应用彩色多普勒超声对糖尿病足病人下肢动脉血管病变的研究

目的观察糖尿病足（DF）病人下肢动脉形态学和血流动力学的改变。方法正常受试者（NS）25例，糖尿病（DM）病人26例，非肢端坏疽糖尿病足病人（NGDF）30例和肢端坏疽糖尿病足（GDF）病人26例。应用Acusonl28xP／10彩色电脑声像仪，线阵探头，频率7．0MHz，观察下肢动脉管径和血流的变化。结果DF两组病人下肢动脉血管病变，主要从胴动脉部位开始动脉硬化，尤其以胫后和足背动脉最为显著，动脉狭窄和闭塞是肢端缺血、坏疽的主要病因。观察发现，DM病人已有下肢胭动脉血流速度增高的血流动力学改变，GDF组病人胫后和足背动脉血流速度明显低于其他各组。结论彩色多普勒超声检测能帮助临床对糖尿病足下肢血管病变严重程度的判断、糖尿病足的诊断和治疗方案的制定有实用价值。     

2型糖尿病下肢动脉病变踝臂指数与纤维蛋白原的相关性

目的 探讨纤维蛋白原变化在糖尿病下肢动脉血管病变(PAD)发生发展中的作用及踝臂指数(ABI)与纤维蛋白原(FIB)的相关性,为临床治疗提供理论依据.方法 2型糖尿病患者63例,进行ABI测定,按测定结果 分为PAD组和对照组,测量FIB及其他PAD相关危险因素.结果 (1)与非PAD组相比,重度PAD组(P＜0.01)及轻度至中度PAD组(P＜0.05)FIB水平显著升高.与轻度至中度PAD组相比,重度PAD组FIB水平显著升高(P＜0.05).(2)PAD组ABI与FIB呈明显负相关(P＜0.01),NPAD组ABI与FIB呈明显负相关(P＜0.05). 结论 (1)血浆高FIB水平是PAD的重要危险因素,与PAD严重程度密切相关.(2)ABI指数与FIB存在明显负相关.(3)ABI与心血管病变危险因素存在相关性,应成为今后临床工作中的重要检测指标.     

2011年国际糖尿病足工作组特别指南介绍

指南1：有关糖尿病足与周围动脉病变特别指南 一、筛查和诊断 周围动脉病变（PAD）是预测糖尿病足溃疡结局的重要因素.50%的糖尿病足溃疡患者存在PAD,因此接诊此类患者时应评估下肢血管状态,尤其是寻找缺血体征.大截肢前通常应考虑血管重建并首先应与多学科团队讨论.应在所有糖尿病足溃疡的患者中排除PAD,需进行以下检查：（1）PAD症状的病史回顾;（2）触诊足部动脉搏动（包括胫后动脉和足背动脉）.     

Ghrelin在糖尿病血管钙化中的作用

目的观察生长激素促分泌素(Ghrelin)在糖尿病血管钙化中的作用。方法选取江苏大学附属医院30例糖尿病足截肢患者。根据超声对下肢动脉狭窄程度的检测将患者分为轻度狭窄组(狭窄50%)(n=10)、中度狭窄组(50%≤狭窄70%)(n=10)及重度狭窄/闭塞组(70%≤狭窄≤100%)(n=10)。通过患者血清学、临床相关指标的检测以及截肢胫动脉组织连续石蜡切片HE染色、Von kossa钙染色、血管钙含量、碱性磷酸酶(ALP)活性检测及Western blot检测观察钙化。结果糖尿病截肢患者胫动脉超声、HE染色及Von Kossa染色一致显示:三组患者胫动脉中膜均有弥散的黑色钙盐;但相对于轻度狭窄和中度狭窄组,重度狭窄/闭塞组胫动脉粥样硬化斑块内可见大量点灶状的黑色钙盐沉积(超声为强回声的硬斑块)。定量检测显示重度狭窄组/闭塞胫动脉ALP活性及钙含量增加显著,分别是轻度狭窄组的2.44倍和2.39倍,但中度狭窄组与轻度狭窄组相比,无统计学差异。Western blot检测显示随着血管狭窄程度加重,病变组织Ghrelin、骨保护素(OPG)表达下调,细胞核因子受体活化因子配体(RANKL)表达上调。Pearson相关性分析显示糖尿病截肢患者血清Ghrelin可能与胫动脉钙含量呈负相关(r=-0.64,P0.001)、与OPG呈正相关(r=0.85,P0.001),与sRANKL呈负相关(r=-0.85,P0.001)。结论随着糖尿病患者血管钙化程度的加重,Ghrelin与OPG表达下调,而RANKL的表达上调,提示血清Ghrelin、OPG/RANKL水平对糖尿病患者不同级别血管钙化可能有一定预警价值。     

