The Diabetic ulcer I/ La ulcera diabetica I

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****** DATA-MÉDICOS *********
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ULCERA DIABÉTICA (I) / DIABETIC ULCER (I)
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***** DERMAGIC-EXPRESS No 14 *********
****** 15 NOVIEMBRE 1.998 *******
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EDITORIAL ESPAÑOL:
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Saludos amigos Dermágicos, el DR. Marcelo Errico (Argentina) la semana pasada me pidió una puesta al día sobre manifestaciones cutáneas de la Diabetes,

El tema es bastante extenso en cuanto a BIBLIOGRAFÍA, para hoy les tengo 22 REFERENCIAS sobre la ulcera diabética bastante interesantes, en la próxima edición libero los nuevos productos para este tipo de ulceras encontrados enla WEB.

Hasta una próxima edición de DERMAGIC,,,,

Dr. José Lapenta

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DERMAGIC/EXPRESS(14)
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ULCERA DIABÉTICA (I) / DIABETIC ULCER (I)
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1.) Promotion and acceleration of diabetic ulcer healing by arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group.
2.) Effects of electrical stimulation on wound healing in patients with diabetic ulcers.
3.) The use and abuse of wound care materials in the treatment of diabetic ulcerations.
4.) Relationship of microalbuminuria with the diabetic foot ulcers in type II diabetes.
5.) Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration.
6.) Effect of topical basic fibroblast growth factor on the healing of chronic diabetic neuropathic ulcer of the foot. A pilot, randomized, double-blind, placebo-controlled study.
7.) Prognostic value of the clinical examination of the diabetic foot ulcer.
8.) Wound healing. New modalities for a new millennium.
9.) Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds?
10.) Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. A randomized study.
11.) [Mri and surgical indications in perforating ulcer in diabetic patients]
12.) 1995 William J. Stickel Gold Award. High strain rate tissue deformation. A theory on the mechanical etiology of diabetic foot ulcerations.
13.) A metabolically active human dermal replacement for the treatment of diabetic foot ulcers.
14.) Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial.
15.) Power spectral analysis of heart rate variation in diabetic patients with neuropathic foot ulceration.
16.) [Prognostic factors in treatment of diabetic foot ulcers]
17.) Total contact casting for diabetic neuropathic ulcers.
18.) Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon.
19.) New uses for benzoyl peroxide: a broad-spectrum antimicrobial agent.
20.) Topical therapy of leg ulcers with 20 percent benzoyl peroxide lotion.
21.) Treatment of cutaneous ulcers with benzoyl peroxide.
22.) Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer Study Group.
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1.) Promotion and acceleration of diabetic ulcer healing by arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group.
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Author
Steed DL; Ricotta JJ; Prendergast JJ; Kaplan RJ; Webster MW; McGill
JB; Schwartz SL
Address
Department of Surgery, University of Pittsburg, Pennsylvania 15213.
Source
Diabetes Care, 18(1):39-46 1995 Jan

Abstract

OBJECTIVE--To determine the effectiveness and safety of arginine-glycine-aspartic acid (RGD) peptide matrix in the treatment of diabetic foot ulcers.

RESEARCH DESIGN AND METHODS--This randomized placebo-controlled investigator- and patient-blinded prospective multicenter investigation was conducted at three institutional and three private U.S. clinics providing ambulatory care. Sixty-five diabetic patients with chronic full-thickness neurotrophic foot ulcers were enrolled. Six discontinued the study because of adverse events. RGD peptide matrix (Argidene Gel; formerly Telio-Derm Gel) was applied topically twice weekly for up to 10 weeks in patients who otherwise received standard care. Control group patients received topical saline as a placebo plus standard care. The primary method of assessment was the incidence and rate of ulcer closure. All patients enrolled were included in the data analysis.

RESULTS--The percentage of patients whose ulcers healed completely in the RGD peptide matrix group (35%; 14 of 40 patients) was over fourfold greater (P = 0.02) than that in the placebo group (8%; 2 of 25 patients). By the study end point (either day of healing or week 10), 30 of 40 (75%) RGD peptide matrix patients had achieved > 50% ulcer closure compared with 12 of 25 (48%) placebo patients (P = 0.03). RGD peptide matrix also significantly (P = 0.03) increased the rate of ulcer closure over the 10 weeks of the study.

CONCLUSIONS--RGD peptide matrix treatment promoted and accelerated the healing of chronic diabetic foot ulcers to a significant

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2.) Effects of electrical stimulation on wound healing in patients with diabetic ulcers.
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Author
Baker LL; Chambers R; DeMuth SK; Villar F
Address
Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles 90033, USA. [email protected]
Source
Diabetes Care, 20(3):405-12 1997 Mar

Abstract

OBJECTIVE: To evaluate the effects of two stimulation waveforms on healing rates in patients with diabetes and open ulcers. The hypothesis was that stimulus waveforms with minimal polar characteristics would provide significant healing for this patient sample.

