于世界糖尿病日重谈糖尿病足的诊治与预防

糖尿病足治疗困难，医疗费用高。临床处理时，首先要明确糖尿病足的主要病因因素，如神经性、缺血性或神经缺血性以及是否合并感染，并根据常用的糖尿病足Wagner分级法来判断糖尿病足的严重程度，以采取相应的治疗措施，如神经性溃疡应减轻局部压力和纠正局部的畸形，周围血管病变则采用内科治疗和介入或外科治疗，感染的局部处理和全身用药等。糖尿病足的防治必须强调多学科合作和综合治疗，预防的重点在于开展糖尿病足危险因素筛查并给予纠正。     

Family studies in Crohn's disease: new horizons in understanding disease pathogenesis, risk and prevention

Crohn's disease (CD) is an incurable intestinal disorder in which the loss of immune tolerance to the commensal gut microbiota leads to chronic inflammation. The reason this occurs in specific individuals is unclear; however, a genetic predisposition is fundamental and relatives of patients with CD are at significant risk of developing the disease. Knowledge relating to the genetic loci that predispose to CD is accumulating, which raises the possibility of disease prediction and prevention in susceptible populations. However, the genetic basis of CD is complex and genotyping alone is likely to be insufficient to predict disease risk accurately. Specific physiological abnormalities associated with CD, such as increased intestinal permeability and raised faecal calprotectin, are also abnormal in some relatives of patients with CD. The combination of genotypic factors and biomarkers of risk makes the development of models of disease prediction a realistic possibility. Furthermore, enhanced understanding of the genotype and phenotype of the at-risk state in relatives of patients with CD allows the earliest stages in the pathogenesis of CD to be investigated and may allow intervention to prevent disease onset. This article reviews current knowledge of the at-risk phenotype in relatives of patients with CD and focuses on the implications for the design of future studies.     

Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations

OBJECTIVE: To demonstrate the effectiveness of a diabetic foot disease management program in a managed care organization. METHODS: We implemented a lower extremity disease management program consisting of screening and treatment protocols for diabetic members in a managed care organization. Screening consisted of evaluation of neuropathy, peripheral vascular disease, deformities, foot pressures, and history of lower extremity pathology. We stratified patients into low and high-risk groups, and implemented preventive or acute care protocols. Utilization was tracked for 28 months and compared to 12 months of historic data prior to implementation of the disease management program. RESULTS: After we implemented the disease management program, the incidence of amputations decreased 47.4% from 12.89 per 1000 diabetics per year to 6.18 (p<0.05). The number of foot-related hospital admissions decreased 37.8% from 22.86 per 1000 members per year to 14.23 (37.8%). The average inpatient length-of-stay (LOS) was reduced 21.7% from 4.75 to 3.72 days (p<0.05). In addition, there was a 69.8% reduction in the number of skilled nursing facility (SNF) admissions per 1000 members per year (Table 1) and a 38.2% reduction in the average SNF LOS from 8.72 to 6.52 days (p<0.05). CONCLUSION: A population-based screening and treatment program for the diabetic foot can dramatically reduce hospitalizations and clinical outcomes.     

New developments in the biomechanics of the diabetic foot

Biomechanical issues are now widely recognized as being important in the treatment of diabetic foot disease. The purpose of the present review is to identify advances that have occurred since the previous International Conference on the Diabetic Foot in 1995 in the understanding of foot biomechanics in relation to diabetes. Attention continues to be focused on the identification of a threshold plantar pressure that leads to tissue damage. Recent studies have suggested that peak barefoot pressure may be only 65% specific for the development of ulceration. The association between foot deformity and plantar pressure has been the subject of several quantitative studies, but new questions have been raised about the etiology of claw toes. The measurement of shear stress continues to be an elusive goal although several small studies have presented possibly feasible technical approaches. The importance of callus as a precursor to ulceration has been confirmed experimentally and quantitative measures of motor neuropathy have been presented. Although a number of new devices have been introduced as alternatives to the Total Contact Cast, few clinical studies of their efficacy are available yet. New information on the properties of insole materials has been published including data on changes with repeated cycling. Complications of prophylactic surgery have been shown to include a high rate of Charcot fractures. Two new series describing the fixation of such fractures have also been reported. Biomechanical issues have also been addressed in two sets of guidelines for treatment that have recently been published. These many studies confirm the central role of mechanical stress and its relief in the treatment of neuropathic foot problems in diabetes.     

