糖尿病足溃疡局部炎性反应状态与伤口愈合的关系

糖尿病伤口局部的炎性反应状态表现为炎性反应起始晚、持续时间长、消退障碍,与巨噬细胞对凋亡中性粒细胞的吞噬减少和促炎消退脂类介质分泌减少有关.而炎性反应过程中中性粒细胞数量和功能的异常、不同表型巨噬细胞比例异常、促炎/抗炎因子失平衡、晚期糖基化终末产物(AGEs)/细胞外新发现的AGEs受体结合蛋白(EN-RAGEs)和AGEs受体相互作用干扰了参与伤口愈合的多种细胞和细胞外基质的功能,导致糖尿病伤口愈合障碍.     

Patient and professional delay in the referral trajectory of patients with diabetic foot ulcers

Aims

A cohort study investigated referral and treatment trajectories of patients with diabetic foot ulceration consulting podiatrists. The study aims were to quantify patient, professional and treatment (=total) delay and to identify relationships between patient- or professional-related characteristics, delays or ulcer healing time.

Methods

Ten podiatrists specialising in diabetes care included 54 consecutive adults with diabetic foot ulceration. Assessments were performed retrospectively (e.g. delays) and prospectively (12 weeks).

Results

Median (SD; range) patient delay was 3.0 days (50.6; 0–243), professional delay 7.0 days (63.4; 0–279) and treatment delay 20.5 days (97.3; 0–522). 57% of patients took >2 weeks before visiting a podiatrist. Ulcers healed in 67% of patients in 49.0 days (90.2; 4–408). The number of health care professionals in the referral trajectory was positively related to treatment delay (p < 0.01) and to ulcer healing time (p < 0.01). Professional delay and treatment delay was positively correlated with the duration of the podiatric treatment (p < 0.05). Patient awareness of ulceration risk tended to decrease the healing time.

Conclusions

Patients with diabetic foot ulcers presented small median delays in the referral trajectory to podiatrists specialising in diabetes. The study results suggest that reducing the number of health care professionals in the referral trajectory might decrease treatment delay and ulcer healing time. Also improving patient awareness of ulceration risk might be beneficial for the healing time.     

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).     

Neuropathic diabetic foot ulcers treated with cerium dioxide nanoparticles: A case report

Wound healing in diabetes is frequently impaired and its treatment remains a challenge. The ability of topical application of cerium (Ce) dioxide nanoparticles (CNPs) to accelerate wound healing in an animal model provides a rationale to develop this technology for use in humans affected by traumatic injury, diabetes and burns. We first described a case report of successful topical treatment of neuropathic diabetic foot ulcers with novel gel containing CNPs. The CNPs has bacteriostatic activity, anti-inflammatory properties and can penetrated into the wound tissue and reduced oxidative damage therefore protect regenerative tissue, suggesting a therapeutic potential for topical treatment of diabetic foot ulcers.     

Efficacy and Safety of Oral Anticoagulants in Patients With Atrial Fibrillation and Stages 4 or 5 Chronic Kidney Disease

PurposeThe aim of this study was to investigate whether oral anticoagulants can provide efficacy and safety profiles better than no anticoagulant in patients with stages 4 or 5 chronic kidney disease and atrial fibrillation.MethodsFrom 2001 to 2017, a cohort of patients with stages 4 or 5 chronic kidney disease and atrial fibrillation based on electronic medical records were selected from Chang Gung Memorial Hospital system in Taiwan. Patients were divided into nonvitamin K antagonist oral anticoagulants (NOACs), warfarin, and nonanticoagulated groups. They were followed from the index date to the occurrence of the study outcomes or for 5 years, whichever occurred first. The outcomes were admissions due to ischemic stroke or systemic embolism or major bleedings. Survival analyses were conducted to estimate the incidence rates of outcomes.ResultsA total of 3771 patients with atrial fibrillation and estimated glomerular filtration rate less than 30 mL/min/1.73m² were enrolled, of whom 2971 were in the nonanticoagulated group, 280 in the NOAC group, and 520 in the warfarin group. About 25% of all subjects (940 patients) were on dialysis. The mean follow-up was 3.2 years. After adjusting for sex, age, comorbidities, and comedication, the warfarin group had a significantly higher risk of ischemic stroke or systemic embolism (adjusted hazard ratio [aHR] 3.1, 95% confidence interval [CI] 2.1-4.6) than the nonanticoagulated group. The NOAC group had a similar risk of ischemic stroke or systemic embolism (aHR 1.1; 95% CI 0.3-3.4) to that of the nonanticoagulated group. Both the warfarin and the NOAC groups had a significantly higher major bleeding risk than the noncoagulated group (aHR 2.8 [95% CI 2.0-3.8] for warfarin; aHR 3.1 [95% CI 1.9-5.2] for NOAC).ConclusionThe use of NOACs or warfarin is not more effective than using no anticoagulants at all in reducing the risk of ischemic stroke or systemic embolism. Both NOACs and warfarin are associated with increased risk of major bleeding. Our results do not support the use of anticoagulants in patients with atrial fibrillation and stages 4-5 chronic kidney disease.     

