Pressure pain thresholds at the diabetic Charcot-foot: an exploratory study

OBJECTIVE

Painless mechanical trauma is believed to induce neuroosteoarthropathy at the neuropathic foot in diabetes (diabetic Charcot-foot). To investigate pressure nociception at the diabetic foot, we measured the pain perception thresholds for deep pressure (DPPPT, using Algometer II®) and cutaneous pressure (CPPPT, using calibrated monofilaments).

METHODS

In 24 diabetic patients with painless neuropathy (11 with a chronic, inactive Charcot-foot and a history of foot ulcer, and 13 control patients who never had an ulcer), and in 20 healthy subjects, CPPPT (at palmar and plantar digital skinfolds) and DPPPT (over musculus abductor pollicis, musculus hallucis longus, and over metacarpophalangeal and metatarsophalangeal joints) was measured.

RESULTS

At the hands, DPPPT and CPPPT were similar in patients and healthy subjects. At the feet, CPPPT was above the upper safety limit of measurement (512 mN) in 2/20 healthy subjects, and in 11/11 Charcot patients compared to 6/13 neuropathic controls (p=0.005). At the feet, median DPPPT was similar in all groups. In Charcot patients only, DPPPT was higher over metatarsophalangeal joint than over m. hallucis longus (p=0.048).

CONCLUSION

Perception thresholds for cutaneous pressure pain, but not for deep pressure pain, may be extremely elevated at the diabetic neuropathic foot, and particularly at the Charcot-foot.

Pathological proteinuria in patients with insulin-dependent diabetes mellitus: relation to intensive insulin therapy

A matched case-control study was performed to assess the prevalence of pathological proteinuria (greater than 50 mg/l) 18-34 years after onset of insulin-dependent diabetes mellitus (IDDM), in relation to intensive insulin therapy. Three groups of patients were studied greater than or equal to 18 years after onset of IDDM. In patients of group A and group B, intervention took place greater than or equal to 8 years after onset of IDDM: group A changed from traditional insulin therapy to continuous subcutaneous insulin infusion (CSII), and patients of group B changed from traditional insulin treatment (less than 3 injections/day) to multiple daily insulin injection therapy. Patients of group C continued traditional insulin therapy without intervention. The prevalence of pathological proteinuria was 3/21, 5/21, and 15/21 in group A, B, and C, respectively; 22.0 (95% confidence interval: 19.5 to 24.5) years, 22.1 (19.9 to 24.3) years, and 22.6 (20.2 to 25.0) years after onset of IDDM in group A, B, and C. The prevalence of pathological proteinuria differed significantly between group A and B vs. group C (x2 = 16.2, p less than 0.001; odds ratio 15 (3.2 to 70.3)). Glycosylated haemoglobin was 7.5 (6.9 to 8.1)% in group A, 7.6 (6.3 to 8.3)% in group B, and 8.9 (8.2 to 9.6)% in group C. In group A and B, 4/21 patients had hypertension, compared to 11/21 patients in group C. In group B, 1/21 patients had serum-creatinine greater than 130 mumol/l.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of lipoatrophy with human insulin-therapy

A case of progressive insulin-induced lipoatrophy is reported in an insulin-dependent diabetic patient having been treated exclusively with human insulin. The lipoatrophy was stopped after insulin therapy was changed from subcutaneous injections to continuous subcutaneous infusion with human insulin.

Weight-bearing intensity produces charcot deformity in injured neuropathic feet in diabetes

The purpose of the study was to investigate the relationship between the intensity of unrestrained weight bearing after a non-fracture injury (e.g. sprain), and the development of osteoarthropathic deformities of the foot (Charcot foot) in patients with diabetic neuropathy.

METHODS

34 diabetic patients (14 Type 1, 20 Type 2) with foot bone injuries were studied in retrospect. At onset of injury symptoms (e.g. foot swelling), 32 of 34 feet displayed unremarkable X-ray, but pathologic MR imaging (e.g. bone marrow edema along the Lisfranc and/or the Chopart joint). Cumulative load forces after the onset of symptoms until treatment by total contact cast (TCC) were estimated using the product of body weight and number of weeks of ambulation (kg x week) as a surrogate. Feet were classified in 3 groups according to the degree of foot deformities found at the start of treatment with TCC: Feet without deformities (group A, n=16), feet with minor deformities (partially reduced plantar arch (group B, n=6) and feet with major deformities (collapsed plantar arch, group C, n=12)

RESULTS

Feet in group A had been exposed to 262 (95% CI 135-390) kg x week, compared to 974 (95% CI 342-1606) in group B, and to 2348 (95% CI 1265-3430) kg x week in group C (p<0.05 between groups), indicative of a dose-response relationship between weight-bearing and progressive foot deformities. Destruction along the Lisfranc joint was observed in 2/16 feet in group A, versus 18/18 feet in group B and C combined (p<0.001). In group A, the undeformed feet were healed without major deformities (except for 2 non-compliant patients), whereas in group B and C feet remained as deformed as they were at TCC application.

