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

Clinical physiology: the crucial role of MRI in evaluation of peripheral artery disease

Peripheral artery disease (PAD) is a common vascular disease that primarily affects the lower limbs and is defined by the constriction or blockage of peripheral arteries and may involve microvascular dysfunction and tissue injury. Patients with diabetes have more prominent disease of microcirculation and develop peripheral neuropathy, autonomic dysfunction, and medial vascular calcification. Early and accurate diagnosis of PAD and disease characterization are essential for personalized management and therapy planning. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and multiplanar imaging capabilities and is useful as a noninvasive imaging tool in the comprehensive physiological assessment of PAD. This review provides an overview of the current state of the art of MRI in the evaluation and characterization of PAD, including an analysis of the many applicable MR imaging techniques, describing the advantages and disadvantages of each approach. We also present recent developments, future clinical applications, and future MRI directions in assessing PAD. The development of new MR imaging technologies and applications in preclinical models with translation to clinical research holds considerable potential for improving the understanding of the pathophysiology of PAD and clinical applications for improving diagnostic precision, risk stratification, and treatment outcomes in patients with PAD.

The ankle-brachial index for assessing the prevalence of peripheral artery disease and cardiovascular risk in patients with type 2 diabetes mellitus

BACKGROUND AND AIMS

Type 2 diabetes mellitus (T2DM) is an important risk factor for peripheral artery disease (PAD). Ankle-Brachial Index (ABI) was found associated with a higher cardiovascular (CV) risk and mortality. The main goals of this study were to establish the prevalence of PAD in a T2DM population, and assess the relationship between PAD and the CV risk calculated with the CUORE Project score (CPS) (https://www.cuore.iss.it/). The association between the ABI, the main risk factors for PAD and T2DM complications was also investigated.

METHODS AND RESULTS

Two hundred patients were consecutively enrolled. The prevalence of PAD in this population was 17%. The CV risk tended to be higher (p = 0.0712) in the group with a pathological ABI than in the group with a normal ABI. Glycated hemoglobin (r = -0.1591; p = 0.0244), total cholesterol (r = -0.1958; p = 0.0054), LDL cholesterol (r = -0.1708; p = 0.0156) and systolic blood pressure (r = -0.1523; p = 0.0313) correlated significantly and inversely with the left ABI. The frequency of diabetic retinopathy was significantly higher in the group with a pathological ABI (p = 0.0316).

CONCLUSIONS

The data reveal a high prevalence of PAD in patients with T2DM. The CPS confirmed that patients with a pathological ABI have tendency to a higher CV risk. The results point to the importance of an accurate CV assessment - also measuring individuals' ABI and calculating their CPS - to better pinpoint those at high risk of PAD, especially among patients with T2DM.

Peripheral Arterial Diseases and Diabetes Mellitus: Associations With Quality of Health Measures in Patients Undergoing Percutaneous Vascular Interventions

BACKGROUND

Peripheral arterial disease (PAD) is more prevalent and severe in patients with diabetes mellitus (DM) compared with those without DM. Peripheral vascular intervention (PVI) is often used in patients failing conservative management. The association of PVI with health status in diabetic patients has yet to be determined.

METHODS

We analyzed the clinical response to PVI in DM (n = 203, 52 %) compared with non-DM patients (n = 183, 48 %), using the Peripheral Arterial Questionnaire (PAQ) for patients during baseline and a maximum 6 months after PVI. We used the PAQ summary score, which summarized the patients' level of physical and social function, patient symptoms, and overall quality of life. This represented the PAD-related Quality of Health (QOH). Our score range is between 0 (lowest health quality) and 100 (highest health quality).

RESULTS

Compared with non-DM patients, those with DM were more likely to have a history of prior PVI, an increased prevalence of PAD risk factors, and significantly lower QOH scores at baseline (32.7 ± 20 vs 37.5 ± 20.6, p = 0.02). After adjustment for baseline confounding, neither the baseline, the change, nor the final summary scores were significantly different between groups, suggesting similar symptomatic and functional improvement in non-DM and DM patients post-PVI.

CONCLUSIONS

Following PVI, PAD-specific health status showed a similar improvement in patients with and without DM, illustrating that use of this strategy among patients with multiple comorbidities or diffuse PAD as useful.

The association between time in the glucose target range and abnormal ankle-brachial index: a cross-sectional analysis

BACKGROUND

Time in range (TIR), a novel proxy measure of glucose control, is found closely related to diabetic microangiopathy and some other chronic complications, but the correlation between TIR and lower limb angiopathy has not been studied yet. Our purpose is to explore the relationship between TIR and abnormal ankle-brachial index(ABI) in type 2 diabetes.

METHODS

We retrospectively collected patients' information from the database and performed cross-sectional analysis. A total of 405 type 2 diabetes patients were enrolled in this study. ABI was measured and patients were stratified into low, normal, and high groups according to ≤ 0.9, > 0.9 and < 1.3, ≥ 1.3 ABI values. All patients underwent continuous glucose monitoring(CGM), and TIR was defined as the percentage of time in which glucose was in the range of 3.9-10 mmol/L during a 24-h period. Correlations between TIR and abnormal ABI were analyzed using Spearman analysis. And logistic regression was used to explore whether TIR is an independent risk factor for abnormal ABI.

RESULTS

The overall prevalence of abnormal ABI was 20.2% (low 4.9% and high 15.3%). TIR was lower in patients with abnormal ABI values (P = 0.009). The prevalence of abnormal ABI decreased with increasing quartiles of TIR (P = 0.026). Abnormal ABI was negatively correlated with TIR and positively correlated with hypertension, age, diabetes duration, UREA, Scr, ACR, TAR, MBG, and M values (P < 0.05). The logistic regression revealed a significant association between TIR and abnormal ABI, while HbA1C and blood glucose variability measures had no explicit correlation with abnormal ABI. Additionally, there was a significant difference in LDL between the low and high ABI groups (P = 0.009), and in Scr between normal and low groups (P = 0.007). And there were significant differences in TIR (P = 0.003), age (P = 0.023), UREA (P = 0.006), ACR (P = 0.004), TAR (P = 0.015), and MBG (P = 0.014) between normal and high ABI groups, and in diabetes duration between both normal and low (P = 0.023) and normal and high (P = 0.006) groups.

CONCLUSIONS

In type 2 diabetes patients, abnormal ABI is associated with lower TIR, and the correlation is stronger than that with HbA1C. Therefore, the role of TIR should be emphasized in the evaluation of lower limb vascular diseases.

Peripheral arterial disease progression and ankle brachial index: a cohort study with newly diagnosed patients with type 2 diabetes

BACKGROUND

Little is known about the evolution of peripheral arterial disease (PAD) since diagnosis and its association with glycemic and lipid control in patients with Type 2 Diabetes Mellitus (T2DM).