Insulin infusion responses in diabetic ketoacidosis alone and with a mixed hypochloremic alkalosis

AimsAlthough diabetic ketoacidosis (DKA) commonly presents as a pure diabetic ketoacidosis (PDKA), up to 30% of cases may be associated with a mixed hypochloremic metabolic alkalosis (HMA). It is unknown whether there is a difference in treatment outcomes between these two entities. We evaluated an insulin infusion protocol (IIP), previously validated for hyperglycemia management in ICU's, for the management of PDKA and HMA.Materials and methodsA retrospective case series/cohort study of 41 DKA admissions was further characterized as having PDKA or HMA. HMA was defined in those having an elevated delta-delta gradient (ΔAG-ΔHCO3) ≥ 5 mmol/L and base excess chloride (BE_Cl) > 2.7 mmol/L. The main outcome measures were times to recovery of glucose levels to ≤250 mg/dL and of anion gap to ≤12 mmol/L.ResultsThe initial serum glucose was 553 ± 265 mg/dL, serum bicarbonate of 8.8 ± 5.1 mmol/L, and venous pH 7.13 ± 0.2). Recovery of glucose occurred in 5 h: 25 min (±3 h:39min), and for anion gap in 11 h:25 min (±6 h:56min). HMA compared with PDKA had a delayed recovery of serum glucose (7 h: 23min ± 3 h: 35min vs. 4 h: 31min ± 3:h:21min, p = 0.017), which was due to the higher initial level of glucose (p = 0.02) rather than level of BE_Cl (p = 0.17). There was no difference in time to anion gap closure between the PDKA and HMA.ConclusionsCorrection of hyperglycemia and acidosis in PDKA as well as in HMA was managed through the IIP. The simultaneous fluid and electrolyte management corrected the hypochloremic alkalosis.     

Negative pressure wound therapy in grade 1 and 2 diabetic foot ulcers: A randomized controlled study

Background and aimsFoot ulcers are one of the major causes of morbidity and mortality among diabetics in India. Early diagnosis and timely management is vital in preventing the progression of the disease which may require amputation. Conventional methods take a long time for healing. This study aims to compare negative pressure wound therapy (NPWT) and conventional saline dressings in diabetic foot ulcer (DFU) healing.MethodsThis prospective randomized study was conducted in 45 patients with grade 1 and 2 DFUs. 22 patients in group A received NPWT and 23 patients in group B received saline dressings. The formation of granulation tissue, reduction in ulcer size, duration of hospital stay and time for complete healing of wounds were assessed.ResultsThe formation of granulation tissue (91.14 vs 52.61%, p < 0.001) and reduction in ulcer size (40.78 vs 21.18%, p = 0.008) at 14 days was significantly more in group A. The duration of hospital stay (15.68 vs 29.00 days, p < 0.001) and time for 100% coverage of the wound with granulation tissue (14.82 ± 7.30 vs 44.57 ± 7.11 days, p < 0.001) was significantly less in group A. Complete healing of wounds at 3 months was observed in 20 patients (90.9%) in group A and 6 patients (26.1%) in group B (p = 0.006).ConclusionIn our study NPWT led to early reduction in ulcer size, more granulation tissue formation, shorter hospital stay and complete wound healing. In lower and middle income countries like India with high prevalence of DFUs, early recovery is a boon to the patients to resume their daily activities.     

Lifestyle factors and macro- and micro-vascular complications among people with type 2 diabetes in Saudi Arabia

AimsThe aim of this study is to identify lifestyle factors that place people with type 2 diabetes in Saudi Arabia at a greater risk of macro- and microvascular complications.MethodsA survey was conducted among adults with type 2 diabetes who attended diabetes centres in three major cities in Saudi Arabia. Participants were interviewed and their medical files were reviewed for lab test results and documented comorbidities. Associations between complication and lifestyle factors were assessed using multiple logistic regression analysis.ResultsA total of 1121 participants were recruited. Mean age was 57.6 (±11.1) years. The prevalence of coronary artery disease, diabetic foot, and stroke was 17.0%, 13.1% and 3.7%, and that of neuropathy, renal impairment, and retinopathy was 20.3%, 14.5%, and 42.8% respectively. Lifestyle factors associated with one or more of the complications were inadequate physical activity, longer sitting time, obesity, current or past smoking, passive smoking, hypertension, poor glycaemic control, low HDL and high triglycerides.ConclusionsDiabetes complications are common among people with type 2 diabetes in Saudi Arabia. Life style factors such as inadequate physical activity, longer sitting time, obesity, smoking, hypertension, and poor control of blood glucose and lipids should be assimilated into complications prevention program.