CONCLUSION

Unrestrained weight-bearing of injured foot bones and joints of more than 400 kg x week (equivalent to 8 weeks of normal walking by a person of 50 kg body weight) prompts Charcot deformities, with disintegration of the Lisfranc joint. Early off-loading by TCC treatment allows healing without deformities.

"Silent" bone stress injuries in the feet of diabetic patients with polyneuropathy: a report on 12 cases

BACKGROUND

Bone stress injuries are rarely being diagnosed in patients with sensory neuropathy, most likely because they may be silent in terms of pain. Load-related pain is considered a key feature of any bone stress injury, a symptom, which may be partially or completely absent in subjects with sensory neuropathy (loss of protective sensation). We evaluated the clinical course of bone stress injuries in insensitive feet in diabetic patients with polyneuropathy.

METHODS

We investigated 12 consecutive diabetic patients with bone stress injuries of the foot (bone marrow edema, bone bruise and microtrabecular fractures, on magnetic resonance imaging MRI), which were undetectable on plain X-ray. All patients suffered from diabetic polyneuropathy, none of them had an active foot ulcer.

RESULTS

The patients presented with a swollen foot, which was only mildly painful and did not prevent them from walking. Complaints were related to the swelling, which increased during load-bearing. In seven cases, a traumatic event preceding the onset of symptoms could be ascertained. MRI disclosed stress injuries in 2.5 (1-8) [median (range)] bones per foot. In 11 patients, treatment was started immediately by off-loading with total contact cast for 17 (8-52) weeks, followed by gradual increase in weight bearing. One patient unfortunately received off-loading treatment only after deforming fractures had developed. All bone injuries healed uneventuelly in eight patients, and with residual mild osteoarthrosis in three patients without gross deformities. However, the untreated patient developed severe Charcot foot deformity.

CONCLUSIONS

In diabetic patients with polyneuropathy, symptoms of bone stress injuries of the foot are atypical, in that there is load-related swelling rather than load-related pain. Immediate diagnosis, and treatment with off-loading, leads to a restitutio ad integrum like in non-neuropathic patients. Delayed cessation of overuse, however, may cause irreversible joint and bone damage (Charcot foot).

Evaluation of the diabetic charcot foot by MR imaging or plain radiography--an observational study

Magnetic resonance (MR) images and concomitant plain radiographs of 26 Charcot feet of different stages (stage 0 to III) were reviewed in retrospect for discordant findings. Bone and joint abnormalities were evaluated qualitatively, and quantitatively guided by the AO integral classification of injuries of the foot. MR images revealed traumatic bone and joint injuries (bone oedema, occult fractures, and joint effusion) already in stage 0, when X-ray still showed normal bone and joint anatomy (p = 0.02). Moreover, MR images revealed bone oedema, joint effusion and soft tissue oedema in addition to fractures and calluses in stage I (bone dissolution), stage II (bone coalescence), and stage III (bone remodeling), i.e., in stages with overt radiographic pathology. According to this observational study, MR imaging, in addition to radiography, provides important information as to the extent and the natural course of bone injury in the diabetic Charcot foot. MR imaging, thus, may improve disease staging, as well as treatment monitoring.

Evaluation of the diabetic charcot foot by MR imaging or plain radiography--an observational study

Magnetic resonance (MR) images and concomitant plain radiographs of 26 Charcot feet of different stages (stage 0 to III) were reviewed in retrospect for discordant findings. Bone and joint abnormalities were evaluated qualitatively, and quantitatively guided by the AO integral classification of injuries of the foot. MR images revealed traumatic bone and joint injuries (bone oedema, occult fractures, and joint effusion) already in stage 0, when X-ray still showed normal bone and joint anatomy (p = 0.02). Moreover, MR images revealed bone oedema, joint effusion and soft tissue oedema in addition to fractures and calluses in stage I (bone dissolution), stage II (bone coalescence), and stage III (bone remodeling), i.e., in stages with overt radiographic pathology. According to this observational study, MR imaging, in addition to radiography, provides important information as to the extent and the natural course of bone injury in the diabetic Charcot foot. MR imaging, thus, may improve disease staging, as well as treatment monitoring.