RESEARCH DESIGN AND METHODS: This was a prospective study that enrolled 80 patients with open ulcers. Patients received stimulation with either an asymmetric biphasic (A) or symmetric biphasic (B) square-wave pulse. Amplitudes were set to activate intact peripheral nerves in the skin. Two other groups received either very low levels of stimulation current (MC), or no electrical stimulation (C). When combined these groups were referred to as the control group. Treatment was carried out daily until the wound healed, the patient withdrew from the study, or the physician changed the overall wound management program. Average healing rates were calculated from weekly measures of the wound perimeter and were used for statistical comparison through a one-way analysis of variance.

RESULTS: Stimulation with the A protocol significantly increased the healing rate, enhancing healing by nearly 60% over the control rate of healing. Stimulation with the B protocol did not increase the healing rate when compared with control subjects.

CONCLUSIONS:
Electrical stimulation, given daily with a short pulsed, asymmetric biphasic waveform, was effective for enhancement of healing rates for patients with diabetes and open ulcers.

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3.) The use and abuse of wound care materials in the treatment of diabetic ulcerations. =====================================================================
Author Day MR; Fish SE; Day RD Address Nashville Family Foot Care, TN 37203, USA.

Source Clin Podiatr Med Surg, 15(1):139-50 1998 Jan

Abstract With the ever-increasing availability of wound care materials for use in diabetic foot ulcerations, a thorough understanding of the indications and applications of these materials is important for wound-management success. The coupling of a lack of understanding of the interaction of wound care materials and the dynamic nature of wound-healing physiology may lead to a protracted healing course that may constitute an abuse of an otherwise useful adjunct to wound healing protocols. This article provides an overview of wound care products, their indications, and possible complications of inappropriate use.
=====================================================================br> 4.) Relationship of microalbuminuria with the diabetic foot ulcers in type II diabetes.
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Author
GGuerrero-Romero F; Rodr´iguez-Mor´an M
Address
Research Group on Diabetes and Chronic Illnesses, Mexican Social Security Institute, Durango.
Source
J Diabetes Complications, 12(4):193-6 1998 Jul-Aug

Abstract

Microalbuminuria is a significant risk factor associated with nephropathy, retinopathy, and cardiovascular disease; however, there are no previous reports on the relationship of microalbuminuria with diabetic foot ulcers or stroke, despite the fact that microalbuminuria is a marker of vascular damage.

The purpose of this study was to determine the relationship of microalbuminuria with diabetic foot ulcers in type II diabetes patients. In this, cross-sectional clinical study, outpatients of the offices at first level medical care in Durango, Mexico, were included in one of two groups; (a) patients with diabetic foot ulcers and (b) control of group patients without diabetic foot ulcers.

Diabetic foot diagnosis was established on the basis of clinical criteria and pletismography. Patients diagnosed with renal disease, urinary tract infection, acute febrile illness, or heart failure and those receiving angiotensin-converting enzyme inhibitors were excluded from the study. Microalbuminuria was measured, on a 24-h urine collection, by precipitation with sulfasalicylic acid, and turbidity was determined by measuring absorbance with a spectrophotometer.

The study included 670 diabetic patients. Using both odds ratio and logistic regression analyses, diabetes duration, cigarette smoking, aging, and microalbuminuria showed a strong relationship with diabetic foot ulcers. Microalbuminuria should be considered as an independent risk factor for diabetic foot ulcers.
=====================================================================br> 5.) Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration.
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Author
AArmstrong DG; Lavery LA; Vela SA; Quebedeaux TL; Fleischli JG
Address
Department of Orthopaedics, University of Texas Health Science Center, San Antonio, Tex., USA.
Source
Arch Intern Med, 158(3):289-92 1998 Feb 9

Abstract

OBJECTIVE: To evaluate the sensitivity and specificity of 3 sensory perception testing instruments to screen for risk of diabetic foot ulceration.

METHODS: This case-control study prospectively measured the degree of peripheral sensory neuropathy in diabetic patients with and without foot ulcers. We enrolled 115 age-matched diabetic patients (40% male) with a case-control ratio of approximately 1:3 (30 cases and 85 controls) from a tertiary care diabetic foot specialty clinic. Cases were defined as individuals who had an existing foot ulceration or a history of a recently (< 4 weeks) healed foot ulceration. Controls were defined as subjects with no foot ulceration history. Using receiver operating characteristic analysis, we evaluated the sensitivity and specificity of 2 commonly used nephropathy assessment tools (vibration perception threshold testing and the Semmes-Weinstein 10-g monofilament wire system) and a 4-question verbal neuropathy score to evaluate for presence of foot ulceration.