OBJECTIVE

Evaluate the actual criteria to start screening PAD with ankle-brachial index (ABI) in T2DM patients and assess its progression and relationship with glycemic and lipid control since diagnosis.

METHODS

We performed a 3-year prospective cohort study with two groups: group 1 (978 individuals with T2DM undergoing drug treatment) and group 2 [221 newly diagnosed drug-naive (< 3 months) patients with T2DM]. PAD diagnosis was by ABI ≤ 0.90, regardless any symptoms.

RESULTS

As expected, abnormal ABI prevalence was higher in group 1 vs. Group 2 (87% vs. 60%, p < 0.001). However, abnormal ABI prevalence did not differ between patients over and under 50 years in both groups. Our drug-naive group stabilizes ABI (0.9 ± 0.1 vs 0.9 ± 0.1, p = NS) and improved glycemic and lipid control during follow-up [glycated hemoglobin (HbA1c) = 8.9 ± 2.1 vs 8.4 ± 2.3%, p < 0.05; LDL = 132 ± 45 vs 113 ± 38 mg/dL, p < 0.01, respectively]. When compared, patients who evolved with normalization or maintained normal ABI levels at the end [Group A, N = 60 (42%)] with those who decreased ABI to abnormal levels (ABI basal 1.0 ± 0.1 vs final 0.85 ± 0.1, p < 0.001) [Group B, N = 26 (18%)], an improvement in HbA1c (9 ± 2 vs 8 ± 2%, p < 0.05) and a correlation between the final HbA1c with ABI (r = - 0.3, p = 0.01) was found only in the first. In addition, a correlation was found between albuminuria variation and ABI solely in group A (r = - 0.3; p < 0.05).

CONCLUSION

Our study suggests that ABI should be measured at diagnosis in T2DM patients, indicating that current criteria to select patients to screen PAD with ABI must be simplified. An improvement in albuminuria and glycemic and lipid control could be related with ABI normalization in newly diagnosed T2DM drug-naive patients.

Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers

The study aims to evaluate the effectiveness of foot revascularization in persons with diabetic foot ulcers (DFUs) and below-the-ankle (BTA) arterial disease. Consecutive patients referred for a new active ischaemic DFU requiring lower limb revascularization were considered. Among those, only patients with a BTA arterial disease were included. Revascularization procedures were retrospectively analysed: in the case of successful foot revascularization (recanalization of pedal artery, or plantar arteries or both) or not, patients were respectively divided in two groups, successful foot perfusion (SFP) and failed foot perfusion (FFP). Healing, minor and major amputation at 12 months of follow-up were evaluated and compared. Eighty patients (80) were included. The mean age was 70.5 ± 10.9 years, 55 (68.7%) were male, 72 (90%) were affected by type 2 diabetes with a mean duration of 22.7 ± 11.3 years. Overall 45 (56.2%) patients healed, 47 (58.7%) had minor amputation and 13 (16.2%) major amputation. Outcomes for SFP and FFP were respectively: healing (89.3 vs. 9.1%, p < 0.0001), minor amputation (44.7 vs. 78.8%, p = 0.0001), major amputation (2.1 vs. 36.3%, p < 0.0001). Failed foot revascularization resulted an independent predictor of non-healing, minor amputation, and major amputation. Foot revascularization is mandatory to achieve healing and avoid major amputation in persons with ischaemic DFU and BTA arterial disease.

Predictive value of abnormal ankle-brachial index in patients with diabetes: A meta-analysis

AIMS

This meta-analysis aimed to examine the association of abnormal ankle brachial index (ABI) with adverse prognosis in patients with diabetes.

METHODS

We systematically searched PubMed and Embase databases from inception to October 31, 2020 for observational studies investigating the predictive utility of abnormal ABI in patients with diabetes. The normal ABI is usually defined by 0.9-1.3 or 1.4.

RESULTS

Data were collected from 9 studies involving 9673 patients. When compared with the reference normal ABI, abnormal ABI was associated with a higher risk of cardiovascular mortality (risk ratio [RR] 1.98; 95% confidence intervals [CI] 1.66-2.37), all-cause mortality (RR 2.12; 95% CI 1.81-2.49), and major adverse cardiovascular events ([MACEs] RR 2.37; 95% CI 1.73-3.26). Subgroup analysis indicated that the pooled RR of cardiovascular mortality was similar in individuals with abnormally low ABI (RR 1.98; 95% CI 1.64-2.39) or high ABI (RR 2.00; 95% CI 1.12-3.59).

CONCLUSIONS

Abnormal ABI independently predicts subsequent risk of cardiovascular or all-cause mortality and MACEs in patients with diabetes. However, the predictive role of abnormal ABI is largely dominated by the low ABI rather than the high ABI.

Effects of Intermittent Calf Muscle Electrical Stimulation on Walking Capacity in Claudicants Living with Type 2 Diabetes

BACKGROUND

First-line therapy for diabetic patients presenting with intermittent claudication includes supervised exercise programs to improve walking distance. However, exercise comes with a variety of barriers and may be contraindicated in certain conditions. The aim of this study was to evaluate whether calf muscle electrostimulation improves claudication distance.

METHODS

A prospective, one-group, pretest-posttest study design was used on 40 participants living with type 2 diabetes mellitus, peripheral artery disease (ankle brachial pressure index, <0.90), and calf muscle claudication. Calf muscle electrostimulation of varying frequencies (1-250 Hz) was prescribed on both limbs for 1-hour daily sessions for 12 consecutive weeks. The absolute claudication distance (ACD) was measured at baseline and after the intervention.

RESULTS

The recruited cohort (30 men and ten women; mean age, 71 years; mean ankle brachial pressure index, 0.70) registered a mean ± SD baseline ACD of 333.71 ± 208 m. After a mean ± SD of 91.68 ± 6.23 days of electrical stimulation, a significant mean ± SD increase of 137 ± 136 m in the ACD (P = .001, Wilcoxon signed rank test) was registered. Improvement was found to be sex independent, but age was negatively correlated with proportion of improvement (r = -0.361; P = .011, Pearson correlation test).

CONCLUSIONS

Electrical stimulation of varying frequencies on ischemic calf muscles significantly increased the maximal walking capacity in claudicants with type 2 diabetes. This therapeutic approach should be considered in patients with impaired exercise tolerance or as an adjunct treatment modality.

Below-the-ankle arterial disease severely impairs the outcomes of diabetic patients with ischemic foot ulcers

AIM

To evaluate the impact of below-the-ankle (BTA) arterial disease in people with ischemic diabetic foot ulcers (DFUs).

METHODS

Patients with ischemic DFUs treated by a pre-set limb salvage protocol including peripheral revascularization were included. They were divided in two groups according to the involvement of BTA arteries (BTA+) or not (BTA-). Not healing, minor amputation, major amputation and mortality have been evaluated as primary outcome. Revascularization failure has been evaluated as secondary outcome.