Endovascular management of patients with coronary artery disease and diabetic foot syndrome: A long-term follow-up

Background To investigate the long-term results of global coronary and peripheral interventional treatment of diabetic foot patients. Methods We retrospectively included 220 diabetic patients (78.5 ± 15.8 years, 107 females, all with Fontaine III or IV class) who were referred to our centre for diabetic foot syndrome and severe limb ischemia from January 2006 to December 2010. Patients were evaluated by a team of interventional cardiologists and diabetologists in order to assess presence of concomitant coronary artery disease (CAD) and eventual need for coronary revascularization. Stress-echo was performed in all patients before diagnostic peripheral angiography. Patients with indications for coronary angiography were submitted to combined diagnostic angiography and then to eventual staged peripheral and coronary interventions. Doppler ultrasonography and foot transcutaneous oximetry of transcutaneous oxygen pressure (TcPO2) before and after the procedure were performed as well as stress-echocardiography and combined cardiologic and diabetic examination at 1 and 6 month and yearly. Results Stress-echocardiography was performed in 94/220 patients and resulted positive in 56 patients who underwent combined coronary and peripheral angiography. In the rest of 126 patients, combined coronary and peripheral angiography was performed directly for concomitant signs and symptoms of coronary heart disease in 35 patients. Coronary revascularization was judged necessary in 85/129 patients and was performed percutaneously after peripheral interventions in 72 patients and surgically in 13 patients. For Diabetic foot interventions the preferred approach was ipsilateral femoral antegrade in 170/220 patients (77.7%) and contralateral cross-over in 40/220 patients (18.8%) and popliteal retrograde + femoral antegrade in 10/220 patients (4.5%). Balloon angioplasty was performed in 252 legs (32 patients had bilateral disease): the procedure was successful in 239/252 legs with an immediate success rate of 94.8% and a significant improvement in TcPO2 and ABI with ulcer healing in 233/252 legs (92.4%). Freedom from major amputation was 82.8% at a mean follow-up of 3.1 ± 1.8 years (range 1 to 5 years) whereas survival was 88%. Conclusions Global coronary and peripheral endovascular management of diabetic foot syndrome patients seems to lead to an high immediate success and limb salvage rates and increasing survival compared to historical series.     

A report from the international consensus on diagnosing and treating the infected diabetic foot

In persons with diabetes, foot infection, that is, invasion and multiplication of microorganisms in tissues accompanied by tissue destruction or a host inflammatory response, usually begins with skin trauma or ulceration 1. While most foot infections remain superficial, they can spread to subcutaneous tissues, including muscle, joints, and bone. Many diabetic foot ulcers eventuate in an amputation; infection plays a role in approximately 60% of cases 2-4. Neuropathy is the main factor leading to skin breaks, while arterial perfusion largely affects infection outcome. Among the factors predisposing diabetic patients to foot infections are ill-defined immunological perturbations 56; foot anatomy may foster proximal spread of infection and ischemic necrosis 78.     

Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update)

Diabetic foot disease results in a major global burden for patients and the health care system. The International Working Group on the Diabetic Foot (IWGDF) has been producing evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. In 2019, all IWGDF Guidelines have been updated based on systematic reviews of the literature and formulation of recommendations by multidisciplinary experts from all over the world. In this document, the IWGDF Practical Guidelines, we describe the basic principles of prevention, classification, and treatment of diabetic foot disease, based on the six IWGDF Guideline chapters. We also describe the organizational levels to successfully prevent and treat diabetic foot disease according to these principles and provide addenda to assist with foot screening. The information in these practical guidelines is aimed at the global community of health care professionals who are involved in the care of persons with diabetes. Many studies around the world support our belief that implementing these prevention and management principles is associated with a decrease in the frequency of diabetes‐related lower extremity amputations. We hope that these updated practical guidelines continue to serve as reference document to aid health care providers in reducing the global burden of diabetic foot disease.     