RESULTS: A vibration perception threshold testing using 25 V and lack of perception at 4 or more sites using the Semmes-Weinstein 10-g monofilament wire system had a significantly higher specificity than neuropathy score used. The neuropathy score was most sensitive when 1 or more answers were affirmative. When modalities were combined, particularly the monofilament wire system plus vibration perception threshold testing and the neuropathy score plus the monofilament wire system, there was a substantial increase in specificity with little or no diminution in sensitivity.

CONCLUSIONS: The early detection of peripheral neuropathy or loss of "protective sensation" is paramount to instituting a structured treatment plan to prevent lower extremity amputation. The results of our study suggest that all 3 sensory perception testing instruments are sensitive in identifying patients at risk for ulceration. Combining modalities appears to increase specificity with very little or no diminution in sensitivity.

=====================================================================br> 6.) Effect of topical basic fibroblast growth factor on the healing of chronic diabetic neuropathic ulcer of the foot. A pilot, randomized, double-blind, placebo-controlled study.
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Author
RRichard JL; Parer-Richard C; Daures JP; Clouet S; Vannereau D; Bringer J; Rodier M; Jacob C; Comte-Bardonnet M
Address
Department of Dietetics and Diabetology, Centre Medical, Le Grau du Roi, France.
Source
Diabetes Care, 18(1):64-9 1995 Jan

Abstract

OBJECTIVE--To assess the efficacy and safety of topical human recombinant basic fibroblast growth factor (bFGF) on the healing of diabetic neurotrophic foot ulcers.

RESEARCH DESIGN AND METHODS--Seventeen diabetic patients suffering from chronic neuropathic ulcer of the plantar surface of the foot entered a pilot, randomized, double-blind study comparing local application of bFGF with placebo. Main inclusion criteria were a typical neuropathic ulcer of Wagner grade I-III, more than 0.5 cm in the largest diameter, with an abnormally high vibration perception threshold in the absence of significant peripheral vascular disease or wound infection. bFGF or placebo was applied daily during the 6 weeks as inpatients then twice a week for 12 weeks. Evolution of ulcer size was assessed through weekly clinical examination and computerized photographs.

RESULTS--In the bFGF group, three of nine ulcers healed compared with five of eight in the placebo group (NS). The weekly reduction in ulcer perimeter and area was identical in both groups, as was the rate of linear advance from entry to the 6th week of treatment (bFGF: 0.053 +/- 0.048 mm vs. placebo: 0.116 +/- 1.129 mm): the same result was obtained at the 11th week. Moreover, percent healed area at the end of the study did not differ significantly. No side effects were observed during bFGF application.

CONCLUSIONS--Topical application of bFGF has no advantage over placebo for healing chronic neuropathic diabetic ulcer of the foot. Because diabetes causes significant wound-healing defects, we hypothesized that using a single growth factor might be insufficient to accelerate wound closure of diabetic ulcers.

=====================================================================br> 7.) Prognostic value of the clinical examination of the diabetic foot ulcer.
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Author
Edelman D; Hough DM; Glazebrook KN; Oddone EZ
Address
CCenter for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC 27705, USA.
Source
J Gen Intern Med, 12(9):537-43 1997 Sep

Abstract

OBJECTIVE: To determine the value of the history, physical examination, and magnetic resonance imaging (MRI) in predicting successful primary healing of a foot ulcer in a diabetic patient.

DESIGN: Prospective cohort study.

SETTING: Durham (NC) Veterans Affairs Medical Center.

PATIENTS: Sixty-four consecutive diabetic patients with 78 dermal ulcers through the full thickness of the skin and at or distal to the malleoli of the ankle.

MEASUREMENTS AND MAIN RESULTS: A structured clinical history and physical examination were performed by two examiners, a physician participating in the study and the referring physician. Fifty of these patients with 63 ulcers underwent MRI. Patients were followed prospectively for 6 months after enrollment to ascertainhealing of the ulcer amputation, and death. During the 6-month follow-up period, 8 (13%) of the patients died. Seventeen (22%) of the ulcers were amputated, 17 (22%) of the ulcers failed to heal, and 36 (47%) healed primarily. Univariate predictors of healing at 6 months included age less than 65 years, diagnosis of diabetes within the last 15 years painless ulcer, palpable ankle pulse, anklebrachial index greater than 0.5, and the physician's assessment of the overall likelihood of osteomyelitis. In a multivariable logistic regression model, predictors of healing included the presence of an audible pulse on Doppler examination (p = .01) and a painless ulcer (p = .04). The diagnosis of osteomyelitis on MRI did not predict healing in these patients.