RESULTS

The study group was composed of 272 patients, 120 (44.1%) belonging to BTA+ group and 152 (55.9%) to BTA-. After 1 year of follow-up the outcomes for BTA+ and BTA- were respectively: not healing (40.8 vs 17.8%, p < 0.0001), minor amputation (80.8 vs 20.4%, p < 0.0001), major amputation (18.3 vs 6.6%, p = 0.002), mortality (16.7% vs 10.5%, p = 0.001). The rate of revascularization failure was respectively 38.3 vs 11.2%, p < 0.0001. At the multivariate analysis BTA arterial disease resulted an independent predictor of not healing [OR 3.5 (CI 95% 2.3-6.1) p = 0.0001], minor amputation [OR 3.1 (1.5-5.9) p < 0.0001] and revascularization failure [OR 3.5 (1.9-6.3) p = 0.0001]. BTA+ patients with successful BTA revascularization showed lower rate of not healing (37.8 vs 89.1%) p < 0.0001, minor amputation (74.3 vs 91.3%) p = 0.002 and major amputation (8.1 vs 34.8%) p = 0.0003 in comparison to patients with unsuccessful BTA revascularization.

CONCLUSION

BTA arterial disease severely impairs the outcomes of diabetics with ischemic foot ulcers. BTA revascularization reduces the rate of not healing, minor and major amputation.

Recurrence of Critical Limb Ischemia After Endovascular Intervention in Patients with Diabetic Foot Ulcers

Objective: To establish the rate of clinical recurrence of critical limb ischemia (CLI) in diabetic patients with ischemic foot ulcers (DFUs) treated by percutaneous transluminal angioplasty (PTA). Approach: The study group was composed of 304 patients with ischemic DFUs treated by PTA. We evaluated the rate of clinical recurrence of CLI requiring a second PTA (repeated PTA [rePTA]), the factors related to CLI relapse, and the outcomes of rePTA patients. The follow-up was 12.5 ± 6.6 months. Results: Seventy-four of 304 patients (24.3%) needed rePTA. The mean time to rePTA was 3.5 ± 0.64 months. rePTA group in comparison with no rePTA group had lower rate of healing (28.5% vs. 71.9% p = 0.0001), higher rate of ulcer recurrence (20% vs. 10.3% p = 0.03), major amputation (24.3% vs. 4.3% p = 0.0005), and death (33.3% vs. 7.9% p = 0.002). Glycated hemoglobin, type A1C (HbA1c; 2.2 [1.9-2.7] p = 0.02) and dialysis (1.5 [1.4-3.6] p = 0.006) were independently associated to clinical recurrence of CLI after PTA. Innovation: To identify the outcomes of patients with clinical recurrence of CLI and the clinical factors involved to reduce the rate of restenosis after endovascular treatment and improve the rate of limb salvage. Conclusions: Clinical recurrence of CLI is associated with a high rate of nonhealing ulcer recurrence, major amputation, and death. Dialysis and impaired glycemic control were independent predictors of CLI relapse after endovascular treatment.

Diabetic foot management: multidisciplinary approach for advanced lesion rescue

The diabetic foot is a complication of diabetes affecting 15% of diabetics in their lives. It is associated to diabetic neuropathy and peripheral vascular disease and its incidence has increased. The ulceration is the initial cause of a dramatic process leading, if not correctly treated, to amputations. Both neuropathy, neuro-ischemia and infections have a role in determining healing or worsening of the lesions and 85% of all amputations in diabetic patients are preceded by a foot ulceration deteriorating to a severe gangrene or infection. The different causative agents and the different clinical presentations of diabetic foot ask a multidisciplinary approach in order to address treatments to the final goals, the prevention of the amputations and the maintenance of a functional foot able with weight-bearing ability. Many professional figures, diabetologists, surgeons (both general and vascular and orthopedics), interventional radiologists, infectious diseases specialists, specialized nurses, podiatrists, orthotic technicians, are called to apply their knowledges to the diabetic patients affected by diabetic foot in a virtuous circle leading to reach the goals, with the imperative action of the multidisciplinary team. The so organized center will allow both a correct and rapid diagnosis, the use in ambulatorial environments of modern tools, or the hospitalization in multitasking wards, in which all the complications and the necessary treatments are possible, both in emergencies or in elective way, considering both revascularizations and surgery.

Augmented Contractility to Noradrenaline in Femoral Arteries from the Otsuka Long-Evans Tokushima Fatty Rat, a Model of Type 2 Diabetes

Although vasculopathies may occur systemically, there are few reports regarding femoral arteries of type 2 diabetes. Here, we investigated whether contractile response to noradrenaline in femoral arteries would change in type 2 diabetic male Otsuka Long-Evans Tokushima Fatty (OLETF) rat at the chronic stage of disease (1 year old) versus age-matched control Long-Evans Tokushima Otsuka (LETO) rat. OLETF rat exhibited hyperglycemia, hypertension, hyperlipidemia, and hypoinsulinemia compared to age-matched LETO rat. Noradrenaline-induced contraction was increased in femoral arteries in OLETF rats compared with LETO rats whereas serotonin- or phenylephrine-induced contractions were similar between these two animals. Acetylcholine- and sodium nitroprusside-induced relaxations were similar between the two groups. Very small relaxations in femoral arteries induced by clonidine and isoprenaline were obtained in LETO but not OLETF group. Noradrenaline-induced contraction was enhanced by treatment with N^G-nitro-L-arginine (L-NNA), a nitric oxide synthase (NOS) inhibitor, and the between-group difference of contraction was eliminated by such treatment. Indomethacin, a non-selective cyclooxygenase (COX) inhibitor, reduced noradrenaline-induced contraction in both groups, whereas the contraction was greater in OLETF group versus LETO. Femoral arterial protein expression of endothelial NOS, COX-1, and superoxide dismutases were similar between the two groups, whereas reduction of COX-2 expression was seen in OLETF group compared with LETO. Increased contractile responsiveness to noradrenaline is seen in OLETF rat femoral artery and this may be due to reduction of suppressive effect of NO.

Pathophysiology of peripheral arterial disease in diabetes mellitus

Peripheral arterial disease (PAD) increases the risk of lower extremity amputation. It is also an independent predictor of cardiovascular and cerebrovascular ischemic events, affecting both the quality and expectancy of life. Many studies have demonstrated that the prevalence of PAD in patients with diabetes mellitus (DM) is higher than in non-diabetic patients. In diabetic patients, PAD occurs early with rapid progression, and is frequently asymptomatic. Multiple metabolic aberrations in DM, such as advanced glycation end-products, low-density lipoprotein cholesterol, and abnormal oxidative stress, have been shown to worsen PAD. However, the role of DM in PAD is not completely understood. The purpose of the present article is to review and discuss the pathophysiology of PAD in DM.

A Critical Evaluation of Existing Diabetic Foot Screening Guidelines

AIM

To evaluate critically the current guidelines for foot screening in patients with diabetes, and to examine their relevance in terms of advancement in clinical practice, improvement in technology, and change in socio-cultural structure.