糖尿病足病患者下肢动脉血管造影特点与临床特点关系分析

目的 探讨糖尿病足病患者下肢动脉血管造影(DSA)特点与临床特点关系.方法 回顾性分析了40例糖尿病足病患者下肢DSA的临床资料,并DSA所见各血管病变分布情况、下肢动脉病变患者的临床特征以及影响膝上、下动脉病变因素进行分析.结果 (1)胫后动脉狭窄分布率与股动脉及胭动脉狭窄分布率差异有统计学意义(P＜0.05);胫后动脉闭塞发生率与其他动脉闭塞病变发生率差异有统计学意义(P＜0.05),且胫前动脉闭塞发生率与股动脉、胭动脉闭塞发生率差异有统计学意义(P＜0.05);胫前动脉病变总发生率均显著高于其他动脉病变发生率,差异有统计学意义(P＜0.05);(2)经多元Logistic回归分析,影响膝上动脉病变的主要因素包括患者的年龄、吸烟以及LDL-C;影响膝下动脉病变的主要因素包括糖尿病病程及患者的年龄.结论 糖尿病足病患者下肢动脉血管造影特点与临床特点存在一定的关系,从而为临床治疗糖尿病足患者提供一定的依据.     

糖尿病足患者下肢血管造影特点及其临床意义

目的探讨糖尿病足下肢动脉的血管造影成像特点,并分析其临床意义。方法分析糖尿病足患者35条患肢的造影结果,分别对下肢缺血病变不同临床分期、不同部位的血管狭窄程度进行比较,并进行统计学分析。结果(1)以管腔狭窄程度<50%为0分,50%~74%为1分,75%~99%为2分,管腔完全闭塞者为3分。膝以上与膝以下共210个动脉节段比较,两组血管的狭窄程度为0,1,2,3分的分别是32.9%比18.5%,20.0%比9.3%,12.9%比14.3%,34.2%比57.9%,差异均有统计学意义(P均<0.05)。膝以上血管以轻中度狭窄为主,膝以下血管则以重度乃至完全闭塞病变为主。(2)每侧患肢腓动脉重度狭窄的几率(57.1%)明显低于胫前(77.1%)和胫后动脉(74.3%)。(3)间歇性跛行患肢膝以下三叉血管系统重度狭窄率41.7%,与静息痛(83.3%)或溃疡(79.5%)患肢相比,差异均有统计学意义(P均<0.05)。结论临床出现静息痛、溃疡及坏疽时,表明膝以下血管出现广泛重度病变,且多为三支血管联合病变。糖尿病足患者血管病变大多累及下肢远段小血管,其双侧动脉病变多为对称性同步发展。腓动脉在糖尿病性动脉硬化发病过程中病变较轻,为膝以下小动脉搭桥提供了良好的流出道。     

干细胞治疗糖尿病下肢动脉病变

一、糖尿病下肢动脉病变的危害 下肢动脉病变(peripheral arterial disease,PAD)是周围动脉病变的一个组成部分,是全身动脉粥样硬化的局部临床表现.动脉内膜粥样斑块形成后可逐渐向血管腔内发展,使管腔变窄甚至闭塞,也可因为斑块内出血或局部血栓形成导致血流中断[1].与非糖尿病患者比较,糖尿病患者PAD更易累及股深动脉及胫前动脉等中小动脉[2].PAD在普通人群中的患病率为3%～10%,且随着年龄的增长而增加.据报道,超过15%的60岁以上老年人罹患PAD[3].同时,由于导致PAD的相关危险因素(如人口老龄化、糖尿病、肥胖和高血压等)在持续增加,预计PAD患病率在将来会进一步增加.     

