in patients with foot ulceration compared with patients with
neuropathy. There
was no difference in the value of the LF:HF ratio, an index of
sympathovagal balance, among
three subgroups. We observed a positive correlation between LF and HF
power in all
subjects; however, the LF and HF powers were not correlated in the
subgroups of patients
with foot ulceration. CONCLUSIONS: These results showed that diabetic
patients with
neuropathic foot ulceration have a greater impairment in spectral
indexes of autonomic
activity obtained by PSA than patients with neuropathy and no history
of foot ulceration,
whereas no difference was present in nerve conduction velocities.
=====================================================================
16.) [Prognostic factors in treatment of diabetic foot ulcers]
=====================================================================
Author
Coerper S; Flesch I; Becker HD; K¨oveker G
Address
Abteilung f¨ur Allgemeine Chirurgie, Chirurgische Universit¨atsklinik
T¨ubingen.
Source
Langenbecks Arch Chir Suppl Kongressbd, 114():566-8 1997
Abstract
138 patients with nonhealing diabetic foot ulcers were treated between
1994 and 1996.
Sixty-nine percent of these foot ulcers healed within 17 weeks. Heel
ulcers had a
significantly lower healing rate, probably because of the difficulty
of taking weight-bearing off
this zone. Ischemia also correlated well with low healing rates,
underlining the importance of
vascular diagnosis and surgery. Since compliance is the most
significant factor for success, it
is mandatory to educate the patient about his disease and prevent
further complications.
=====================================================================
17.) Total contact casting for diabetic neuropathic ulcers.
=====================================================================
Author
Sinacore DR
Address
Program in Physical Therapy, Washington University School of Medicine,
St. Louis, MO
63110, USA.
Source
Phys Ther, 76(3):296-301 1996 Mar
Abstract
Despite its limited therapeutic use, several research reports indicate
that TCC is currently the
most rapid and effective technique for healing diabetic neuropathic
ulcers. Skilled
application and careful follow-up of the wound are necessary to avoid
complications and
minimize the risks for reulceration. As more clinicians adopt this
form of therapy, the
successful treatment of neuropathic ulcers using TCC should result in
a lower incidence of
infection, hospitalization and lost income in patients with chronic
sensory neuropathies.
=====================================================================
18.) Electron microscopic investigation of the effects of diabetes mellitus
on the Achilles tendon.
=====================================================================
Author
Grant WP; Sullivan R; Sonenshine DE; Adam M; Slusser JH; Carson KA;
Vinik AI
Address
Tidewater Foot and Ankle Center, Virginia Beach, Virginia, USA.
Source
J Foot Ankle Surg, 36(4):272-8; discussion 330 1997 Jul-Aug
Abstract
Fine structural changes in the Achilles tendons of patients with
long-term diabetes mellitus
were investigated. All patients had clinical and electrophysiological
evidence of diabetic
neuropathy and had ulceration and/or Charcot neuroarthropathy. Several
differences
between tendons of diabetic (n = 12) and nondiabetic (n = 5)
individuals were observed by
electron microscopy. In diabetics, these differences included
increased packing density of
collagen fibrils, decreases in fibrillar diameter, and abnormal fibril
morphology. In one
diabetic patient, individual collagen fibrils were tightly apposed so
that many areas of tendon
appeared as a single mass of closely adhering fibrillae. In addition,
foci in which collagen
fibrils appeared twisted, curved, overlapping and otherwise highly
disorganized were
common in specimens from most patients (11 of 12). These morphologic
abnormalities in the
Achilles tendons of diabetics appear to reflect a poorly known process
of structural
reorganization that may be the result of nonenzymatic glycation
expressed over many years.
Such structural changes could contribute to the tightening of the
Achilles tendor a
phenomenon consistent with clinical observations of extreme shortening
of the Achilles
tendon-gastrocnemius-soleus complex common in advanced diabetic
neuropaths. In patients
with diabetic neuropathy, tendon shortening causes severe equinus that
may precipitate
serious ulceration, stress fractures, and Charcot collapse of the
foot. However, in
nondiabetics, the fine structure of the Achilles tendon appears
normal, consistent with the
finding that the ultrastructural changes result from diabetes rather
than neuropathy.
=====================================================================
19.) - New uses for benzoyl peroxide: a broad-spectrum antimicrobial agent.