METHODS

A structured literature search was conducted in Pubmed/Medline, CINAHL, Cochrane Register of Controlled Trials, and Google between January 2011 and January 2015 using the keywords '(Diabetes) AND (Foot Screening) AND (Guidelines)'.

RESULTS

Ten complete diabetes foot screening guidelines were identified and selected for analysis. Six of them included the full-process guidelines recommended by the International Diabetes Federation. Evaluation of the existing diabetes foot screening guidelines showed substantial variability in terms of different evidence-based methods and grading systems to achieve targets, making it difficult to compare the guidelines. In some of the guidelines, it is unclear how the authors have derived the recommendations, i.e. on which study results they are based, making it difficult for the users to understand them.

CONCLUSIONS

Limitations of currently available guidelines and lack of evidence on which the guidelines are based are responsible for the current gaps between guidelines, standard clinical practice, and development of complications. For the development of standard recommendations and everyday clinical practice, it will be necessary to pay more attention to both the limitations of guidelines and the underlying evidence.

Pulse-wave velocity, the ankle-brachial index, and the visceral fat area are highly associated with colorectal adenoma

BACKGROUND

Although both colorectal neoplasms and atherosclerosis may be induced by visceral fat accumulation, no association between these factors has yet been elucidated.

METHODS

Among Japanese participants in our colonoscopic screening and annual surveillance programs, asymptomatic subjects were investigated. Visceral fat area was measured by computed tomography, and the ankle-brachial index and pulse-wave velocity (markers of systemic atherosclerosis) were also estimated. Colorectal findings during screening were investigated in association with these parameters.

RESULTS

Nine hundred and seven subjects (males: 71.9%; mean age: 57.3±8.7 years) were enrolled. Colorectal adenomas were identified during colorectal screening of 407 subjects (44.9%). The prevalence of all colorectal adenoma and advanced neoplasia increased with an elevated pulse-wave velocity from 32.2% (advanced neoplasia, 2.6) to 62.1% (8.4%) in higher quartiles (p<0.001 and p=0.003). The risk of advanced neoplasia was higher in subjects with an abnormal ankle-brachial index (33% vs. 4.6%, p<0.001). Upon multivariate analysis, visceral fat area and pulse-wave velocity were associated with all adenoma, and the ankle-brachial index with advanced neoplasia.

CONCLUSIONS

The risk of colorectal adenoma was strongly associated with visceral fat area and markers of atherosclerosis. Colorectal adenoma and atherosclerosis may share a common pathogenesis and the same populations are at high-risk.

Sulodexide as Adjunctive Therapy in Diabetic Foot Patients With Critical Limb Ischemia Treated With Percutaneous Transluminal Angioplasty

We evaluated the safety and efficacy of sulodexide, a biocompound of glycosamin-glicans, as adjunct medical therapy to percutaneous transluminal angioplasty (PTA) in diabetes mellitus (DM) patients with critical limb ischemia (CLI). We studied 27 consecutive DM patients with CLI successfully subjected to PTA who, on top of standard antiplatelet therapy, received sulodexide 25 mg bid, and were followed-up for 24 weeks, monitoring adverse events, transcutaneous oxygen tension (TcPO₂), ankle-brachial pressure index, pain, and ulcer dimension. At the end of follow-up, ulcer healing, amputation rates, and cardiovascular risk profile of patients were evaluated. Patients were compared with a historical superimposable control group that was treated for the same indications in the same way as the study group, except for sulodexide inception. No differences in ulcer healing and amputation rates were found at the end of follow-up between the groups. In the study group, TcPO₂ was significantly (P < .05) higher at the end of follow-up, and pain intensity was reduced more rapidly. Plasma fibrinogen and plasma creatinine concentration were significantly (P < .05) reduced in study group at the end of follow-up. No differences in adverse events were observed between the groups during follow-up. Our data suggest that sulodexide administration after PTA, on top of antiplatelet therapy, may improve the outcome of PTA in DM patients with CLI by improving microcirculatory function.

[Preliminary analysis of the relationship between peripheral arterial disease and other atherosclerosis markers and diabetic nephropathy]

OBJECTIVES

To determine lipid serum levels, lipoproteins and other markers related to nephropathy and peripheral arterial disease (PAD) in a type 2 diabetes population stratified according to their level of renal dysfunction.

METHODS

A cross-sectional study was conducted on 72 type 2 diabetic patients followed-up in outpatient clinics. Patients were divided into 4 groups according to their estimated glomerular filtration rate (eGFR, mL/min) and albumin/creatinine ratio (ACR, mg/g) (eGFR > 60 and ACR < 30 [n = 23], eGFR > 60 and ACR > 30 [n = 12], eGFR30-60 [n = 23] and eGFR < 30 [n = 14]). Clinical and anthropometric characteristic of all patients were recorded. Fasting lipids and apolipoproteins, as well as renal and hematology parameters were measured. Finally, a multivariate Wald stepwise logistic regression statistic analysis was performed to determine variables independently associated with the presence of renal dysfunction.

RESULTS

The univariate statistical analysis showed that the higher renal dysfunction, the higher the prevalence of hypertension, smoking habit and triglycerides levels, and the lower hemoglobin levels (P < .05). The multivariate statistical analysis showed that only triglycerides levels (OR: 1.019, 95% CI: 1.004-1.034) and hemoglobin levels (OR: 0.516 95% CI: 0.292-0.914) were independently associated to the presence of renal dysfunction (eGFR < 60 mL/min.). The further inclusion of the presence of PAD in the statistical model did not modify those associations.

CONCLUSION

The results confirm the relationship between triglycerides levels and diabetic nephropathy, independently of the presence of PAD.

Treatment of peripheral arterial disease in diabetes: a consensus of the Italian Societies of Diabetes (SID, AMD), Radiology (SIRM) and Vascular Endovascular Surgery (SICVE)

Diabetic foot (DF) is a chronic and highly disabling complication of diabetes. The prevalence of peripheral arterial disease (PAD) is high in diabetic patients and, associated or not with peripheral neuropathy (PN), can be found in 50% of cases of DF. It is worth pointing out that the number of major amputations in diabetic patients is still very high. Many PAD diabetic patients are not revascularised due to lack of technical expertise or, even worse, negative beliefs because of poor experience. This despite the progress obtained in the techniques of distal revascularisation that nowadays allow to reopen distal arteries of the leg and foot. Italy has one of the lowest prevalence rates of major amputations in Europe, and has a long tradition in the field of limb salvage by means of an aggressive approach in debridement, antibiotic therapy and distal revascularisation. Therefore, we believe it is appropriate to produce a consensus document concerning the treatment of PAD and limb salvage in diabetic patients, based on the Italian experience in this field, to share with the scientific community.