颅内动脉狭窄性急性脑梗死与神经功能缺损相关性及其危险因素

目的 颅内动脉狭窄性急性脑梗死与神经功能缺损相关性及其危险因素分析.方法 对100例急性脑梗死患者进行磁共振血管成像(MRA)检查.按是否颅内动脉狭窄分两组(颅内动脉狭窄组和非狭窄组),颅内动脉狭窄组分单支病变和多支病变组,分别对两组急性神经功能缺损评分及血管危险因素进行统计学分析.结果 颅内动脉狭窄组的美国国立卫生研究院卒中量表(NHISS)评分(5.85±4.305)明显高于非狭窄组(3.24±2.288)(P=0.0001).单因素及Logistic多因素回归分析比较显示糖尿病对颅内动脉狭窄的发生有显著差异(P=0.021;OR=5.375,P=0.035).Logistic多因素回归分析,显示年龄与颅内动脉多支狭窄有相关性(OR=4.632,P=0.031).结论 颅内动脉狭窄性的急性脑梗死患者,其神经功能缺损程度相对较重,影响预后.糖尿病是颅内动脉狭窄的独立危险因素,在多支狭窄中年龄更是不可忽视的危险因素.     

不同年龄组急性心肌梗死患者冠状动脉病变特点及危险因素分析

目的 研究不同年龄组急性心肌梗死(AMI)患者的危险因素及冠状动脉病变特点.方法 系统回顾性分析225 例不同年龄(分为青年组、壮年组、老年组)AMI 患者的危险因素及冠状动脉造影资料.结果 青年组AMI 危险因素以吸烟(与壮年组及老年组比较P＜0.05)及血脂异常为主;壮年组在此基础上增加高血压危险;老年组糖尿病是重要的危险因素.老年女性糖尿病发病率(35.1%)明显上升;梗死相关动脉狭窄程度各年龄组差异均有统计学意义(P＜0.05);临界病变(50%～75%狭窄)壮年组最多;重度狭窄(76%～95%狭窄)的概率随年龄增加而增加,分别为18.8%、38.4%和43.4%;成角和钙化病变老年组概率升高,与壮年组比较差异有统计学意义(P＜0.01).结论 吸烟、血脂异常、高血压、糖尿病等冠心病危险因素在不同年龄组男性和女性AMI 患者所占比重不同.随年龄增高,冠状动脉多支、复杂病变多见,不同年龄段应该采取相应的防治措施.     