The diabetic charcot foot: MRI discloses bone stress injury as trigger mechanism of neuroarthropathy

It is generally accepted that traumatic bone injury contributes to the clinical picture of neuroarthropathy of the foot in diabetes, i.e., of the diabetic Charcot foot. While radiology is capable of visualizing only advanced bone injuries, like complete fractures, magnetic resonance imaging (MRI) discloses bone injuries that precede complete fractures (stress bone injuries). In diabetic polyneuropathy, stress bone injuries are silent in terms of pain, due to the lack of pain sensation. At the foot, their clinical appearance is characterized by inflammatory swelling with little or no pain. The present paper reviews the contribution of MRI to the detection of bone injuries in what is called stage 0 Charcot foot, with emphasis on the bearings for the treatment strategy.

Charcot foot in diabetes: farewell to the neurotrophic theory

Neuropathic osteoarthropathy is characterised by relatively painless swelling together with extensive damage in bones and joints, predominantly in the feet and ankles. The uncontrolled natural course of the condition leads to gross foot deformity, skin pressure ulceration, spreading infections, and sometimes amputation. Jean-Martin Charcot in 1883 described "Charcot foot" named after him in patients with tabes dorsalis insensitivity. Charcot believed that intrinsic bone weakness was the underlying condition, and was caused by neurogenic deficiencies in bone nutrition. His followers believed such dystrophy to be mediated by sympathetic denervation of the bone vasculature (neurotrophic, or neurovascular theory). Attempts to prove this theory were futile. A neurogenic circulatory disorder potentially relevant to bone nutrition could not be identified. Nowadays, Charcot foot is mostly seen in diabetic neuropathy, which has replaced syphilis as a frequent cause of peripheral nerve dysfunction. Recent studies in the diabetic Charcot foot and bone turnover indicate that the neurotrophic theory is a myth. The assumption of bone resorption due to sympathetic denervation proved to be false--sympathetic activity increases osteoclastic activity and thereby bone loss (sympathomimetic bone resorption). Except for the transient, inflammatory stage of the diabetic Charcot foot, there is no evidence of relevant osteoporosis or demineralisation of the foot skeleton in diabetes.

The perils of procrastination: effects of early vs. delayed detection and treatment of incipient Charcot fracture

BACKGROUND

At the onset of acute diabetic Charcot foot, therapeutic intervention may be delayed because plain X-rays may not show fractures.

AIM OF THE STUDY

To assess the clinical course of acute Charcot foot in 24 patients without evidence of definite fractures on the first X-ray after onset of symptoms, who were referred to the foot clinic for diagnosis and treatment either early or delayed, i.e. before or after definite fractures were detectable on repeat X-rays.

PATIENTS AND METHODS

Eleven patients were referred early (incipient Charcot foot, case group), and 13 patients were referred delayed (overt Charcot foot, control group). In the foot clinic, both groups were immediately treated with off-loading and total contact casting. After the healing process of the Charcot foot was complete, the extent of fractures and subsequent deformities were evaluated.

RESULTS

Based on X-rays at the onset of symptoms, in 19 of the 24 patients the condition had been misdiagnosed prior to referral (in 11 patients as sprain injury). Additional imaging techniques (MRI, CT scan or bone scintigraphy) had been performed in 10 patients prior to referral. While these techniques had been used more frequently in the cases vs. the controls (P=0.012), misdiagnosis was less frequent in the cases vs. the controls (P=0.013). Only one out of 11 case patients developed extended foot fractures and severe deformity, vs. 12 out of 13 control patients (P<0.001).

CONCLUSION

Early detection of incipient Charcot foot is facilitated by imaging techniques other than plain X-rays. Immediate off-loading of incipient Charcot foot appears to minimize fractures and incapacitating deformities.

