Effect of Buerger-Allen exercise on wound healing in patients with diabetic foot ulcers: a randomised controlled trial

OBJECTIVE

A diabetic foot ulcer (DFU) is a complication of type 2 diabetes that is difficult to treat. Buerger-Allen exercise has shown effectiveness in improving foot circulation and neuropathy in several studies; however, to the best of our knowledge, no randomised controlled study has investigated its effectiveness for DFU healing. Therefore, this study aimed to assess the effects of Buerger-Allen exercise on the healing of DFUs in patients with type 2 diabetes.

METHOD

This is a parallel-group randomised controlled trial (RCT). Of 50 patients with neuropathic DFUs, 41 completed the study. They were assigned randomly to a study group (n=21) and a control group (n=20). Patients in the study group received the standard medical treatment and semi-supervised Buerger-Allen exercise for three sessions per week for four weeks, while patients in the control group only received the standard medical treatment. The outcome measures were: ankle-brachial pressure index (ABPI); ulcer size; ulcer depth; SINBAD score; and ulcer risk for poor outcomes (based on the SINBAD score).

RESULTS

The study group's mean age was 49.48±6.45 years and the control group's mean age was 49.15±5.85. The study group's ABPI increased significantly compared to the baseline (1.17±0.04 versus 1.11±0.05, respectively; p<0.001) and the control group (1.17±0.04 versus 1.14±0.05, respectively; p=0.04) post-intervention. Ulcer size also reduced significantly in the study group compared to the baseline (2.63±2.0 versus 7.48±5.55cm2, respectively; p<0.001) and the control group (2.63±2.0 versus 6.43±4.45cm2, respectively; p<0.001) post-intervention. Ulcer depth decreased significantly in the study group compared to the baseline (1.71±1.05 versus 4.19±1.74mm, respectively; p<0.001) and the control group (1.71±1.05 versus 2.80±1.57mm, respectively; p=0.01) post-intervention. Furthermore, the SINBAD score in the study group decreased significantly compared to the baseline (1.38±0.86 versus 2.14±1.06, respectively; p<0.001) and the control group (1.38±0.86 versus 2.0±0.79, respectively; p=0.02) post-intervention. Moreover, the ulcer risk for poor outcomes, based on the SINBAD score, reduced significantly only in the study group, compared to the baseline (p=0.041). The control group showed non-significant changes compared to the baseline in all outcome measures (p>0.05).

CONCLUSION

From the findings of this RCT, Buerger-Allen exercise, in combination with standard wound care, may help accelerate the healing of neuropathic DFUs in patients with type 2 diabetes, and could be suggested as part of the management plan for such conditions as an easy-to-perform offloading exercise intervention.

Role of the cutaneous extraneuronal cholinergic system in the pathogenesis of psoriasis: a case-control study

BACKGROUND

Although during recent years there have been considerable advances in elucidating the mechanisms of psoriasis pathogenesis, its full understanding is still distant. A cholinergic dysfunction has been proposed in the pathophysiology of some inflammatory and autoimmune diseases, including psoriasis.

AIM

To determine tissue levels of acetylcholine (ACh) and its muscarinic and nicotinic receptors (mAChR and nAChR) in psoriasis vulgaris lesions in comparison with normal control skin.

METHODS

This case-control study included 30 patients with psoriasis vulgaris and 30 controls. A 4-mm punch skin biopsy was taken from the psoriatic plaques of patients and normal skin of controls. ACh level was measured in tissues using the colorimetric method, while mAChR and nAChR gene expression was determined by real-time PCR.

RESULTS

The level of ACh was significantly higher in patients (mean ± SD: 5.95 ± 2.69) than in controls (1.12 ± 0.34) (P < 0.001). mAChR and nAChR expressions were significantly higher in patients compared with the controls (P < 0.001). A significant positive correlation was detected between the expression of nAChR in patients and the duration of psoriasis (r = 0.46, P = 0.01), and the body mass index of the patients correlated positively with both nAChR (r = 0.40, P = 0.027) and mAChR expression (r = 0.448, P = 0.013).

CONCLUSION

Abnormalities in the cutaneous extraneuronal cholinergic system could be involved in the pathogenesis of psoriasis. The high expression of nAChRs in patients with longer disease durations might represent an attempt by the body to regulate the inflammatory cascade in psoriatic lesions. The high expression of mAChR in psoriatic lesions may provide a link between psoriasis and obesity.

Preoperative exposure to calcium channel blockers suggests increased blood product use following cardiac surgery

PURPOSE

In this study the authors reviewed the medical records of a random sample of patients undergoing coronary artery bypass grafting (CABG) during the preceding ten years at University Medical Center. The purpose of this study was to evaluate the impact of exposure to calcium channel blockers (CCB's) on blood product use following cardiopulmonary bypass (CPB).

METHODS

DESIGN

Retrospective medical record review.

SETTING

University hospital.

PARTICIPANTS

527 patients undergoing CABG or re-do CABG.

INTERVENTIONS

The medical records of approximately 50% of patients undergoing CABG or re-do CABG at University Medical Center between 1988 and 1998 were randomly selected by the medical records librarian for review. Preoperative medications, bypass time and temperature, and blood product use were recorded.

RESULTS

Of the 527 patients studied, 309 (59%) had no exposure to CCB's. 218 (41%) were on CCB's at the time of admission. Patients who were on CCB's had an average 12.5 (+/- 1.0) blood product units transfused following bypass whereas those not on CCB's had an average 8.7 (+/- 0.6) units transfused (p < 0.001). Use of packed red blood cells (p < 0.001), fresh frozen plasma (p = 0.018) and platelets (p = 0.023) were each individually significantly increased.