糖尿病足合并糖尿病视网膜病变危险因素

目的探讨解糖尿病足(DF)合并糖尿病视网膜病变的危险因素。方法 132例DF患者根据是否合并糖尿病视网膜病变分组,合并糖尿病视网膜病变患者再根据是否存在增殖性视网膜病变分组。比较组间资料,明确DF合并糖尿病视网膜病变及发生增殖性视网膜病变的危险因素。结果存在糖尿病视网膜病变者96例,与非糖尿病视网膜病变组比较,糖尿病视网膜病变组具有年龄更小、糖尿病病程更长的特点(P0.01、P0.001),空腹血糖(FBG)、糖化血红蛋白(HbA1c)更高(P0.05),空腹C肽(Cps)、血清白蛋白(Alb)、红细胞计数(RBC)、血红蛋白(Hgb)更低(P0.05),脑梗死患病率更高(P0.05)。回归分析显示糖尿病病程(OR=1.091,95%CI为1.025～1.162)为DF合并糖尿病视网膜病变的独立危险因素,年龄(OR=0.909,95%CI为0.861～0.906)为保护因素。糖尿病病程对DF合并糖尿病视网膜病变预测能力的受试者工作特征(ROC)曲线下面积为0.658(95%CI为0.556～0.760,P0.01),当糖尿病病程取最佳临界值11.5年时,其预测DF合并糖尿病视网膜病变的敏感性为53.10%,特异性为80.60%,准确性为60.60%。96例合并糖尿病视网膜病变的DF患者中39例为增殖性视网膜病变,与非增殖性视网膜病变组比较,增殖性视网膜病变组的糖尿病病程更长(P0.05),重型DF比例、截肢率更高(P0.05、P0.01),Alb、RBC、Hgb更低(P0.05、P0.01)。回归分析显示糖尿病病程(OR=1.062,95%CI为1.003～1.125)为DF合并增殖性视网膜病变的独立危险因素。糖尿病病程对DF合并增殖性视网膜病变预测能力的ROC曲线下面积为0.681(95%CI为0.567～0.795,P0.01),当糖尿病病程取最佳临界值16.5年时,其预测DF合并增殖性糖尿病视网膜病变的灵敏感度为53.80%,特异性为82.50%,准确性为70.83%。结论糖尿病病程为DF合并糖尿病视网膜病变、DF合并增殖性视网膜病变的独立危险因素。糖尿病病程大于11.5年的DF患者合并糖尿病视网膜病变的风险明显升高。糖尿病病程大于16.5年的DF患者合并增殖性视网膜病变的风险明显升高。     

中国部分省市糖尿病足调查及医学经济学分析

目的调查和分析2型糖尿病患者糖尿病足的分类分期和医疗费用。方法以统一的调查方法对全国11个省市、14家三级甲等医院2004年全年门诊和住院糖尿病足患者进行调查,包括病史回顾、体格检查、生化检查及医疗费用等,对足溃疡进行分类、分期和病因分析,以及采用踝肱动脉压比值确定下肢血管病变程度。结果共调查糖尿病足与周围血管病变患者634例。足病高发在年龄71~80岁、病程11~20年、文化程度初小及初中、月收入501~1500元的糖尿病患者。足病患者合并糖尿病并发症或相关病变依次为神经病变(68.0%)、高血压(57.4%)、视网膜病变(42.8%)、肾病(40.4%)、血脂异常(30.0%)、下肢动脉病变(28.7%)、冠心病(28.5%)、脑血管病(24.3%),吸烟率为38.8%。足溃疡诱因以物理因素(77.7%)为主。足溃疡和(或)坏疽患者中,溃疡以单发(57.3%)、Wagner1级和2级溃疡(63.2%)为主,合并坏疽者28.8%,部位多在足趾(88.0%),干性坏疽居多(49.1%)。足溃疡以混合型溃疡为主(60.4%),67.9%的溃疡合并感染。糖尿病足溃疡患者平均住院日数为26天,住院总费用为14906元。206例糖尿病足患者的主要费用的分布为药品费7661元、检查费2567元、治疗费1548元、处置-换药费771元。结论糖尿病足患者多为高龄、文化程度低、收入低者;多已合并大血管及微血管病并发症。足溃疡中单发、表浅及缺血溃疡多见,合并感染率高;医疗花费大,以药品花费最多。     

Screening for peripheral arterial disease by means of the ankle-brachial index in newly diagnosed Type 2 diabetic patients.