Custom-made orthesis and shoes in a structured follow-up program reduces the incidence of neuropathic ulcers in high-risk diabetic foot patients

OBJECTIVE

The objective of this study was to assess the impact of a structured follow-up program on the incidence of diabetic foot ulceration (DFU) in high-risk diabetic patients.

RESEARCH DESIGN AND METHODS

A total of 1874 diabetic patients referred to the Diabetic Foot Unit of the University of Pisa were ranked based on the ulcerative risk score proposed by the International Consensus on Diabetic Foot. Out of 334 patients (17.8%) with a score ≥2, 298 accepted to participate in this prospective trial and were randomized into 2 groups: group A, which received standard treatment, and group B, in which the patients received, as a part of a structured prevention program, custom-made orthesis and shoes. Incidence of new DFUs was observed for no less than 1 year and in a subset of patients after 3 and 5 years, respectively. Incidence of new DFUs and recurrences were considered as primary endpoints to establish the effectiveness of the program; costs were also compared.

RESULTS

Among the patients enrolled in this follow-up analysis, 46% had neuropathy and deformities, 20% had previous ulceration, 25% had previous minor amputation, and 9% had neuro-osteoarthropathy. During the first 12-month follow-up, 11.5% of patients in group B developed a DFU compared with 38.6% in group A (P < .0001). In the extended follow-up, the cumulative incidence of ulcer in group B compared with group A was 17.6% versus 61% (P < .0001) after 3 years and 23.5% versus 72% (P < .0001) after 5 years, respectively. The net balance at the end of the follow-up was highly in favor of the prevention program, with a saving of more than €100 000 per year.

CONCLUSIONS

The implementation of a structured follow-up with the use of orthesis and shoes can reduce the incidence of DFU in diabetic patients who are at high ulcerative risk and its related costs.

The prevalence of peripheral arterial disease in korean patients with type 2 diabetes mellitus attending a university hospital

BACKGROUND

Peripheral arterial disease (PAD) is a common manifestation of systemic atherosclerosis and is associated with significant morbidity and mortality. Diabetes is known to increase the risk of PAD two- to four-fold. The prevalence of PAD in Korean diabetic patients has not been established. In this study, we investigated the prevalence of PAD in Korean patients with type 2 diabetes attending a large university hospital and analyzed the factors associated with PAD.

METHODS

A total of 2,002 patients with type 2 diabetes who underwent ankle-brachial index (ABI) measurement in an outpatient clinic were enrolled. PAD was defined as an ABI ≤0.9. Clinical characteristics of 64 patients with PAD were compared with those of 192 age- and sex-matched control patients without PAD.

RESULTS

Of the 2,002 type 2 diabetic patients, 64 (3.2%) were diagnosed as having PAD. PAD was associated with higher prevalences of retinopathy, nephropathy, neuropathy, cerebrovascular and coronary artery disease. Patients with PAD had higher systolic blood pressure and serum triglyceride level and reported higher pack-years of smoking. Multivariate analysis showed that the presence of micro- and macrovascular complications and high systolic blood pressure are factors independently associated with PAD.

CONCLUSION

The prevalence of PAD in diabetic patients was 3.2%, suggesting that the prevalence in Korean diabetic patients is lower than that of patients in Western countries.

Characteristics of peripheral arterial disease and its relevance to the diabetic population

Peripheral arterial disease (PAD) is very frequent in diabetics, and it increases with age. Foot examination contributes poorly to diagnosis of PAD. The ankle-brachial index (ABI) measurement is considered the most accurate noninvasive diagnostic method when evaluating PAD: ABI evaluation is recommended in all diabetics aged >50 years. Many diabetic patients with PAD have a concomitant sensitive neuropathy: as a consequence, perception of ischemic pain is remarkably reduced or completely blocked. The result is that the prevalence of claudication in the diabetic population with PAD is lower than the prevalence of critical limb ischemia (CLI) in this population. CLI is a major risk factor for lower extremity amputation without revascularization. Ankle and toe pressures and oxygen tension at the foot are the noninvasive diagnostic parameters of CLI though the medial artery calcification inhibits accurate determination of the ankle and toe pressures, especially when a forefoot ulcer is present. In diabetics, the anatomical localization is mainly distal; arterial wall calcification is frequently observed and occlusion occurs more frequently than stenosis. Such anatomical features, along with the difficulties in the diagnostic approach, account for the fundamental role of CLI as the main prognostic indicator for major amputation. PAD is an expression of systemic atherosclerotic disease. Prognosis of patients with PAD is related to the presence and extent of underlying coronary artery disease (CAD) but also to the severity of PAD: in particular, patients in whom revascularization is not feasible have the highest mortality rate.

NT-proBNP levels, atherosclerosis and vascular function in asymptomatic type 2 diabetic patients with microalbuminuria: peripheral reactive hyperaemia index but not NT-proBNP is an independent predictor of coronary atherosclerosis

Intensive multifactorial treatment aimed at cardiovascular (CV) risk factor reduction in type 2 diabetic patients with microalbuminuria can diminish fatal and non-fatal CV. Plasma N-terminal (NT)-proBNP predicts CV mortality in diabetic patients but the utility of P-NT-proBNP in screening for atherosclerosis is unclear. We examined the interrelationship between P-NT-proBNP, presence of atherosclerosis and/or vascular dysfunction in the coronary, carotid and peripheral arteries in asymptomatic type 2 diabetic patients with microalbuminuria that received intensive multifactorial treatment.

METHODS AND RESULTS

P-NT-proBNP was measured in 200 asymptomatic type 2 patients without known cardiac disease that received intensive multifactorial treatment for CV risk reduction. Patients were examined for coronary, carotid and peripheral atherosclerosis, as defined by coronary calcium score≥400, carotid intima-media thickness (CIMT)>0.90 mm, ankle-brachial index<0.90, and/or toe-brachial index<0.64, respectively. Carotid artery compliance was also determined and the reactive hyperaemia index (RHI) measured by peripheral artery tonometry was used as a surrogate for endothelial function.P-NT-proBNP was associated with atherosclerosis in the unadjusted analysis, but not after adjustment for conventional risk factors. P-NT-proBNP was not associated with vascular dysfunction. The prevalence of atherosclerosis in the coronary, carotid and peripheral arteries was 35%, 10% and 21% of all patients, respectively. In total 49% had atherosclerosis in one territory and 15.6% and 1.0% in two and three territories. Low RHI was an independent predictor of coronary atherosclerosis (odds ratio [CI], 2.60 [1.15-5.88] and systolic blood pressure was the only independent determinant of CIMT (0.02 mm increase in CIMT per 10 mmHg increase in systolic blood pressure [p=0.003]).

CONCLUSIONS

Half of asymptomatic patients with type 2 diabetes mellitus and microalbuminuria had significant atherosclerosis in at least one vascular territory despite receiving intensive multifactorial treatment for CV risk reduction. Coronary atherosclerosis was most prevalent, whereas carotid disease was more rarely observed. RHI but not plasma NT-proBNP was predictive of coronary atherosclerosis.