New horizons in the medical treatment of gastro-oesophageal reflux disease

Proton pump inhibitors (PPIs) have revolutionized the treatment of gastro-oesophageal reflux disease (GERD). However, nearly 30% of all GERD patients are still symptomatic despite standard dose PPI treatment. Consequently, better treatment options are needed particularly in nonerosive reflux disease (NERD), which provides the largest number of patients that fail PPI. Transient lower esophageal relaxation (TLESR) is the underlying mechanism for most acid reflux events. Therefore, reducing the rate of TLESRs pharmacologically is an attractive therapeutic approach. Some compounds that were evaluated include: anticholinergics, opioids, cholecystokinin antagonists, nitric oxide antagonists, somatostatin, and GABA-B agonists. Currently, the GABA-B agonist baclofen generated the most promising results. Although data regarding GERD is lacking, visceral pain modulation, either pharmacologically or via mind-body interventions, was found to be efficacious in a variety of functional bowel disorders, including functional chest pain of presumed esophageal origin. Finally, intensive research is currently undergoing to develop newer acid suppressive agents. The acid pump inhibitors are reversible competitive inhibitors of the proton pump. These agents are potent suppressors of gastric acid secretion, and their effect is unrelated to food intake. Moreover, they demonstrate a faster onset of action and a predictable dose response effect as compared to the current PPIs. Although some of the preliminary clinical data is promising, thus far none of these agents is commercially available.     

The Diabetes Initiative of South Carolina and the 18th Annual Diabetes Fall Symposium for Health Care Professionals

The Diabetes Initiative of South Carolina (DSC) is charged with the development of guidelines for the management of diabetes and supporting adherence to evidence-based standards for education and care. The DSC is committed to lowering the burden of diabetes in the state through translation of evidence-based standards of clinical practice, and patient and community education centered on blood glucose control, blood pressure control, healthy eating, physical activity, and foot care. The DSC has developed many programs for the education of a variety of health professionals about diabetes and its complications. DSC has sponsored 18^th Annual Diabetes Fall Symposia for primary health care professionals featuring education on all aspects of diabetes mellitus. The intent of the program is to enhance the lifelong learning process of physicians, nurses, pharmacists, dietitians and other health care professionals by providing educational opportunities and to advance the quality and safety of patient care.     

Diagnosis and assessment of peripheral arterial disease in the diabetic foot

Approximately half of all patients with a diabetic foot ulcer have co‐existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.     

Expert opinion on the management of infections in the diabetic foot

This update of the International Working Group on the Diabetic Foot incorporates some information from a related review of diabetic foot osteomyelitis (DFO) and a systematic review of the management of infection of the diabetic foot. The pathophysiology of these infections is now well understood, and there is a validated system for classifying the severity of infections based on their clinical findings. Diagnosing osteomyelitis remains difficult, but several recent publications have clarified the role of clinical, laboratory and imaging tests. Magnetic resonance imaging has emerged as the most accurate means of diagnosing bone infection, but bone biopsy for culture and histopathology remains the criterion standard. Determining the organisms responsible for a diabetic foot infection via culture of appropriately collected tissue specimens enables clinicians to make optimal antibiotic choices based on culture and sensitivity results. In addition to culture-directed antibiotic therapy, most infections require some surgical intervention, ranging from minor debridement to major resection, amputation or revascularization. Clinicians must also provide proper wound care to ensure healing of the wound. Various adjunctive therapies may benefit some patients, but the data supporting them are weak. If properly treated, most diabetic foot infections can be cured. Providers practising in developing countries, and their patients, face especially challenging situations.     

The advantages and disadvantages of non-surgical management of the diabetic foot

It is frequently stated that diabetic foot ulcers should be managed by a multidisciplinary team, comprising individuals who can deliver all the necessary and wide-ranging skills: medical and surgical, podiatric, nursing and orthotic. Whilst there are some data to support this multidisciplinary approach there is little to guide us in ensuring the patient is seen by the right professional for the right treatment at the right time. This article will examine the evidence supporting the most effective use of the multidisciplinary team. It will look at medical managements of ulcers including dressings, offloading and the treatment of infection, either cellulitis or osteomyelitis. By contrast, the role of surgery in offloading, and the treatment of osteomyelitis will be examined, as well as the role of vascular surgery. The most important aspect of management choice, however, is the need to focus on the needs of the person with a diabetic foot ulcer rather than simply on the treatment of the ulcer in isolation. Other complications of diabetes, which may have an effect on wound healing such as glycaemic control, renal failure and visual disturbance will be explored.Finally, there will be discussion of the relevance of outcome measure, both of ulcers as well as those more patient-centred. The ways in which these can be used to monitor individual clinical responses to treatment will be described, as well as their potential use as an aid to comparison of the effectiveness of treatment protocols adopted in different centres.