AIM: To evaluate the prevalence of peripheral arterial disease (PAD) with the ankle-brachial index (ABI) in newly diagnosed Type 2 diabetic subjects. METHODS: Between autumn 2002 and spring 2003, 2559 newly diagnosed Type 2 diabetic subjects (about 15% of the cases/year in Italy) were enrolled in 265 diabetology centres. Family history of diabetes, smoking, height, weight, waistline, fasting glycaemia, glycosylated haemoglobin, total and HDL-cholesterol and triglyceride values were collected. Claudication, cyanosis, cold foot, foot hair anomalies, skin thinning and femoral, popliteal, posterior tibial and dorsalis pedis pulses were assessed. The ABI was measured with a portable Doppler continuous-wave instrument. RESULTS: An ABI < 0.9 was found in 539 (21.1%) patients. Claudication was present in 187 (7.3%). Femoral pulse was absent in 218 (8.5%), popliteal in 316 (12.3%), tibial in 563 (22.0%) and dorsalis pedis in 578 (22.6%). Foot cyanosis was observed in 88 (3.4%), cold foot in 359 (13.9%), skin thinning in 468 (18.3%) and hair anomalies in 857 (33.5%). Multivariate analysis of the variables associated with ABI < 0.9 in the univariate analysis confirmed the independent role of age [relative risk (RR) 1.02, P < 0.001, confidence interval (CI) 1.01, 1.04], claudication (RR 4.53, P < 0.001, CI 2.97, 6.93), absence of tibial pulse (RR 3.45, P < or = 0.001. CI 2.54, 4.68) and pedis pulse (RR 1.96, P < or = 0.001, CI 1.4, 2.68). CONCLUSIONS: PAD, as represented by ABI < 0.9, is common in newly diagnosed Type 2 diabetic patients.     

Guidelines on diagnosis,prognosis, and management of peripheral artery disease in patients with foot ulcers and diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis, prognosis, and management of peripheral artery disease (PAD) in patients with foot ulcers and diabetes and updates the previous IWGDF Guideline. Up to 50% of patients with diabetes and foot ulceration have concurrent PAD, which confers a significantly elevated risk of adverse limb events and cardiovascular disease. We know that the diagnosis, prognosis, and treatment of these patients are markedly different to patients with diabetes who do not have PAD and yet there are few good quality studies addressing this important subset of patients. We followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to devise clinical questions and critically important outcomes in the patient‐intervention‐comparison‐outcome (PICO) format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We here present the updated 2019 guidelines on diagnosis, prognosis, and management of PAD in patients with a foot ulcer and diabetes, and we suggest some key future topics of particular research interest.     

Patients’ clinical charecteristics and predictors for diabetic foot amputation

IntroductionMedical and surgical treatment options are available for patients with diabetic foot ulcers. In more severe cases, amputation decisions are determined by patient comorbidities, performance, imaging studies, and clinical examination results. However, an objective indicator that predicts how this amputation process will end has not yet been clarified. This study identifiies clinical characteristics that can be predictors of the need for diabetic foot amputation among patients.MethodsIn this retrospective observational study, a total of 400 patients with type 2 diabetes who were over the age of 18 and possessed diabetic foot ulcers were examined. The clinical, radiological, and scintigraphic profiles of these patients including age, gender, duration of diabetes, smoking history, previous diabetic foot amputation, presence of hypertension (HT), coronary artery disease (CAD), peripheral artery disease (PAD), cerebrovascular disease, cardiovascular disease, retinopathy, neuropathy and nephropathy were analyzed.ResultsOf the 400 patients with diabetic foot ulcers, 143 (35.75%) underwent foot amputation. Moreover, the frequency of proteinuria in amputees was significantly higher than in non-amputees (p < 0,05). Amputees also exhibited significantly longer smoking histories (p < 0,001), and the frequency of reamputation was significantly higher in those who possesed histories of previous amputation (p = 0.038). After multivariate analysis PAD presence and previous diabetic ulcer history were the significant factors to determine the amputation decision.ConclusionThe following patient characteristics were determined as being effective for predicting the need for amputation: male sex, CAD, PAD, HT, proteinuria, ulcers with Wagner Stages 4–5, smoking histories, previous diabetic ulcer histories, and previous amputation histories. The specificity of the model with these variables was determined as 86% in the patients who did not need amputation. Significant determinants were peripheral artery disease presence and diabetic foot ulcer history. Still, further and more extensive research with higher numbers of patients is necessary for determining more precisely the need for amputation.     