CONCLUSIONS: Foot ulcers in patients with diabetes frequently have poor outcomes; fewer than half the patients in this study healed their ulcers within 6 months. The vascular components of the clinical examination are the best predictors of healing in patients with a diabetic foot ulcer.

=====================================================================br> 8.) Wound healing. New modalities for a new millennium.
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Author
WWilliams RL; Armstrong DG
Address
Department of Anesthesia, University of Texas Health Science Center, San Antonio, USA.
Source
Clin Podiatr Med Surg, 15(1):117-28 1998 Jan

Abstract

Common to all studies of wound healing modalities is the need to convert the chronic wound into an acute wound and to maintain the wound in an acute state while subsequently using adjunctive therapy. Hence, precise control and documentation of wound care is extremely important in order to avoid contamination of the effects of a specific modality with the effects of good wound care. Falanga has noted that neuropathy of diabetes has been given wide support as the primary pathogenic component of diabetic ulcers, whereas less recognition has been made of the wound-healing failure component.

The therapies discussed in this article considered the wound-healing failure component. Oxygen is a drug. The use of oxygen under normobaric conditions at higher than normal inspired partial pressures is standard operating procedure when clinicians are faced with patients with respiratory embarrassment or heart failure. The use of oxygen under hyperbaric conditions, however, remains estranged from the mainstream thoughts of most clinicians. Abnormally hypoxic wounds may benefit from specific oxygen therapy in hyperbaric dosage ranges.

However, correction of abnormal wound oxygen tension alone does not guarantee healing. Hyperbaric studies have been criticized for the lack of well-defined wound care protocols, the absence of precise wound healing measures, and poorly defined wound healing endpoints. Studies with growth factors and human skin equivalents exclude patients typically referred for hyperbaric therapy. Patients referred for hyperbaric therapy often have larger wounds with greater severity of peripheral vascular disease with ABIs < 0.7 and TcPO2 < 30 to 40 mm Hg, are often on medications known to inhibit wound healing (e.g., steroids), or have concomitant medical disorders (collagen vascular disease, renal failure) associated with poor healing. No hyperbaric study has controlled stringently for all of these factors.

Nevertheless, HBO2 is more specific and successful for the intended purpose of correction of abnormal tissue oxygen tensions than are growth factors for the intended purpose of growth. Similarly, skin substitutes are limited in their application and have not been tried in patients with ABIs < 0.7 or TcPO2 values < 30 mm Hg. In our view, hyperbaric therapy probably can be combined successfully with allogenic grafts and human skin equivalents in this group of patients.

Hyperbaric therapy can generate a sufficient granulation base in which these products should be able to close properly selected wounds successfully. No studies of this combined modality approach exist. Finally, regardless of the modality used to aid in wound closure, long-term outcomes probably depend more on neuropathy and large vessel disease than on microangiopathy and local wound-healing defects. The modalities presented in this article must prove to be both cost effective and practical before they are widely disseminated. Nevertheless, the ability to manipulate the local wound environment is no longer inviolate as was once presumed, and current investigations continue to advance therapeutic options in this most fascinating and challenging discipline. Language Eng
=====================================================================br> 9.) Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds?
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Author
Ciaravino ME; Friedell ML; Kammerlocher TC
Address
Department of Surgical Education, Orlando Regional Medical Center, FL 32806, USA.
Source
Ann Vasc Surg, 10(6):558-62 1996 Nov

Abstract

Hyperbaric oxygen (HBO) is currently being used in the treatment of nonhealing or "problem" wounds of the lower extremities. In an attempt to evaluate the efficacy of HBO in problem wounds, a retrospective study of the HBO experience at Orlando Regional Medical Centerbr was conducted. From 1989 to 1994, fifty-four patients with nonhealing lower extremity wounds resulting from underlying peripheral vascular disease and/or diabetes mellitus were treated with HBO. Wounds were grouped into the following five categories: (1) diabetic ulcers (n = 17 [31%]); (2) arterial insufficiency (n = 8 [15%]); (3) gangrenous lesions (n = 6 [11%]); (4) nonhealing amputation stumps (n = 13 [24%]); and (5) nonhealing operative wounds (n = 10 [19%]).

Each patient received an average of 30 treatments. Outcomes for all 54 patients treated with HBO in this study were dismal. None of the patients experienced complete healing, six (11%) showed some improvement, 43 (80%) showed no improvement, and in five cases (9%) results were inconclusive because these patients underwent concomitant revascularization or amputation. Thirty-eight of the 43 patients who showed no improvement (88%) ultimately required at least one surgical procedureto treat their wounds.Thirty-four patients (63%) developed complications, most commonlybarotrauma to the ears,which occurred in 23 patients (43%).