An assessment of peripheral vascular disease in patients with diabetic foot ulcer

BACKGROUND

Peripheral vascular disease (PVD) is a chronic limb ischaemia caused by atherosclerosis of the peripheral arteries. Diabetes mellitus is a risk factor for this disease. The most common symptom of PVD is muscle pain in the lower limbs on exercise. In diabetes, pain perception may be blunted by the presence of peripheral neuropathy. Therefore, a patient with diabetes and PVD is more likely to present with an ischaemic ulcer or gangrene than a patient without diabetes. The use of ankle-brachial-pressure index (ABI) in the clinic and bedside provide a measure of blood flow to the ankle. This could help early detection, initiate early therapy and may thus reduce the risk of critical limb ischaemia and limb loss.

OBJECTIVE

The purpose of this study is to evaluate the occurrence of peripheral vascular disease using ankle-brachial index in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcer (DFU).

METHOD

This prospective study involved all type 2 DM patients with foot ulcer (DFU population) and those without foot ulcers (non-DFU population) seen in our hospital. Their demographic, clinical and laboratory parameters were noted and documented. Measurement of ABI was done using a portable hand held Doppler and ankle pressures<0.9 is suggestive of PVD.

RESULTS

A total of 74 patients were recruited. Males were 42 (56.8%) and females were 32 (43.2%). The mean age of the patients was 62.89±10.66 years and the duration of diabetes was 7.61±7.57 years. Forty-six (62.2%) presented with foot ulcer while 28 (37.8%) were without foot ulcer. Patients with PVD represented by ABI<0.9 was DFU 31(76.4%) while in non-DFU it was 10 (13.4%). Multivariant analysis of variables associated with DFU in those with ABI<0.9 showed correlation with tobacco use r=.235, p=0.044; duration of diabetes r=-.427; p=0.001; and systolic blood pressure r=-.301; p=0.009.

DISCUSSION

The occurrence of PVD determined by the absence of >2 pulses by palpation alone and using ABI was 25.7% and 55.4% respectively. This suggests that assessment by palpation is subjective while the use of Doppler is quantitative and more reliable. DFU patients with PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure but not with dyslipidaemia.

CONCLUSION

This study shows that these patients had risk factors for PVD. The use of hand held Doppler will aid early diagnosis of critical limb at risk of loss and help to prevent and reduce the high rate of limb loss in our patients.

Evaluation of Feasibility of Ankle Pressure and Foot Oxymetry Values for the Detection of Critical Limb Ischemia in Diabetic Patients

A total of 261 diabetic patients were admitted because of rest pain and/or foot ulcer in 1 limb. Ankle pressure (AP) and transcutaneous oxygen tension (TcPO2) were measured, and digital subtraction arteriography was performed. Transcutaneous oxygen tension was <30 mm Hg in 213 patients and ≥30<50 mm Hg in 48 patients. Ankle pressure could not be measured in 109 patients. In 50 patients, AP was <70 mm Hg and in 102 patients, it was ≥70 mm Hg. Arteriography showed evidence of stenoses >50% of vessel lumen diameter in all patients. Major amputation was performed in 16 patients; AP was <70 mm Hg in 4 patients and ≥70 mm Hg in 6. It was not practicable in the remaining 6 patients. Transcutaneous oxygen tension was <30 mm Hg in 15 patients and ≥30 mm Hg in 1 patient. For diagnosis of critical limb ischemia (CLI) in diabetic patients presenting with rest pain or foot ulcer, measurement of TcPO 2 is essential not only when AP is not measurable but also when this value is ≥70 mm Hg.

Postprandial apolipoprotein B48 is associated with asymptomatic peripheral arterial disease: a study in patients with type 2 diabetes and controls

BACKGROUND

Postprandial hyperlipidemia is a common feature in type 2 diabetes; our aim was to investigate whether there is an association between subclinical peripheral arterial disease (PAD) and the levels of apolipoprotein B48, as a specific marker for postprandial lipidemia.

METHODS

We enrolled 101 patients with type 2 diabetes and 73 controls free from clinical cardiovascular disease. Main outcome measures were the presence of subclinical PAD, assessed by the ankle-brachial index, and the intestinal particles measured as the concentration of apolipoprotein B48 at fasting and 4h after a mixed breakfast.

RESULTS

No control had subclinical PAD. Of the 101 diabetic patients, 21 had subclinical PAD. The levels of apo B48, both fasting and postprandial, were only significantly raised in the diabetic patients who had PAD. The diabetic patients without vascular disease had similar concentrations of triglycerides and apo B48 to the controls. In binary logistic regression analyses, only smoking and postprandial B48 levels, in addition to diabetes, were independently associated with PAD. On the other hand, PAD but not diabetes was associated with the fasting and postprandial levels of apo B48.

CONCLUSION

Our study suggests that apolipoprotein B48 levels might be a marker of occult PAD in patients suffering from type 2 diabetes mellitus. Accordingly, subclinical PAD should be taken into account in studies on postprandial lipidemia involving patients with diabetes.

Myocardial ischemia, carotid, and peripheral arterial disease and their interrelationship in type 2 diabetes patients

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death in type 2 diabetes mellitus (T2DM) patients. We examined the relationship between CVD in different vascular territories.

METHODS

T2DM patients without known or suspected CVD (n = 305) referred consecutively to a diabetes clinic for the first time and age-matched nondiabetic reference subjects (n = 40) were screened for myocardial ischemia, carotid, and peripheral arterial disease by means of myocardial perfusion scintigraphy, carotid artery ultrasonography, and peripheral ankle and toe systolic blood pressure measurements.

RESULTS

In the T2DM patients, the prevalence of myocardial ischemia, carotid, and peripheral arterial disease was 30%, 42%, and 15%, respectively, almost three times higher than in the reference subjects (P = 0.007, P = 0.001, and P = 0.09, respectively). T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease had a significantly increased risk of CVD in other vascular territories as well (OR: 1.99, 2.09, and 3.09, respectively). However, 40%, 52%, and 22% of the T2DM patients with myocardial ischemia, carotid, or peripheral arterial disease demonstrated exclusively this particular type of CVD manifestation.

CONCLUSIONS

In T2DM patients, signs of CVD in one vascular territory carry a significantly increased risk of CVD in other territories, although many patients only presented one manifestation.

A natural history and framework for managing diabetic foot ulcers

When treating diabetic foot ulcers it is important to be aware of the natural history of the diabetic foot, which can be divided into five stages: stage 1 - normal foot; stage 2 - high risk foot; stage 3 - ulcerated foot; stage 4 - infected foot; stage 5 - necrotic foot. This covers the entire spectrum of foot disease but emphasizes the development of the foot ulcer as a pivotal event in stage 3, demanding urgent and aggressive management. Diabetic foot wound care in all stages needs multidisciplinary management to control mechanical, wound, microbiological, vascular, metabolic and educational aspects. Achieving good metabolic control of blood glucose, lipids and blood pressure is important in each stage, as is educational control to teach proper foot care appropriate for each stage. Aggressive management of diabetic foot ulceration will reduce the number of feet proceeding to infection and necrosis and thus reduce the number of major amputations in diabetic foot patients.