Predictors of diabetes foot complications among patients with diabetes in Saudi Arabia

AimsTo identify risk factors and clinical biomarkers of prevalent diabetes foot complications, including foot ulcers, gangrene and amputations among patients with diabetes in Jeddah, Saudi Arabia.Methods598 diabetes patients from Jeddah participated in the current study. Patients were considered to have diabetes foot complications if they reported diagnosis of foot ulcers or gangrene or amputations in a questionnaire administered by a physician and confirmed by clinical exams. Information on socio-demographic and lifestyle variables was self-reported by patients, and several clinical markers were assessed following standard procedures.ResultsThe prevalence of diabetes foot complications in this population was 11.4%. In the multivariable model without adjustment for PAD (peripheral artery disease) and DPN (diabetes peripheral neuropathy), non-Saudi nationality, longer diabetes duration and insulin use was significantly associated with higher diabetes foot complications prevalence. Each 1 g/L increase of hemoglobin was associated with 2.8% lower prevalence of diabetes foot complications. In the multivariable model adjusting for PAD and DPN, the previously observed associations except for nationality were no longer significant. Patients with both DPN and PAD had 9.73 times the odds of diabetes foot complications compared to the patients with neither condition.ConclusionIn this population, longer diabetes duration, insulin use, lower hemoglobin levels and non-Saudi nationality were associated with higher prevalence of foot complications. These associations were largely explained by the presence of DPN and PAD except for non-Saudi nationality. Diabetes patients with both DPN and PAD had nearly 10-fold increased risk of foot complications than those with neither condition.     

The patient presenting with chronic limb‐threatening ischaemia. Does diabetes influence presentation,limb outcomes and survival?

Peripheral arterial disease (PAD) confers an elevated risk of major amputation and delayed wound healing in diabetic patients with foot ulcers. The major international vascular societies recently developed evidence‐based guidelines for the assessment and management of patients with chronic limb‐threatening ischaemia (CLTI). CLTI represents the cohort of diabetic and non‐diabetic patients who have PAD which is of sufficient severity to delay wound healing and increase amputation risk. Diabetic patients with CLTI are more likely to present with tissue loss, infection and have less favourable anatomy for revascularization than those without diabetes. Although diabetes is not consistently reported as a strong independent risk factor for limb loss, major morbidity and mortality in CLTI patients, it is impossible in clinical practice to isolate diabetes from comorbidities, such as end‐stage renal disease and coronary artery disease which occur more commonly in diabetic patients. Treatment of CLTI in the diabetic patient is complex and should involve a multi‐disciplinary team to optimize outcomes. Clinicians should use an integrated approach to management based on patient risk assessment, an assessment of the severity of the foot pathology and a structured anatomical assessment of arterial disease as suggested by the Global Vascular Guidelines for CLTI.     

Association of diabetic foot ulcers with chronic vascular diabetic complications in patients with type 2 diabetes

ContextDiabetes mellitus is a common disease which is prevalent globally, presenting with chronic complications and constitutes a major risk to the patient. Diabetic foot ulcers are the single biggest risk factor for non-traumatic lower limb amputations in persons with diabetes. We aimed to screen for the chronic vascular diabetic complications in patients with diabetic foot ulcers (DFUs) and to assess the association of diabetic foot ulcers with these complications in the study group.Subjects and methodsThis cross-sectional study included 180 type 2 diabetic patients (aged 30–70 years) with diabetic foot ulcers who attended the Outpatient Clinic of Diabetes in Alexandria Main University Hospital. Full diabetic foot examination was done to all study subjects. DFUs were assessed using University of Texas Diabetic Wound Classification System. HbA1c, LDL-C, serum creatinine, and urinary albumin creatinine ratio (ACR) were measured for all study subjects. Estimated glomerular filtration rate (eGFR) was calculated using CKD-EPI equation. Fundus examination was done for all study subjects.ResultsThe prevalence of diabetic kidney disease (DKD) and diabetic retinopathy (DR) was 86.1% and 90% respectively among the study group. 86.7% of patients had neuropathic DFUs, 11.1% of them had ischemic DFUs and 2.2% had neuro-ischemic DFUs. Regarding diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) as risk factors for developing DFU, the prevalence of both of them respectively was 82% and 20% among the study group. There was statistically significant association between both DKD, DR and peripheral neuropathy. There was also statistically significant association between both DKD, DR and peripheral arterial disease (PAD).ConclusionChronic vascular diabetic complications are common among type 2 diabetic patients with diabetic foot ulcers. There is statistically significant association between these complications and diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD).     