Progression of diabetic retinopathy during improved metabolic control may be treated with reduced insulin dosage and/or somatostatin analogue administration -- a case report

It is well known that intensified insulin treatment of poorly controlled type 1 diabetic patients may worsen an existing diabetic retinopathy (DR). This observation has been explained by an insulin-induced stimulation of the GH/IGF-I axis. Here, we report on three cases, where the progression of DR during intensified metabolic control was treated with manipulation of insulin therapy and/or by administration of octreotide. Serum concentrations of IGF-I, IGFBP-3, insulin, cystatin C, creatinine, endogenous creatinine clearance and HbA1c-levels were assessed by routine laboratory methods; serum IGF-I bioactivity was estimated by a highly specific kinase receptor activation assay. Visual acuity and retinopathy stage was assessed by established clinical methods including fluorescein angiography. After glycaemic control was improved by intensified insulin therapy, serum IGF-I levels acutely increased. Subsequently, DR progressed to an advanced stage ("florid retinopathy"), with macular edema, and proliferation of new vessels (in two cases). Immediate reduction of insulin dosage and administration of octreotide lowered serum total IGF-I levels (and IGF-I bioactivity as measured in one patient). Subsequently, macular edema resolved partly, and visual acuity improved, allowing laser photocoagulation to be performed. In conclusion, in poorly controlled type 1 diabetic patients, intensified insulin therapy is able to cause florid DR with acute macular edema. These sight-threatening changes may improve by short-term reduction of insulin dosage or by administration of octreotide, and we speculate that this may be related to down-regulation of (serum) IGF-I.

New insights into the pathogenesis of diabetic retinopathy – hormonal rather than metabolic factors are important

Diabetic retinopathy has traditionally been viewed as a metabolite-driven, occlusive vasculopathy that affects both retinal microvascular haemodynamics and structure; analogies to cholesterol-driven occlusive atherosclerosis of the macrovascular circulation were drawn. However, this paradigm may no longer be appropriate. Recent evidence suggests that diabetic retinopathy from the beginning is the consequence of a complex hormonal dysfunction, which is related to insulin-dependent up- and downregulation of growth factors, to which metabolic, haemodynamic, endocrine, paracrine, and autocrine mechanisms contribute.

[Diabetic foot disease--a review of pathogenesis, treatment and prevention of diabetic podopathy]

An update is presented of the pathogenesis, treatment and prevention of diabetic podopathy. Although the underlying conditions, polyneuropathy and peripheral ischaemic vessel disease presently cannot be cured, their complications, i.e. foot ulcers, foot gangrene and foot fractures in most cases can nowadays be treated successfully without major amputations.

Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre

Background: We sought to establish risk factors predicting the outcome of foot lesions in longstanding diabetic patients with critical foot ischaemia (CFI). Patients and methods: We investigated retrospectively 98 consecutive diabetic patients with ischaemic foot lesions. The patients (mean age 70 years, duration of diabetes 21 years) were jointly cared for by specialised diabetologists and vascular surgeons; 75 patients were treated by arterial revascularisation. Results: Good outcome (lesions healing) was observed in 53 patients (54%). Bad outcome was observed in 45 patients: not healing lesions (n = 5), major amputation(n = 19), and death in relation to the foot lesion (n = 21). Patients with good and bad outcome did not differ regarding age, sex, smoking status, type, duration and treatment of diabetes mellitus, presence of neuropathy, coronary heart disease, stroke, previous amputations, current revascularization, and localization of the foot lesion. The risk of bad outcome was increased 8.9 times in patients on dialysis for end-stage renal disease; 7.0 times if surgical complications were present; and 5.4 times with C-reactive protein (CRP) above the second quintile (cut-off value 8 mg/dl). Conclusion: Management of longstanding diabetic patients with ischaemic foot lesions leaves room for improvement. Dialysis treatment, elevated CRP levels and surgical complications were strongly predictive of non-healing lesions, major amputation and death.

Reversion of 'early worsening' of diabetic retinopathy by deliberate restoration of poor metabolic control

Acutely lowering long-standing severe hyperglycaemia can trigger progression ('early worsening') of diabetic retinopathy, most likely by up-regulation of the circulating insulin-like growth factor 1 (IGF-1). This condition, also called 'florid retinopathy', rarely responds to standard laser coagulation treatment. In this retrospective report, 2 young patients with type 2 diabetes are described, in whom deliberate restoration of poor diabetes control reduced the serum IGF-1 levels and improved 'early worsened' diabetic retinopathy.