=====================================================================
SO - Int J Dermatol 1977 Jun;16(5):413-7
AU - Kligman AM; Leyden JJ; Stewart R
MJ - Benzoyl Peroxide [therapeutic use]; Peroxides [therapeutic use];
Tinea [drug therapy]
MN - Tinea Pedis [drug therapy]; Tinea Versicolor [drug therapy]
MT - Human
PT - JOURNAL ARTICLE
AB - Benzoyl peroxide is a useful agent in the treatment of acne, chronic
ulcers, tinea pedis, and tinea versicolor, probably because of its
antimicrobial power. 2.5% concentration is almost as active as 5%. Although
potential irritancy and allergic reaction have not been a problem on the
face, benzoyl peroxide should be used judiciously in chronically inflamed
or ulcerated skin. Several potential uses are mentioned.
=====================================================================
20.) Topical therapy of leg ulcers with 20 percent benzoyl peroxide lotion.
=====================================================================
SO - Cutis 1978 Apr;21(4):491-4
AU - Colman GJ; Roenigk HH Jr
MJ - Benzoyl Peroxide [therapeutic use]; Leg Ulcer [drug therapy];
Peroxides [therapeutic use]
MN - Administration, Topical; Benzoyl Peroxide [administration & dosage];
Leg Ulcer [pathology]
MT - Human
PT - JOURNAL ARTICLE
AB - Preliminary clinical observations suggest that benzoyl peroxide
lotion (20%) may be a useful topical treatment for various types of leg
ulcers. Further studies utilizing patients as their own controls (treating
half of the ulcer surface with 20% benzoyl peroxide) are now underway.
=====================================================================
21 - Treatment of cutaneous ulcers with benzoyl peroxide.
=====================================================================
SO - Can Med Assoc J 1976 Dec 4;115(11):1101-6
AU - Pace WE
MJ - Benzoyl Peroxide [therapeutic use]; Peroxides [therapeutic use]; Skin
Ulcer [drug therapy]
MN - Administration, Topical; Adult; Aged; Benzoyl Peroxide
[administration & dosage] [adverse effects]; Child, Preschool; Child;
Methods; Middle Age; Skin Ulcer [pathology]
MT - Case Report; Female; Human; Male
PT - JOURNAL ARTICLE
AB - Benzoyl peroxide, a powerful organic oxidizing agent, was applied
topically according to a carefully developed technique to cutaneous ulcers
of different types. The healing time was shortened greatly by the rapid
development of healthy granulation tissue and the quick ingrowth of
epithelium. Exceptionally large pressure ulcers with deep cavities,
undercut edges and sinus tracts were sucessfully treated, as were stasis
ulcers of long duration resistant to all other therapy. There were only 13
treatment failures among the 133 cases. The slow, sustained release of
oxygen by benzoyl peroxide was though to be responsible for the success.
The only complications were contact irritant dermatitis in 3% and contact
allergic dermatitis in 2% of patients treated.
=====================================================================
22.) Clinical evaluation of recombinant human platelet-derived growth
factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer
Study Group.
=====================================================================
Author
Steed DL
Address
University of Pittsburgh, Presbyterian University Hospital, PA 15213.
Source
J Vasc Surg, 21(1):71-8; discussion 79-81 1995 Jan
Abstract
PURPOSE: The purpose of this study was to investigate the efficacy and
safety of
recombinant human platelet-derived growth factor (rhPDGF-BB) in a
double-blind,
placebo-controlled, multicenter study of patients with chronic
diabetic ulcers. METHODS:
Patients with chronic, full-thickness, lower-extremity diabetic
neurotrophic ulcers of at least
8 weeks' duration, free of necrotic and infected tissue after
debridement, and with
transcutaneous oxygen tensions of 30 mm Hg or greater were studied. A
total of 118 patients
were randomized to receive either topical rhPDGF-BB (2.2
micrograms/cm2 of ulcer area)
or placebo until the ulcer was completely resurfaced or for a maximum
of 20 weeks,
whichever occurred first. RESULTS: Twenty-nine (48%) of 61 patients
randomized to the
rhPDGF-BB group achieved complete wound healing during the study
compared with only
14 (25%) of 57 patients randomized to the placebo group (p = 0.01).
The median reduction
in wound area in the group given rhPDGF-BB was 98.8% compared with
82.1% in the
group given placebo (p = 0.09). There were no significant differences
in the incidence or
severity of adverse events between the rhPDGF-BB and placebo groups.
CONCLUSIONS: Once-daily topical application of rhPDGF-BB is safe and
effective in
stimulating the healing of chronic, full-thickness, lower-extremity
diabetic neurotrophic
ulcers.
======================================================================
DATA-MEDICOS/DERMAGIC-EXPRESS No(15) 10/11/98 DR. JOSE LAPENTA R. DERMATOLOGO
======================================================================
Dr. Jose Lapenta R.
Maracay, Venezuela
[email protected]
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