Why to screen heart disease in diabetes

The expanding diabetic epidemic and the high risk of cardiovascular events in diabetic patients suggest that screening heart disease in this population is an important issue. Nonetheless, the advisability of large-scale screening in asymptomatic individuals with diabetes is debated, because available techniques are expensive and have suboptimal diagnostic accuracy. Moreover, all diabetic patients should be treated aggressively as if they all had a positive screening test, because diabetes could be considered a coronary risk equivalent. In this article, we underline the importance of an early diagnosis of coronary artery disease and heart failure in diabetic patients, suggesting that positive screening tests have significant implications in clinical management.

Sub-clinical vascular disease in type 2 diabetic subjects: relationship with chronic complications of diabetes and the presence of cardiovascular disease risk factors

BACKGROUND

We evaluated the association between a low ankle-brachial index (ABI), chronic complications of diabetes, and the presence of traditional cardiovascular disease risk factors in subjects with type 2 diabetes but without known cardiovascular disease.

METHODS

We included diabetic subjects (n=923; 52% male; age range 50-85 years) without clinical evidence of coronary, cerebrovascular, or peripheral artery disease (PAD). A history of nephropathy, retinopathy, or neuropathy was collected from the medical records. A 12-lead electrocardiogram and ABI measurements were conducted on all study participants.

RESULTS

The mean duration of diabetes was 9.6 years. Prevalence of a low ABI (<0.9) was 26.2%. Multivariate analysis indicated that factors significantly associated with a low ABI were age (OR: 1.06; 95%CI: 1.033-1.084; p<0.001), plasma triglyceride concentration (OR: 1.002; 95%CI: 1.001-1.004; p=0.006), duration of diabetes (OR: 1.029; 95%CI: 1.008-1.051; p=0.007), and smoking habit (OR: 1.755; 95%CI: 1.053-2.925; p=0.03). The presence of nephropathy, neuropathy, retinopathy, left ventricular hypertrophy, left bundle branch block, and atrial fibrillation were all associated with a low ABI, but only renal disease remained significant after adjusting for age, duration of diabetes, and cardiovascular risk factors.

CONCLUSION

A low ABI is highly prevalent in subjects with diabetes and is related to age, duration of diabetes, smoking habit, and hypertriglyceridemia. Although chronic complications are frequently associated with a low ABI, only renal damage is independently associated with peripheral artery disease.

Non-traditional cardiovascular risk factors contribute to peripheral arterial disease in patients with type 2 diabetes

OBJECTIVE

This study evaluated the prevalence of peripheral arterial disease (PAD) in type 2 diabetes and its association with traditional and non-traditional cardiovascular (CV) risk factors.

SUBJECTS AND METHODS

In 1610 type 2 diabetics PAD was defined as ankle-brachial pressure index (ABPI)<0.9.

RESULTS

PAD prevalence was 17%, increased with age, diabetes duration, HbA 1c levels, previous CV events. There were no significant differences in the prevalence of traditional CV risk factors between patients with and without PAD. PAD patients had higher levels of fibrinogen (10.88+/-2.32 versus 10.2+/-2.23micromol/L; p<0.0001), uric acid (327.1+/-89.2 versus 315.2+/-83.3micromol/L, p<0.01), pulse pressure (70+/-18 versus 60+/-16mm Hg, p<0.0001), higher rate of microalbuminuria (21.3% versus 13.7%; p<0.05) and lower glomerular filtration rate (GFR, 80.7+/-24 versus 89.9+/-22 ml/min/1.73 m2; p<0.001) than those without. In age-gender-adjusted analysis, smoking (OR 1.5; CI: 1.07-2.2), HbA 1c (OR 1.45; CI: 1.07-2.08), high pulse pressure (OR 2.81; CI: 1.63-4.82), reduced GFR (OR 2.16; CI: 1.4-3.3), microalbuminuria (OR 1.62; CI: 1.11-2.36), high fibrinogen levels (OR 2.03; CI: 1.34-3.07) were associated with PAD. In multivariate analysis age, male sex, smoking, high pulse pressure, low GFR, high fibrinogen levels, previous CV events were independent risk factors for PAD.

CONCLUSIONS

PAD prevalence is high in Type 2 diabetic patients. Non-traditional cardiovascular risk factors may be involved in the development of this complication.

Smoking and postprandial triglycerides are associated with vascular disease in patients with type 2 diabetes

AIMS

To determine whether postprandial lipid levels are markers of clinical and subclinical macrovascular disease in a select group of patients with type 2 diabetes.

METHODS

We recruited 119 local patients with type 2 diabetes and moderate metabolic control (HbA1c <8%). The patients were being treated with dietary measures and/or oral antihyperglycemic therapy. No patient was receiving lipid-lowering therapy. A history of cardiovascular events was recorded and the ankle-arm index was measured to assess subclinical peripheral artery disease. The patients underwent a lipid analysis after a 12-h fast and 4h after a mixed breakfast (50 g of fat, 40 g of carbohydrates).

RESULTS

The patients with clinical and subclinical macrovascular disease had a greater history of smoking, a longer disease duration, and higher serum creatinine levels. The groups with macroangiopathy had lower postprandial concentrations of HDL cholesterol (p<0.05) and a trend towards lower fasting levels of HDL cholesterol (p=0.08) and higher fasting and postprandial levels of triglycerides (p=0.07). Multivariate analysis showed the presence of vascular (both clinical and subclinical) disease to be significantly associated with smoking (OR 3.06; 95% CI, 1.15-8.4), disease duration (for each year, OR 1.12; 95% CI, 1.03-1.22) and postprandial levels of triglycerides (for each 50mg, OR 1.73; 95% CI, 1.13-2.65).

CONCLUSIONS

In our diabetic patients, the postprandial level of triglycerides 4h after a fatty breakfast, though not fasting lipids, plus smoking and disease duration were independently associated to clinical and subclinical macrovascular disease.