Effectiveness of a new brand of stock 'diabetic' shoes to protect against diabetic foot ulcer relapse. A prospective cohort study

AIMS

Diabetic patients with podopathy (diabetic foot syndrome) may need protective footwear, be it customized or industrially produced stock 'diabetic' shoes (SDS). The effectiveness of each type of 'diabetic' shoe needs to be proven clinically, e.g. in terms of prevention of foot ulceration. The following study assesses a new German SDS, the LucRo shoe, which consists of rocker-shaped walking sole, a standardized shock absorption insole, and soft uppers without stiff toe-caps. The LucRo SDS has been registered as a Medicinal Product according to the European Community Guideline 93/42/EC.

PATIENTS AND METHODS

A total of 92 high-risk diabetic patients (mean age 63 years, duration of diabetes 13 years) with healed foot ulcer were recruited prospectively over 31 months; 87 patients suffered from polyneuropathy, 24 patients had peripheral ischaemic vessel disease. One group of patients (n = 60) received the LucRo SDS and wore them, while the remaining patients (n = 32) did not receive the SDS and were forced to use their normal footwear. This allocation reflects the haphazard reimbursement policies of the individual patients' health insurance, and is in accordance with the current German legislation. The patients were followed up for up to 42 months until the first foot ulcer relapse, or the end of the study.

RESULTS

There were no differences between the groups concerning age, sex, type and duration of diabetes, prevalence of polyneuropathy and peripheral ischaemic vessel disease, frequency of foot care and mortality rate. The first year annual rate of foot ulcer relapse was significantly different between the groups: 60% without SDS vs. 15% with SDS. The overall cumulative ulcer-free survival was significantly greater with SDS (P < 0.0001, log rank test).

CONCLUSION

The LucRo stock 'diabetic' shoe appears effective in the prevention of foot re-ulceration in high-risk patients with diabetic podopathy.

Foot dimensions of elderly people with and without diabetes mellitus - a data basis for shoe design

BACKGROUND

Injuries from footwear are common in elderly people, particularly in those with diabetes mellitus and polyneuropathy. A common cause is a mismatch between foot and shoe.

OBJECTIVE

To assess the length and the breadth of the feet by an automatic measuring device in 568 patients with diabetic polyneuropathy and in 100 nondiabetic control subjects of the same mean age of 64 years.

RESULTS

While the foot length in all cases matched well with the size of the normal footwear available on the market, more than two thirds of the feet were considerably broader than the normal footwear available. The foot breadth correlated variably with the foot length. Tables of foot dimensions for men and women are provided over the complete range of shoe sizes.

CONCLUSIONS

This anthropometric data set on feet, which is the first conducted in elderly people, proves that most feet of elderly people with or without diabetic neuropathy do not fit ordinary casual footwear. Therefore, the construction of shoes according to the anthropometric data of elderly people is required in order to prevent foot injuries in this particular population.

HLA-patterns in patients with multiple sclerosis and type I diabetes mellitus: evidence for possible mutual exclusion of both diseases

BACKGROUND

Type I diabetes mellitus (T1DM) and multiple sclerosis (MS), both immune-mediated diseases, rarely co-exist in the same individual or co-segregate in families. HLA susceptibility genes for T1DM (DRB1*0401, DRB1*0404, DQB1*0302, DRB1*0301, DQB1*0201) rarely occur in MS patients. HLA genes known to confer "resistance" to T1DM (DRB1*1501, DQB1*0602-DQA1*0102) predispose to MS. To test the hypothesis of mutually exclusive HLA patterns, patients affected by T1DM plus MS were compared to those of patients affected by either of the diseases alone in a case-control study.

METHODS

Blood was sampled for analysis of HLA class I and class II alleles from 66 patients of German ancestry, of whom 33 had T1DM plus MS, and 33 had MS-only. For comparison to patients with T1 DM-only we referred to published data. HLA typing was performed using conventional serology (immuno-magnetic beads) and genotyping (SSP-PCR Dynal(R) SSP low/high resolution kits).