The average cost of 30 HBOtreatments was $14,000excluding daily inpatient charges. Based on the experience with HBOtherapy at OrlandoRegional Medical Center and the paucity of good supporting literature,it is difficult to justifysuch an expensive, ineffective complication-prone treatment modalityfor problem extremitywounds.
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10.) Adjunctive systemic hyperbaric oxygen therapy in treatment of severeprevalently ischemic diabetic foot ulcer. A randomized study.
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Author
Faglia E; Favales F; Aldeghi A; Calia P; Quarantiello A; Oriani G; Michael M; Campagnoli P; Morabito A
Address
Diabetology Center, Niguarda Hospital, Milan, Italy.
Source
Diabetes Care, 19(12):1338-43 1996 Dec

Abstract

OBJECTIVE: To evaluate the effectiveness of systemic hyperbaric oxygentherapy (sHBOT) in addition to a comprehensive protocol in decreasing majoramputation rate indiabetic patients hospitalized for severe foot ulcer.

RESEARCH DESIGN ANDMETHODS: From August 1993 to August 1995, 70 diabetic subjects wereconsecutivelyadmitted into our diabetologic unit for foot ulcers. All the subjectsunderwent ourdiagnostic-therapeutic protocol and were randomized to undergo s-HBOT.Two subjects,one in the arm of the treated group and one in the arm of nontreatedgroup, did not complete the protocol and were therefore excluded from the analysis of the results. Finally, 35 subjects received s-HBOT and another 33 did not.

RESULTS: Of the treated group (mean session = 38.8 +/- 8), three subjects (8.6%) underwent major amputation: two below the knee and one above the knee. In the nontreated group, 11 subjects (33.3%) underwent major amputation: 7 below the knee and 4 above the knee. The difference is statistically significant (P = 0.016). The relative risk for the treated group was 0.26 (95% CI 0.08-0.84). The transcutaneous oxygen tension measured on the dorsum of the foot significantly increased in subjects treated with hyperbaric oxygen therapy: 14.0 +/- 11.8 mmHg in treated group, 5.0 +/- 5.4 mmHg in nontreated group (P = 0.0002). Multivariate analysis of major amputation on all the considered variables confirmed the protective role of s-HBOT (odds ratio 0.084, P = 0.033, 95% CI 0.008-0.821) and indicated as negative prognostic determinants low ankle-brachial index values (odds ratio 1.715, P = 0.013, 95% CI 1.121-2.626) and high Wagner grade (odds ratio 11.199, P = 0.022, 95% CI 1.406-89.146).

CONCLUSIONS: s-HBOT, in conjunction with an aggressive multidisciplinary therapeutic protocol, is effective in decreasing major amputations in diabetic patients with severe prevalently ischemic foot ulcers.

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11.) [Mri and surgical indications in perforating ulcer in diabetic patients]
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Author

Jarde O; Filloux V; Filloux JF; Remond A; Vives P
Address
Service d'orthop´edie-taumatologie, H^opital Nord, AMIENS, France.
Source
Acta Orthop Belg, 63(3):156-64 1997 Sep

Abstract

The authors report a series of thirty-six perforating ulcers of the foot in diabetic patients, evaluated using M.R.I. M.R.I. showed osteomyelitis in 16 cases, cellulitis in 15 cases, osteoarthropathies in 21 cases, tenosynovitis of flexor tendons in 2 cases, oedema in 2 cases and abscess in one case. In 19 cases, M.R.I. was used to improve diagnostic accuracy.

The medical treatment made use of thermo-moulded soles allowing for the recovery of walking, with a hole facing the perforating ulcer of the foot. The application of insulin-soaked sponges in the event of clean perforating ulcer of the foot and iodized solution in the event of infected perforating ulcer of the foot promoted healing. The treatment was only conservative, when the lesions were limited to the soft tissues.

Surgical treatment was performed in 19 cases due to a global involvement of soft and osteoarticular tissues. In fourteen cases the surgical treatment was limited and was performed through the perforating ulcer. Resection of metatarsal heads or metatarso-phalangeal joints was performed in 10 cases, with resection of surrounding pathologic tissue. The surgical treatment was limited to the soft tissues in 6 cases. In 4 cases, M.R.I. findings resulted into a transmetatarsal amputation because the vascular plexus was of poor quality and infection spread from the perforating ulcer to the dorsal aspect of the foot.

In our opinion, dorsal infectious involvement in a perforating ulcer of the foot, is a factor of poor prognosis. A below-knee amputation has been performed in one patient.