Ankle brachial pressure index usefulness as predictor factor for coronary heart disease in diabetic patients

Ankle brachial pressure index (ABPI) is a non-invasive marker of atherosclerosis, helpful to identify subjects at high-risk for coronary heart disease (CHD) among large populations with cardiovascular disease (CVD) risk factors. The diagnostic role of ABPI has been also recognized in patients with diabetes. In the present study, the role of an ABPI score < 0.90 in predicting CHD has been evaluated in a large series of patients with Type 2 diabetes mellitus and compared to other known CVD risk factors. Nine hundred and sixty-nine (mean age was 66.1 yr) consecutive patients with Type 2 diabetes mellitus were evaluated. The patients were followed-up for 18.3+/-5.2 months (range 12- 24) and all events of CHD, defined as myocardial infarction, unstable and resting angina or coronary atherosclerosis at the instrumental investigation (at the coronary angiography and/or perfusion stress testing) were recorded. A rate of 17.5% of CHD events were recorded in diabetic population during the follow-up period. The relative risk of CHD was significantly increased for male patients [odds ratio (OR): 1.6; 95% confidence interval (CI): 1.1-2.2], patients with age > or = 66 yr (OR: 1.8; 95% CI: 1.3-2.5), body mass index (BMI) > 30 (OR: 1.5; 95% CI: 1.1-2.1), waist circumference > 88 cm for females and 102 cm for males (OR: 1.5; 95% CI: 1.0-2.1), proteinuria > or = 30 microg per min (OR: 1.6; 95% CI: 1.1-2.3), LDL-cholesterol > or = 100 mg/dl (OR: 2.1; 95% CI: 1.5-3.0), glycated hemoglobin > 7% (OR: 1.6; 95% CI: 1.1-2.3), insulin therapy (OR: 1.9; 95% CI: 1.3-2.9), and ABPI < 0.90 (OR: 3.7; 95% CI: 2.2- 6.2). BMI was higher in patients with ABPI < 0.90 than in those with ABPI > or = 0.90 (p<0.05). At the multivariate analysis, ABPI < 0.90 was the best factor independently associated with CHD (p<0.001). APBI < 0.90 is strongly associated to CHD in Type 2 diabetic patients. We recommend to use ABPI in diabetic patients and to carefully monitor diabetic subjects with an ABPI lower than 0.90.

Diabetic foot disease in the elderly

Elderly diabetic patients are particularly burdened by foot disease. The main causes for foot disease are peripheral neuropathy, foot deformities and peripheral arterial disease (PAD). Other risk factors include poor vision, gait abnormalities, reduced mobility an medical co-morbidities. The risk of major amputations increases with age, along with the increased prevalence of these risk factors. Th true risk of amputation and other burdens of foot disease in the elderly are likely underestimated by current epidemiological data. Th prevalence of neuropathy, foot deformities and PAD as well as the risk of amputation all increase with age even in non-diabetic patients. The principles of prevention and management of diabetic foot disease may also apply to large segments of the elderly non-diabetic population. Foot ulcer prevention relies on the identification of high risk patients and avoidance of triggering events, such as ill-fitting shoes, walking barefoot or poor self-care. PAD is a major cause of amputation and should be prevented by lifelong attention to glycaemic control, treatment of hypertension and dyslipidemia, and avoidance of smoking. The treatment of foot ulcers relies on pressure relief (off-loading), wound debridement, and treatment of infection and ischemia. It requires an individualized approach considering the patient's co-morbidities and functional status. Off-loading remains essential, but devices such as total contact casts or crutches can only rarely be implemented. However, providing adapted standard foot-wear and insisting on its consistent use even at home is often effective. The benefits of aggressive vascular or orthopaedic surgery should be weighed against the risks of prolonged hospitalisation and resulting functional decline. Greater attention to prevention and individualized care are needed to reduce the burden of diabetic foot disease in the elderly.

Clinical and metabolic characteristics of newly diagnosed diabetes patients: experience of a university hospital in Tunis

PURPOSE

The aim of our retrospective study was to explore the clinical and metabolic characteristics of newly diagnosed diabetes patients over the age of 30 years.

METHODS

Study participants were consecutive, newly diagnosed patients with diabetes, over the age of 30 years, presenting to our university hospital department between January 1999 and June 2003. Clinical and metabolic data were collected retrospectively by medical record review.

RESULTS

Three hundred seventy patients were included; mean age was 54.1+/-14.0 years; 49% were women and a family history of diabetes was reported in 52% of patients. Patients presented with acute complications in 40% of cases. Symptoms of polyuria-polydipsia and weight loss were present at diagnosis in 87% and 76% of cases respectively. 58% of our patients were obese or overweight (BMI> or =25 kg/m(2)), hypertension was present in 22%, hypertriglyceridemia in 27% and high LDL cholesterol in 27%. Neuropathy was diagnosed in 24%, nephropathy in 13%, coronary heart disease in 9%, retinopathy in 8% of cases, stroke in 3% and peripheral arterial disease in 2%. Insulin was prescribed initially in 47% of cases.

CONCLUSIONS

Our results demonstrate that clinical symptoms and acute ketosis are the most common presenting features of diabetes mellitus in adults at the hospital level. Associated chronic complications are frequent.

Diabetic Foot Ulcers

When treating diabetic foot ulcers it is important to be aware of the natural history of the diabetic foot, which can be divided into five stages: stage 1, a normal foot; stage 2, a high risk foot; stage 3, an ulcerated foot; stage 4, an infected foot; and stage 5, a necrotic foot. This covers the entire spectrum of foot disease but emphasises the development of the foot ulcer as a pivotal event in stage 3, which demands urgent and aggressive management. Diabetic foot care in all stages needs multidisciplinary management to control mechanical, wound, microbiological, vascular, metabolic and educational aspects. Achieving good metabolic control of blood glucose, lipids and blood pressure is important in each stage, as is education to teach proper foot care appropriate for each stage. Ideally, it is important to prevent the development of ulcers in stages 1 and 2. In stage 1, the normal foot, it is important to encourage the use of suitable footwear, and to educate the patient to promote healthy foot care and footwear habits. In stage 2, the foot has developed one or more of the following risk factors for ulceration: neuropathy, ischaemia, deformity, swelling and callus. The majority of deformities can be accommodated in special footwear and as callus is an important precursor of ulceration it should be treated aggressively, especially in the neuropathic foot. In stage 3, ulcers can be divided into two distinct entities: those in the neuropathic foot and those in the neuroischaemic foot. In the neuropathic foot, ulcers commonly develop on the plantar surface of the foot and the toes, and are associated with neglected callus and high plantar pressures. In the neuroischaemic foot, ulcers are commonly seen around the edges of the foot, including the apices of the toes and back of the heel, and are associated with trauma or wearing unsuitable shoes. Ulcers in stage 3 need relief of pressure (mechanical control), sharp debridement and dressings (wound control), and neuroischaemic foot ulcers may need vascular intervention (vascular control). In stage 4, microbiological control is crucial and severe infections need intravenous antibacterial therapy, and urgent assessment of the need for surgical drainage and debridement. Without urgent treatment, severe infections will progress to necrosis. In stage 5, necrosis can be divided into wet and dry necrosis. Wet necrosis in neuropathic feet requires intravenous antibacterials and surgical debridement, and wet necrosis in neuroischaemic feet also needs vascular reconstruction. Aggressive management of diabetic foot ulceration will reduce the number of feet proceeding to infection and necrosis, and thus reduce the number of major amputations in diabetic patients.