RESULTS

Individuals with co-existing MS plus T1DM displayed the expected T1DM associated HLA-pattern (75.8% carried DRB1*04, 69.7% carried DQB1*0302, 42% were DR4, DR3 heterozygous), but failed to display the expected MS associated HLA-pattern (0% carried DQB1*0602, 3.1% carried DQA1*0102). The expected MS associated HLA-pattern of Caucasoid patients, however, was found in the MS-only patients (42% carried DRB1*1501-DQB1*0602, 58% carried DQA1*0102), while the prevalence of T1DM susceptibility and 'resistance' alleles was not different from the general population. The allele frequency of DRB1*1501 was 16/66, 24.2% in the 33 MS-only patients, and 0% in the 33 MS plus T1DM patients. The allele frequency of DQB1*0602 was 16/66, 24.2% in the 33 MS-only patients, and 0% in the 33 MS plus T1DM patients. The allele frequency of DQA1*0102 was 18/66, 27.3%, in the 33 MS-only patients, and 1/66 1.5% in the 33 MS plus T1DM patients.

CONCLUSION

These data confirm the hypothesis of mutually exclusive HLA-patterns of T1DM and MS, and are consistent with a low rate of co-morbidity of both diseases.

Elevation of serum IGF-1 rather than sex steroids precedes proliferative diabetic retinopathy in Mauriac's syndrome

We report the case of a 21-year-old man with Mauriac's syndrome, in whom diabetic retinopathy progressed to the proliferative state despite slightly improved glycemic control and completely suppressed sex steroids (by a GnRH agonist). However, a gradual increase in serum IGF-1 from 162 to 482 ng/ml over 9 months clearly preceded retinal deterioration, which responded to panretinal laser coagulation. We conclude that substantial elevation of serum IGF-1 may be another risk factor for the progression of mild diabetic retinopathy to the proliferative state.

What may be gained from standard photocoagulation during early worsening of diabetic retinopathy? An observational study in type-1 diabetic patients after tightening of glycaemic control

OBJECTIVE

To assess the outcome of laser photocoagulation treatment for rapidly progressing diabetic retinopathy, socalled early worsening, subsequent to a rapid improvement of glycemic control. For the purpose of this study, early worsening was defined as any incidence or progression of retinopathy that followed a reduction in HbA1c by > 2% within 6 months.

MATERIAL AND METHODS

Retrospective observational study in type-1 diabetic patients in a university diabetes center.

PATIENTS

23 patients with early worsening were identfied during a 16-year period, with a mean age of 25 years, duration of diabetes of 12 years, and glycated hemoglobin HbA1c of 12.4%; retinopathy was absent or mild nonproliferative at baseline. Focal, and/or panretinal laser coagulation was performed according to standard ETDRS criteria. Retinal pathology and visual acuity was followed-up for 12-120 months.

RESULTS

Improving metabolic control induced mild non-proliferative retinopathy without macular edema in 4 patients, which regressed without treatment. In 19 patients, symptomatic diabetic maculopathy developed with macular edema, resolving by focal coagulation in 3 patients. Of the remaining 16 patients, 14 developed proliferative retinopathy (7 of whom despite focal, grid or scatter coagulation pretreatment), and were treated by full panretinal coagulation. In 7 of the 14 patients with proliferative retinopathy, vitreous hemorrhages occurred requiring pars plana vitrectomy. Proteinuria, polyneuropathy, and impaired vision prior to laser treatment were indicative of poor prognosis. Visual acuity > 0.3 in at least one eye was preserved in 22 of the 23 patients.

CONCLUSIONS

In patients with type-1 diabetes mellitus and early worsening of diabetic retinopathy, the benefit of standard laser photocoagulation was limited, and particularly in the presence of symptomatic macular edema.

Possible activation of auto-immune thyroiditis from continuous subcutaneous infusion of genapol-containing insulin

A case of a type 1 diabetic woman with auto-immune thyroiditis is reported, in whom repeated exposure to insulin containing Genapol(R) (polyethylen-polypropylenglycol) over 3 years reproducibly parallels with an increase of serum TSH (thyroid-stimulating hormone) above the normal limit. Previously, adverse effects of Genapol(R) insulin have been related to its intraperitoneal application, and thought to be restricted to anti-insulin-immunity; activating effects on thyroid auto-immunity have been repeatedly disputed. We suggest that Genapol(R) insulin should be replaced by other insulin preparations with a better safety record.

[The "diabetic foot" syndrome. An overview]

Amputation has been used most frequently to treat the diabetic foot syndrome, occlusive microangiopathy being suspected as the underlying cause. This paradigm is obsolete: most diabetic foot lesions are due to traumatic painless (neuropathic) infections. Evidence is presented for alternative treatment strategies to effectively reduce exorbitant amputation rates in diabetic patients.