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12.) 1995 William J. Stickel Gold Award. High strain rate tissue deformation. A theory on the mechanical etiology of diabetic foot ulcerations.
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Author
Landsman AS; Meaney DF; Cargill RS 2nd; Macarak EJ; Thibault LE
Address
Dr. William M. Scholl College of Podiatric Medicine, Chicago, IL 60610, USA.
Source
J Am Podiatr Med Assoc, 85(10):519-27 1995 Oct

Abstract

Foot ulcerations are one of the most common and dangerous complications associated with chronic diabetes mellitus. Many studies have focused on neuropathy, in conjunction with elevated ground reactive forces, as the principal cause of these ulcerations. The authors discuss the mechanical cause of diabetic ulcerations at the cellular level. It is hypothesized that increased rate of tissue deformation associated with foot slap secondary to progressive motor neuropathy is the actual culprit, and not the magnitude of local pressure applied. The authors present a cellular model that shows that high rates of tissue deformation may result in elevated intracellular calcium concentrations, which may lead to cellular death, while comparable loads gradually applied do not.

Furthermore, there is no significant difference in the response observed at 5 psi and 10 psi. Based on these findings, it is hypothesized that techniques such as ankle foot orthoses, which control the velocity of foot strike, may be useful in treating diabetic foot ulcerations.
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13.) A metabolically active human dermal replacement for the treatment of diabetic foot ulcers.
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Author
Naughton G; Mansbridge J; Gentzkow G
Address
Advanced Tissue Sciences, Inc., La Jolla, California 92037, U.S.A.
Source
Artif Organs, 21(11):1203-10 1997 Nov

Abstract

Tissue engineering, the science of growing living human tissues for transplantation, promises to revolutionize aspects of medical care. Ulcers of the skin of the feet of diabetic patients are a serious health problem and a major cause of amputations. Dermagraft, a tissue-engineered, living human dermal tissue, which provides normal growth factors and matrix proteins, has been implanted to replace a patients' destroyed dermises and heal these ulcers. Large-scale clinical studies and in vitro experiments have demonstrated the importance of controlling specific product parameters, especially the metabolic activity of the tissue, to provide, upon implantation into the wound bed, a living tissue that facilitates healing. Implanting tissue within a defined therapeutic range of metabolic activity dramatically improves healing of diabetic foot ulcers, with significantly more ulcers healed completely in a shorter time. In this new, rapidly moving science, such elucidation of the mechanism of action is vital to ensure that tissues will provide their intended
benefit.
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14.) Cavity foot ulcers in diabetic patients: a comparative study of cadexomer iodine ointment and standard treatment. An economic analysis alongside a clinical trial.
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Author
Apelqvist J; Ragnarson Tennvall G
Address
Department of Internal Medicine, University Hospital of Lund, Sweden.
Source
Acta Derm Venereol, 76(3):231-5 1996 May

Abstract

Diabetic foot ulcers with exposure of tendon, muscle, or bone imply a high probability for deep infections and amputations. Delayed healing times are often described. The aim of this study was to compare the clinical effect and economic cost of cadexomer iodine with standard treatment in diabetic feet with cavity ulcers. Patients with deep, exudative foot ulcers were included in a 12-week open, randomised, comparative study. When ulcers stopped exudating, vaseline gauze was used in both groups until the end of the study. Costs were estimated for dressing material, staff and transportation.

Clinically relevant improvement was seen in 12 patients treated with cadexomer iodine and in 13 patients treated with standard treatment. The average weekly cost was SEK 903 and SEK 1,421, respectively, of which the major part was costs for staff and transportation related to frequency of dressing changes. Treatment with cadexomer iodine ointment (Iodosorb) showed no clinical difference compared to topical treatment consisting of gentamicin solution, streptodornase/streptokinase, or dry saline gauze but was associated with considerably lower weekly treatment costs.

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15.) Power spectral analysis of heart rate variation in diabetic patients with neuropathic foot ulceration.
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Author
Aso Y; Fujiwara Y; Inukai T; Takemura Y
Address
Department of Medicine, Koshigaya Hospital, Dokkyo University School of Medicine, Saitama, Japan.
Source
Diabetes Care, 21(7):1173-7 1998 Jul

Abstract

OBJECTIVE: To evaluate the relationship between diabetic autonomic neuropathy and diabetic neuropathic foot ulceration, we used power spectral analysis (PSA) of heart rate variation, which provides the accurate simultaneous quantification of parasympathetic and sympathetic activities, to assess autonomic function in diabetic patients.

RESEARCH DESIGN AND METHODS: We studied 55 NIDDM patients including 10 diabetic patients without neuropathy, 23 diabetic patients with neuropathy and no history of foot ulceration, and 22 diabetic patients with neuropathic foot ulceration. We performed PSA of 100 R-R intervals at rest and analyzed the results by fast Fourier transformation.