Identification of patients at risk for diabetic foot: a comparison of standardized noninvasive testing with routine practice at community diabetes clinics

The aim of the study was the comparison of a simple standardized noninvasive examination of neuropathy and angiopathy with routine diagnostic practice in community diabetes clinics for the identification of patients at risk of foot ulceration. Consecutive patients (n=322), aged 30 years and more, with a diabetes duration of more than 5 years, were examined by trained podiatric nurses in six diabetes clinics over a 1-year period; 44 of these patients had active or previous foot ulcerations. We evaluated the differences between the routine diagnostic practice (based on the patient's medical history and a physical examination) and noninvasive testing of peripheral neuropathy [vibration perception threshold (VPT) and the Semmes-Weinstein 10-g monofilament wire system] and angiopathy [Doppler ankle/brachial index (ABI)]. Using receiver operating characteristic (ROC) analysis, we evaluated the sensitivity and specificity of noninvasive testing methods for identifying patients at risk and selecting the optimal diagnostic cutoff points. Patients with severe neuropathy, as determined by noninvasive testing (VPT > or =30 V and/or insensitivity to 10 g monofilament), had been diagnosed to have neuropathy in diabetes clinics in 54% of cases. Patients with angiopathy at risk of developing diabetic foot ulcers (ABI < or =0.8) had been diagnosed, in diabetes clinics, to have peripheral arterial disease in 50% (they reported claudications in 41%, had femoral artery bruits detected in 29% and nonpalpable peripheral pulsations in 12%). Our findings stress the importance of using standardized simple noninvasive testing methods to increase the accuracy of identifying patients at risk for the diabetic foot at the community level.     

Health-related quality of life and all-cause mortality in patients with diabetes on dialysis

ABSTRACT: BACKGROUND: This study tests the hypotheses that health-related quality of life (HRQOL) in prevalent dialysis patients with diabetes is lower than in dialysis patients without diabetes, and is at least as poor as diabetic patients with another severe complication, i.e.. foot ulcers. This study also explores the mortality risk associated with diabetes in dialysis patients. METHODS: HRQOL was assessed using the Short Form-36 Health Survey (SF-36), in a cross-sectional study of 301 prevalent dialysis patients (26% with diabetes), and compared with diabetic patients not on dialysis (n = 221), diabetic patients with foot ulcers (n = 127), and a sample of the general population (n = 5903). Mortality risk was assessed using a Kaplan-Meier plot and Cox proportional hazards analysis. RESULTS: Self-assessed vitality, general and mental health, and physical function were significantly lower in dialysis patients with diabetes than in those without. Vitality (p = 0.011) and general health (p <0.001) was impaired in diabetic patients receiving dialysis compared to diabetic patients with foot ulcers, but other subscales did not differ. Diabetes was a significant predictor for mortality in dialysis patients, with a hazard ratio (HR) of 1.6 (95% CI 1.0-2.5) after adjustment for age, dialysis vintage and coronary artery disease. Mental aspects of HRQOL were an independent predictor of mortality in diabetic patients receiving dialysis after adjusting for age and dialysis vintage (HR 2.2, 95% CI 1.0-5.0). CONCLUSIONS: Physical aspects of HRQOL were perceived very low in dialysis patients with diabetes, and lower than in other dialysis patients and diabetic patients without dialysis. Mental aspects predicted mortality in dialysis patients with diabetes. Increased awareness and measures to assist physical function impairment may be particularly important in diabetes patients on dialysis.