CONCLUSIONS

In this study, it appeared that patients exposed to CCB's before cardiac revascularization received significantly more blood products than those who were not exposed to CCB's. Because of the limitations imposed by retrospective studies, further prospective studies are warranted to define the clinical significance of CCB use in the perioperative period.

Prevalence of certain sexually transmitted viruses in Egypt

The magnitude of Sexually Transmitted Diseases (STD) in the Eastern Mediterranean Region is not exactly known but considered to be not insignificant. A realistic estimate of the problem is necessary, to design an effective control program. This present study aimed to identify the most prevalent sexually transmitted viral agents among patients attending the STD clinic at Cairo Hospital for Skin and Venereal Diseases (El-Haud El-Marsoud). From persons attending this clinic whether complaining or visiting for screening, between October 1993 to April 1995, 95 cases were studied by history taking, clinical examination, bacteriological and serological examination for the detection of the most prevalent sexually transmitted organisms. Certain demographic and socio-economic factors interacting with sexual attitudes and practices were also studied. All the collected data for each patient were recorded. Antibodies (IgG) to cytomegalovirus (CMV) were detected in 86.3%, HBsAg in 10.5%, and antibodies to HBcAg were detected in 45.3%. Antibodies to HCV were detected in 8.4%, and antibodies to HIV in 5.3%.

Family planning in Jordan: 1983 survey data

Data from the 1983 fertility survey in Jordan indicate that 26 percent of married women were using contraceptives, reflecting a very small relative increase in use in the seven years before the survey. Only 5 percent of nonusers stated that they desired to use a method. Other data from the same survey suggest a potential demand for contraception, for spacing as well as limiting births, among those not using. For example, many recent pregnancies were reported to be unplanned. Also, among nonusers who did not desire to use a method, many stated they did not desire to become pregnant, yet were exposed to the risk of pregnancy. A pool of potential users exists who can be considered in need of contraception (i.e., fecund, not pregnant or desiring pregnancy, and not using contraceptives)--20 percent of all currently married, childbearing-age women--who may become contraceptive users as attitudes toward contraception change.

Pilonidal sinus caused by cutting trauma

The implantation of hair in the deep corium is responsible for the production of pilonidal sinus. The mechanism responsible may be the drilling of hair, suction, implantation, or sequestration. Cutting trauma can be responsible for the production of pilonidal sinus, if the hair fragments are implanted in the deep corium of the skin.

Study of the pattern of Widal test in infants and children; II. Pattern of Widal test in children with enteric fevers. An attempt to define the diagnostic titer for upper Egypt

The study embodied 45 children with enteric fevers proved by bacteriological culture of blood, stools and urine and 20 children with rheumatic fever. Widal test was done for the rheumatic fever cases and was done repeatedly at weekly intervals for the enteric fever cases. The clinical features of children with enteric fevers was discussed. By contrasting the results of Widal test in children with enteric fever with the results in apparently normal infants and children from the same locality, a minimal diagnostic dual Widal titer was suggested. This combines "O" agglutinin in a titer of 1/160 provided that the other "H" agglutinins are at a lower titer. This suggested diagnostic titer improved the specificity of Widal test. This titer is encountered only in 0.58% of normal individuals and in none of 20 children with rheumatic fever. This titer also yielded an excellent sensitivity to diagnose actual enteric fever cases reaching up to 93.3%. Bacterial isolates from enteric fever cases were S. typhi in 55.5%, S. paratyphi A in 33.3% and S. paratyphi B in 11.1%. Chloramphenicol therapy resulted in a higher cure rate and a more rapid defervescence than ampicillin therapy. Regarding the effect of these antibiotic therapies on the rise of Widal agglutinin titers in children with enteric fevers there are two observations : 1--A four fold rise, is uncommon. A two fold rise is the common finding. 2--There is no consistent difference between chloramphenicol and ampicillin as regards their effect on the rise of agglutinin titers.

Study of the pattern of Widal test in infants and children. III. Effect of T.A.B., diphtheria tetanus, pertussis and measles vaccinations on the level of enteric fever agglutinins

Widal test was done before and 15 days after the last dose of T.A.B. (33 Children) Diphtheria (13) Tetanus (16), Pertussis (7) and Measles (7) vaccinations. The tremendous rise of Widal agglutinin titers after T.A.B. vaccination could not foul up the results of the Widal test if we follow closely the suggested diagnostic Widal criterion combining a titer of 1/80 or more for "O" and 1/60 or more for one"H" agglutinin with the other "H" agglutinins at a lower titer.

The nature of the adrenoceptors in the post-partum rat uterus

1. Uteri were removed from rats 0.5 h to 8 days after parturition and were suspended in Locke solution at 37 degrees C.2. The agonists isoprenaline, adrenaline, noradrenaline and phenylephrine produced an inhibition of the post-partum rat uterus.3. In the presence of propranolol, the agonists noradrenaline, adrenaline, and phenylephrine had an excitatory effect on the post-partum rat uterus. This excitatory effect was blocked by phenoxybenzamine indicating that it is mediated through alpha-adrenoceptors.4. These excitatory alpha-adrenoceptors could be demonstrated for 5-6 days after parturition. By the 7th-8th days their existence was no longer apparent.5. Excitatory alpha-adrenoceptors were also demonstrated in the late pregnant rat uterus.