Effects on parameters of glucose homeostasis in healthy humans from ingestion of leguminous versus maize starches

BACKGROUND

Due to their lower glycaemic index, leguminous seeds affect human carbohydrate metabolism lesser than do cereals. Problems, however, could arise from side effects, e.g., increasing flatulence.

AIM OF THE STUDY AND METHODS

In 26 healthy subjects, metabolic and symptomatic responses following acute ingestion of equivalent amounts of pure pea starch (NASTAR (Cosucra BV, Rosendaal/The Netherlands), crude yellow pea flour (CPC Deutschland, Germany), and modified and unmodified cornstarches (SNOWFLAKE and SIRONA, Cerestar/Germany) were assessed, i.e., plasma glucose, serum insulin, C-peptide, hydrogen exhalation, and flatulence.

RESULTS

Pure pea starch elicited less hyperglycaemia (minus 47 %), hyperinsulinaemia (minus 54 %), and C-peptide secretion (minus 37 %) as compared to cornstarch (p<0.05), while the responses to modified versus unmodified corn starch were similar (8 subjects, n.s.). Pure pea and corn starches were equally well tolerated, while flatulence and breath hydrogen concentration were increased only after the intake of crude pea flour. Maldigestion of pea flour was calculated to be around 10 % (reference lactulose).

CONCLUSIONS

The well-known metabolic advantages of pea starch over cornstarch were confirmed. Tolerability of pure pea starch was excellent, but not of crude pea flour. Provided it has the same technical characteristics, pure pea starch as a "prebiotic" could replace cornstarch in industrial food production.

Evidence that upregulation of serum IGF-1 concentration can trigger acceleration of diabetic retinopathy

BACKGROUND

Acute reduction of chronic hyperglycaemia can accelerate early diabetic retinopathy. In adolescent patients with Mauriac's syndrome, this phenomenon is related to an upregulation of subnormal serum IGF-1 levels.

AIM

To obtain longitudinal data on serum IGF-1 and retinopathy status in poorly controlled adult insulin dependent (type 1) diabetic patients without Mauriac's syndrome, in whom hyperglycaemia is reduced by intensive insulin therapy.

METHODS

Four patients with chronic severe insulin deficiency and early micro-angiopathy were studied prospectively. Changes in plasma glucose, HbA1c, serum IGF-1 levels, proteinuria, retinopathy, and clinical status were followed up closely.

RESULTS

Reducing hyperglycaemia from > 16 mmol/l (equivalent to HbA1c > 11%) to < 10 mmol/l (HbA1c < 8%) within 5 months increased serum IGF-1 levels by 70-220%. While proteinuria and symptomatic neuropathy regressed, retinopathy progressed from the mild to the severe non-proliferative stage with maculopathy (n = 4), and to the proliferative stage (n = 1). Laser coagulation was commenced upon the appearance of sight threatening macular oedema (n = 4).

CONCLUSION

Upregulation of serum IGF-1 preceding retinal deterioration in these patients suggests a cause-effect relation, consistent with earlier experimental and clinical data.

Effect of patient-selected intensive insulin therapy on quality of life

The purpose of the study was to assess quality of life in patients with IDDM in relation to the type of insulin therapy. Two patient cohorts were studied. In cohort A, 77 patients deliberately intensified their traditional insulin injection therapy from up to two daily injections with syringe to multiple daily injections with insulin-pen; in cohort B, 55 patients changed from intensive therapy with pen to insulin pump-treatment (CSII). The therapeutic regimens were changed during a 5-day in-patient treatment and teaching course. The DCCT questionnaire was applied before and up to 6 months after changing of therapy. Treatment satisfaction increased after intensification of insulin therapy in both groups, mainly due to greater flexibility with leisure-time activities, and with the diet. Pump-users reported reduced problems with hypoglycemia (P < 0.02). HbA1c indicating acceptable metabolic control already before the study, remained unchanged. Therapy-associated inconvenience, mainly in association with lifestyle, improved in IDDM patients deliberately intensifying their insulin therapy by pens or pumps (CSII). Pump-treatment, rather than pen-therapy, conferred particular protection from hypoglycaemia.

Distal arterial occlusive disease in diabetes is related to medial arterial calcification

In diabetes mellitus, peripheral arterial occlusive disease predominantly affects the lower leg (tibial and peroneal vessel disease). Our study suggests that this feature is related to the presence of forefoot medial arterial calcification.