The Association between Cognitive Impairment and Diabetic Foot Care: Role of Neuropathy and Glycated Hemoglobin

Diabetes mellitus is associated with impairment in cognitive functions which can complicate adherence to self-care behaviors. We evaluated the incidence of cognitive impairment in patients with diabetes mellitus to determine the strength of the association between diabetic foot (a complication that occurs in about 10% of diabetic patients), adherence to the clinician’s recommendations, glycemic control, and cognitive function. A prospective study was carried out in a probabilistic sample of older patients with diabetic foot living in three nursing homes. Cognitive functions were evaluated by the MMSE (Mini-Mental State Examination), the Trail Making test (TMT), and the Michigan neuropathy screening instrument (MNSI). There were no significant associations between cognitive function and neuropathy or foot alterations, although glycated hemoglobin (HB1Ac > 7%) significantly (p < 0.05) associated with MMSE and adherence to treatment in the 1 month follow-up visit. Receiver operating characteristic curve analysis showed that both HB1Ac and the MNSI score significantly (p < 0.05) discriminate subsequent adherence to treatment for foot complication, with a sensitivity of 80.0–73.3% and specificity 70.6–64.7%, respectively. Proper control of foot complications in diabetic patients involves appropriate glycemic control and less severe neuropathy, and seems to be unrelated to cognitive dysfunction, and warrants further studies in order to tailor appropriate treatments to central and peripheral nervous system disorders. Poor glycemic control (Hb1Ac level > 7%) and a neuropathy score of 5.5 in the MNSI are the best-cut off points to discriminate poor adherence to the clinician’s recommendations for self-care behaviors in people with diabetic foot complication. In this study, we observed that foot disorders were associated with impaired global cognitive function in elderly patients (aged ≥ 65). Podiatrists and physicians should consider cognitive dysfunction as an important chronic complication in the management of diabetic foot.     

Frequency of daytime tooth clenching episodes in individuals affected by masticatory muscle pain and pain-free controls during standardized ability tasks

Objectives

Tooth clenching has been suggested to be related to temporomandibular pain. However, the electromyographic characteristics of daytime clenching episodes have been minimally investigated. This study aimed to analyze the frequency, amplitude, and duration of daytime clenching episodes in patients with masticatory muscle pain and pain-free individuals.

Methods

Fifteen women with masticatory muscles myalgia (MP group, mean ± SD age = 26.4 ± 7.6 years) matched for age to 18 pain-free women (CTR group, mean ± SD age = 25.3 ± 2.8 years) were submitted to three different ability tasks (filling out questionnaires for 40 min, reading for 20 min, and playing a videogame for 20 min). The electromyographic activity periods (AP) of the right masseter greater than 10 % (AP10), 20 % (AP20), and 30 % (AP30) of the maximum voluntary contraction were analyzed.

Results

The mean frequencies of AP10, AP20, and AP30 were greater in MP than in CTR individuals (all p < 0.05). The mean duration of AP10 was higher in MP group than CTR group only while filling out the questionnaires (p = 0.0033). CTR group had an increased frequency and duration of AP10 while playing the videogame than while reading a magazine. The ability tasks did not affect the muscle activity in the MP group.

Conclusions

Individuals with masticatory muscle pain have an increased frequency of both high and low-intense daytime clenching episodes. The type of ability task affects the frequency and the duration of clenching episodes only in pain-free individuals.

Clinical relevance

Clinicians should recognize that the frequency and intensity of daytime clenching are noticeably increased in individuals with masticatory muscle pain in order to better tailor treatment.

     

Microvascular Dysfunction, Myocardial Ischemia, and Progression to Heart Failure in Patients with Hypertrophic Cardiomyopathy

Microvascular dysfunction can be demonstrated in most patients with hypertrophic cardiomyopathy (HCM), both in the hypertrophied and nonhypertrophied myocardial walls, mostly due to intimal and medial hyperplasia of the intramural coronary arteries and subsequent lumen reduction. As a consequence, regional myocardial ischemia may be triggered by exercise, increased heart rate, or arrhythmias, in areas which are unable to increase myocardial blood flow. In patients with HCM, microvascular dysfunction leading to severe myocardial hypoperfusion during maximal hyperemia represents a strong predictor of unfavorable outcome, left ventricular remodeling with progressive wall thinning, left ventricular dysfunction, and heart failure. Accurate quantitative assessment of microvascular dysfunction and myocardial ischemia is not easily feasible in clinical practice. Although signs of inducible myocardial ischemia may be detected by electrocardiogram, echocardiography, or myocardial scintigraphy, the vasodilator response to dipyridamole by positron emission tomography is considered the method of choice for the assessment of maximal regional and global flow. Cardiac magnetic resonance provides further information, by late gadolinium enhancement (LGE), which may show areas where replacement fibrosis has occurred following microvascular ischemia and focal necrosis. LGE areas colocalize with severe regional microvascular dysfunction, are associated with increased prevalence of ventricular arrhythmias, and show more extensive distribution in the late stages of the disease, when heart failure is the dominant feature. The present review aims to provide a concise overview of the available evidence of microvascular dysfunction and ischemia eventually leading to disease progression and heart failure in HCM patients.     