RESULTS: The low frequency (LF) power, which reflects sympathetic activity, and the high frequency (HF) power, which reflects parasympathetic (vagal) activity, were inversely correlated with the duration of diabetes and the fasting plasma glucose (FPG) levels. By multiple regression analysis, the FPG remained with significant influence on both LF and HF powers. The LF and HF powers were positively correlated with motor nerve conduction velocity (MCV) and sensory nerve conduction velocity (SCV) in the upper and lower limbs and the coefficient of variation of R-R intervals. The LF and HF powers were significantly reduced in patients with neuropathy and patients with foot ulceration compared with patients without neuropathy. Although the median MCV and SCV were similar between diabetic patients with neuropathy and patients with foot ulceration, both the LF and HF powers were significantly decreased in patients with foot ulceration compared with patients with neuropathy. There was no difference in the value of the LF:HF ratio, an index of sympathovagal balance, among three subgroups. We observed a positive correlation between LF and HF power in all subjects; however, the LF and HF powers were not correlated in the subgroups of patients with foot ulceration.

CONCLUSIONS: These results showed that diabetic patients with neuropathic foot ulceration have a greater impairment in spectral indexes of autonomic activity obtained by PSA than patients with neuropathy and no history of foot ulceration, whereas no difference was present in nerve conduction velocities.

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16.) [Prognostic factors in treatment of diabetic foot ulcers]
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Author
Coerper S; Flesch I; Becker HD; K¨oveker G
Address
Abteilung f¨ur Allgemeine Chirurgie, Chirurgische Universit¨atsklinik T¨ubingen.
Source
Langenbecks Arch Chir Suppl Kongressbd, 114():566-8 1997

Abstract

138 patients with nonhealing diabetic foot ulcers were treated between 1994 and 1996. Sixty-nine percent of these foot ulcers healed within 17 weeks. Heel ulcers had a significantly lower healing rate, probably because of the difficulty of taking weight-bearing off this zone. Ischemia also correlated well with low healing rates, underlining the importance of vascular diagnosis and surgery. Since compliance is the most significant factor for success, it is mandatory to educate the patient about his disease and prevent further complications.

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17.) Total contact casting for diabetic neuropathic ulcers.
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Author
Sinacore DR
Address
Program in Physical Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA.
Source
Phys Ther, 76(3):296-301 1996 Mar

Abstract

Despite its limited therapeutic use, several research reports indicate that TCC is currently the most rapid and effective technique for healing diabetic neuropathic ulcers. Skilled application and careful follow-up of the wound are necessary to avoid complications and minimize the risks for reulceration. As more clinicians adopt this form of therapy, the successful treatment of neuropathic ulcers using TCC should result in a lower incidence of infection, hospitalization and lost income in patients with chronic sensory neuropathies.
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18.) Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon.
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Author
Grant WP; Sullivan R; Sonenshine DE; Adam M; Slusser JH; Carson KA; Vinik AI
Address
Tidewater Foot and Ankle Center, Virginia Beach, Virginia, USA.
Source
J Foot Ankle Surg, 36(4):272-8; discussion 330 1997 Jul-Aug

Abstract

Fine structural changes in the Achilles tendons of patients with long-term diabetes mellitus were investigated. All patients had clinical and electrophysiological evidence of diabetic neuropathy and had ulceration and/or Charcot neuroarthropathy. Several differences between tendons of diabetic (n = 12) and nondiabetic (n = 5) individuals were observed by electron microscopy. In diabetics, these differences included increased packing density of collagen fibrils, decreases in fibrillar diameter, and abnormal fibril morphology. In one diabetic patient, individual collagen fibrils were tightly apposed so that many areas of tendon appeared as a single mass of closely adhering fibrillae. In addition, foci in which collagen fibrils appeared twisted, curved, overlapping and otherwise highly disorganized were common in specimens from most patients (11 of 12).

These morphologic abnormalities in the Achilles tendons of diabetics appear to reflect a poorly known process of structural reorganization that may be the result of nonenzymatic glycation expressed over many years. Such structural changes could contribute to the tightening of the Achilles tendor a phenomenon consistent with clinical observations of extreme shortening of the Achilles tendon-gastrocnemius-soleus complex common in advanced diabetic neuropaths.