Down-regulation of nitric oxide synthase-2 and cyclooxygenase-2 pathways by p53 in squamous cell carcinoma

The goal of this study was to analyze the correlation between inducible nitric oxide synthase (iNOS) and COX-2 activities and p53 gene status in head and neck squamous cell carcinomas (HNSCCs) in vivo and in vitro. In a series of 43 HNSCCs we observed an up-regulation of both iNOS and COX-2 pathways in tumor tissues and both activities were correlated each other (rs = 0.612 and P = 0.0002). We also found that p53-mutated HNSCCs (25 cases, 58.1%) showed higher levels of iNOS activity and cGMP in comparison with wild-type p53 tumors (18 cases, 41.9%) (P = 0.0005 and P = 0.01), as well as higher iNOS immunohistochemical expression (P = 0.03). Analogously, higher PgE2 levels were documented in p53-mutated HNSCCs when compared with wild-type p53 tumors (P = 0.015) and COX-2 protein expression was higher in p53-mutated HNSCCs (P = 0.007). A431 cancer cells expressing a p53 temperature-sensitive mutant showed an approximately 1.9- and 2.6-fold decrease in spontaneous NO(2-)/NO(3-) and PgE2 synthesis at permissive temperature, respectively, when compared with the same cells at nonpermissive temperature (P 相似文献   

Inducible nitric oxide synthase expression in human colorectal cancer: correlation with tumor angiogenesis

To investigate the potential involvement of the nitric oxide (NO) pathway in colorectal carcinogenesis, we correlated the expression and the activity of inducible nitric oxide synthase (iNOS) with the degree of tumor angiogenesis in human colorectal cancer. Tumor samples and adjacent normal mucosa were obtained from 46 surgical specimens. Immunohistochemical expression of iNOS, vascular endothelial growth factor (VEGF), and CD31 was analyzed on paraffin-embedded tissue sections. iNOS activity and cyclic GMP levels were assessed by specific biochemical assays. iNOS protein expression was determined by Western blot analysis. iNOS and VEGF mRNA levels were evaluated using Northern blot analysis. Both iNOS and VEGF expressions correlated significantly with intratumor microvessel density (r(s) = 0.31, P = 0.02 and r(s) = 0.67, P < 0.0001, respectively). A significant correlation was also found between iNOS and VEGF expression (P = 0.001). iNOS activity and cyclic GMP production were significantly higher in the cancer specimens than in the normal mucosa (P < 0.0001 and P < 0.0001, respectively), as well as in metastatic tumors than in nonmetastatic ones (P = 0.002 and P = 0.04, respectively). Western and Northern blot analyses confirmed the up-regulation of the iNOS protein and gene in the tumor specimens as compared with normal mucosa. NO seems to play a role in colorectal cancer growth by promoting tumor angiogenesis.     

Degree of Mineralization at the Attachment of Lateral Pterygoid

The degree of mineralization of bone (DMB) in the human mandibular condyle is heterogeneous, and differences in DMB have been related to variations in bone turnover caused by local strains. The lateral pterygoid muscle inserts at the anterior surface of the condyle. The aim of this study is to analyze the DMB at the attachment of this muscle as compared with a control region. It was hypothesized that, DMB at the attachment sites of lateral pterygoid muscles was lower than at the control regions, because of the larger number of loadings and subsequently higher remodeling rates. Also, as the human lateral pterygoid muscle is heterogeneous in its internal architecture, variations in DMB within the attachment sites were expected. 10 human mandibular condyles were scanned in a micro CT system. Within each condyle, two regions, that is, the pterygoid fovea and a posterior (control) region where no muscle was inserted, were selected to analyze regional differences in DMB. The attachment site was further divided into eight subregions to analyze subregional differences. At the pterygoid fovea the DMB of cortical bone was significantly lower than at the control region (p = 0.003) and increased in medio‐lateral direction. The results of this study could suggest an influence of the lateral pterygoid muscle on bone turnover at this site. Anat Rec 293:1387–1392, 2010. © 2010 Wiley‐Liss, Inc.     

High rate of endometriosis recurrence in young women

Objective

To evaluate rate and determinants of long-term recurrence of endometriosis in a population of young women.

Design

Retrospective cohort study.

Setting

University tertiary care referral center for women with benign gynecologic diseases.

Participants

Young women undergoing first-line conservative surgery for endometriosis were eligible for the study. Data on age at surgery, disease stage, anatomical characteristics of endometriotic lesions, and endometriosis-related symptoms were collected. After diagnosis, patients were treated according to the standard care of the center. The protocol required all women to be followed up 1 month after surgery, and every 6 months afterward, with an interview to investigate persistence of symptoms, a clinical examination, and an ultrasound pelvic assessment.

Results

Fifty-seven women aged ≤ 21 (mean age at diagnosis ± SD: 19.0 ± 1.1 years) entered the study. During a 5-year follow-up, 32 (56%, 95% confidence interval [CI]: 43%-68%) recurrences of endometriosis were diagnosed. A second laparoscopy to treat the recurrence was performed in 11 (34%) cases and confirmed the presence of the disease in all of them. In the remaining 21 (66%) cases, the recurrence was based on the reappearance of the symptoms or clinical or sonographic findings. The recurrence rate increased constantly with time from first surgery. No association emerged between recurrence rate and endometriosis-related symptoms, site/stage of the disease, type of surgery, and post-surgical medical treatment.

Conclusions

The recurrence rate of endometriosis in young women appears higher than in older women. Since no determinants for recurrence have been detected among the factors examined, a profile of women at increased risk cannot be drawn.