In patients with diabetic neuropathy, tendon shortening causes severe equinus that may precipitate serious ulceration, stress fractures, and Charcot collapse of the foot. However, in nondiabetics, the fine structure of the Achilles tendon appears normal, consistent with the finding that the ultrastructural changes result from diabetes rather than neuropathy.
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19.) - New uses for benzoyl peroxide: a broad-spectrum antimicrobial agent.
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SO - Int J Dermatol 1977 Jun;16(5):413-7
AU - Kligman AM; Leyden JJ; Stewart R
MJ - Benzoyl Peroxide [therapeutic use]; Peroxides [therapeutic use]; Tinea [drug therapy]
MN - Tinea Pedis [drug therapy]; Tinea Versicolor [drug therapy]
MT - Human
PT - JOURNAL ARTICLE

AB - Benzoyl peroxide is a useful agent in the treatment of acne, chronic ulcers, tinea pedis, and tinea versicolor, probably because of its antimicrobial power. 2.5% concentration is almost as active as 5%. Although potential irritancy and allergic reaction have not been a problem on the face, benzoyl peroxide should be used judiciously in chronically inflamed or ulcerated skin. Several potential uses are mentioned.

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20.) Topical therapy of leg ulcers with 20 percent benzoyl peroxide lotion.
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SO - Cutis 1978 Apr;21(4):491-4
AU - Colman GJ; Roenigk HH Jr
MJ - Benzoyl Peroxide [therapeutic use]; Leg Ulcer [drug therapy]; Peroxides [therapeutic use]
MN - Administration, Topical; Benzoyl Peroxide [administration & dosage];
Leg Ulcer [pathology]
MT - Human
PT - JOURNAL ARTICLE

AB - Preliminary clinical observations suggest that benzoyl peroxide lotion (20%) may be a useful topical treatment for various types of leg ulcers. Further studies utilizing patients as their own controls (treating half of the ulcer surface with 20% benzoyl peroxide) are now underway.

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21 - Treatment of cutaneous ulcers with benzoyl peroxide.
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SO - Can Med Assoc J 1976 Dec 4;115(11):1101-6
AU - Pace WE
MJ - Benzoyl Peroxide [therapeutic use]; Peroxides [therapeutic use]; Skin Ulcer [drug therapy]
MN - Administration, Topical; Adult; Aged; Benzoyl Peroxide
[administration & dosage] [adverse effects]; Child, Preschool; Child; Methods; Middle Age; Skin Ulcer [pathology] MT - Case Report; Female; Human; Male
PT - JOURNAL ARTICLE

AB - Benzoyl peroxide, a powerful organic oxidizing agent, was applied topically according to a carefully developed technique to cutaneous ulcers of different types. The healing time was shortened greatly by the rapid development of healthy granulation tissue and the quick ingrowth of epithelium. Exceptionally large pressure ulcers with deep cavities, undercut edges and sinus tracts were sucessfully treated, as were stasis ulcers of long duration resistant to all other therapy. There were only 13 treatment failures among the 133 cases. The slow, sustained release of oxygen by benzoyl peroxide was though to be responsible for the success. The only complications were contact irritant dermatitis in 3% and contact allergic dermatitis in 2% of patients treated.
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22.) Clinical evaluation of recombinant human platelet-derived growth factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer Study Group.
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Author
Steed DL
Address
University of Pittsburgh, Presbyterian University Hospital, PA 15213.
Source
J Vasc Surg, 21(1):71-8; discussion 79-81 1995 Jan

Abstract

PURPOSE: The purpose of this study was to investigate the efficacy and safety of recombinant human platelet-derived growth factor (rhPDGF-BB) in a double-blind, placebo-controlled, multicenter study of patients with chronic diabetic ulcers.

METHODS: Patients with chronic, full-thickness, lower-extremity diabetic neurotrophic ulcers of at least 8 weeks' duration, free of necrotic and infected tissue after debridement, and with transcutaneous oxygen tensions of 30 mm Hg or greater were studied. A total of 118 patients were randomized to receive either topical rhPDGF-BB (2.2 micrograms/cm2 of ulcer area) or placebo until the ulcer was completely resurfaced or for a maximum of 20 weeks, whichever occurred first.

RESULTS: Twenty-nine (48%) of 61 patients randomized to the rhPDGF-BB group achieved complete wound healing during the study compared with only 14 (25%) of 57 patients randomized to the placebo group (p = 0.01). The median reduction in wound area in the group given rhPDGF-BB was 98.8% compared with 82.1% in the group given placebo (p = 0.09). There were no significant differences in the incidence or severity of adverse events between the rhPDGF-BB and placebo groups.

CONCLUSIONS: Once-daily topical application of rhPDGF-BB is safe and effective in stimulating the healing of chronic, full-thickness, lower-extremity diabetic neurotrophic ulcers.
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DATA-MÉDICOS/DERMAGIC-EXPRESS No(14) 10/11/98 DR. JOSÉ LAPENTA R.
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