Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers

The importance of wound classification and site of ulceration was evaluated in 314 consecutive diabetic patients with foot ulcers. The ulcers were classified as superficial (through the full thickness of the dermis; n = 150), deep (n = 50), osteomyelitis and/or abscess (n = 46), minor gangrene (n = 39) or major gangrene (n = 29). Wound healing was defined as intact skin for at least 6 months. In patients with superficial and deep ulcers, primary healing occurred in 88% and 78%, respectively, compared with 57% in those patient who developed an abscess and/or osteomyelitis. Only 2 out of 68 patients with gangrene healed (through mummification) without amputation. Patients with gangrene had lower ankle and toe blood pressure than patients with all other types of ulcers. There were only marginal differences in primary healing rate between different ulcer sites. The highest rate was seen in ulcers localized to the metatarsal heads (78%). Patients with multiple ulcers had the lowest primary healing rate (5%) compared with single ulcers at all sites. These differences were probably due to circulatory factors, since patients with multiple ulcers had lower distal perfusion pressures compared with all other groups.

The prevalence of retinopathy and associated medical risk factors in type I (insulin-dependent) diabetes mellitus

The prevalence of diabetic retinopathy and the associated medical risk factors, such as age at onset and duration of diabetes, metabolic control, blood pressure, albumin clearance and serum creatinine, were studied in 501 patients with type I diabetes mellitus. The prevalence of retinopathy, characterized as simplex, maculopathy, preproliferative, and proliferative, was 60.5%. Patients with retinopathy were younger at the onset of diabetes, and had a longer duration of disease. In patients with more than 10 years of diabetes, proliferative retinopathy was more frequent if onset was before they were 15 years old, despite the fact that the duration of diabetes did not differ. Patients with severe retinopathy had worse metabolic control, and were more frequently treated for hypertension. In addition, the systolic blood pressure was elevated in all groups of patients with any type of retinopathy, whereas the diastolic blood pressure was elevated only in patients with more severe forms. Patients with severe retinopathy also had higher levels of albumin clearance.

Prognostic value of systolic ankle and toe blood pressure levels in outcome of diabetic foot ulcer

The prognostic value of distal blood pressure measurements has been studied in 314 consecutive diabetic patients with foot ulcers. Systolic toe blood pressure was measured with a strain-gauge technique, and ankle pressure was measured with strain-gauge or Doppler techniques. Wound healing was defined as intact skin for at least 6 mo. One hundred ninety-seven patients healed primarily, 77 had amputations, and 40 died before healing had occurred. In 294 of 300 patients, it was possible to measure either ankle or toe pressure. Fourteen patients were not available for pressure measurements. Of these, 10 patients healed primarily, and 4 died before healing occurred. Both ankle and toe pressures were higher (P less than .001) among patients who healed without amputation compared with those who underwent amputation or died before healing. No differences were seen in ankle or toe pressure levels among those who had amputations or died. No patient healed primarily with an ankle pressure less than 40 mmHg. An upper limit above which amputation was not required could not be defined. Primary healing was achieved in 139 of 164 patients (85%) with a toe pressure level greater than 45 mmHg, whereas 43 of 117 patients (36%; P less than .001) healed without amputation when toe pressure was less than or equal to 45 mmHg. In conclusion, a combination of ankle and toe pressure measurements is a useful tool to predict primary healing in diabetic foot ulcers.

Nicotine does not affect plasma lipoprotein concentrations in healthy men

The effects of nicotine administration (2 mg eight-times daily as nicotine chewing gum for two weeks) on plasma lipid and lipoprotein concentrations were studied in young healthy volunteers. Plasma levels of the nicotine metabolite, cotinine, reached levels comparable to those seen in smokers. Plasma concentrations of triglyceride, cholesterol, HDL cholesterol, LDL cholesterol, and apolipoproteins AI and B, were determined repeatedly before, during and after cessation of nicotine intake. All these variables, as well as the activities of lipoprotein lipase and hepatic lipase in post-heparin plasma, remained unchanged throughout the study. The results strongly suggest that the effects of smoking on plasma lipoprotein metabolism are not mediated via nicotine, and indicate that nicotine chewing gum, when used therapeutically in anti-smoking programmes, does not carry the same metabolic side effects as smoking.

High density lipoprotein concentrations after cessation of smoking: the importance of alterations in diet

Cessation of smoking is followed by a rapid rise in plasma HDL concentrations. An earlier study has demonstrated a significant relationship between the increase in HDL concentrations and spontaneous changes in food intake, specifically an increased fat intake. In this investigation we have dissociated the effects of cessation of smoking as such from those of dietary alterations by monitoring plasma lipid and lipoprotein concentrations after cessation of smoking in 12 subjects whose diet was kept constant during an initial 2-week control period and during 2 weeks following cessation of smoking. Under these conditions plasma HDL-cholesterol levels did not increase significantly (1.01 +/- 0.26 mmol/l (mean +/- SD) before and 1.04 +/- 0.27 mmol/l after cessation of smoking). Similarly, no significant alterations were recorded for other plasma lipid or lipoprotein concentrations. Activities of lipoprotein lipase and hepatic lipase were unchanged throughout the study. These results suggest that the marked rise in HDL concentrations after stopping smoking is largely related to spontaneous changes in dietary habits which occur upon cessation of smoking.

The influence of different insulin regimens on quality of life and metabolic control in insulin-dependent diabetics

Administration of insulin with premeal boluses of short-acting insulin using a new injection device (Novopen) was compared with a conventional three times daily injection regimen regarding aspects of quality of life and metabolic control in insulin-dependent diabetes mellitus (IDDM). Eighteen C-peptide-negative patients with IDDM (16 men, two women, aged 31.0 +/- 7.4 years, duration of diabetes 13.0 +/- 4.6 years; mean +/- SD) participated in the study. All patients had been treated with three daily insulin injections for at least 1 year prior to the study. The patients were randomized into two groups. Group A started a 3-month treatment period with premeal injections of short-acting insulin and intermediate-acting insulin at bedtime. This period was followed by another 3 months using the initial three times daily injection regimen. Group B completed the study in the reverse order. Quality of life was assessed by using questionnaires and personal interviews by the same clinical psychologist. Metabolic control was assessed by measuring the levels of glycosylated hemoglobin. The results show that both treatment groups experienced a general improvement in mood and well-being during the period with multiple insulin injection treatment. Furthermore, during the periods of insulin pen treatment, an increased experience of freedom and less dependence on fixed meal times were noted. Overall metabolic control, insulin dosage, body weight, and number of hypoglycemic episodes did not change during the study. It is concluded that metabolic control, safety, and number of hypoglycemic episodes using premeal doses of short-acting insulin using Novopen were not different from those seen during conventional treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Optic disc swelling in an insulin-dependent diabetic. A result of drastic improvement of glucose control?

Rapid improvement of glucose control in diabetics may cause a transient progression of ischemic retinopathy. We report a transient bilateral acute asymptomatic optic disc swelling associated with rapid improvement of metabolic control in a male Type I diabetic. It is d, suggested that the optic disc swelling could be caused n of by a rapid near-normal normalization of the blood glucose.

Urinary N-acetyl-beta-D-glucosaminidase activity does not predict development of diabetic nephropathy

Urinary activity of N-acetyl-beta-D-glucosaminidase (NAG) has been suggested as a marker for diabetic nephropathy. In this study, urinary activity of NAG was measured with an interval of 5 yr in 36 insulin-dependent diabetic subjects to evaluate its predictive value for development of diabetic nephropathy. During the observation period, 9 patients developed detectable signs of diabetic nephropathy. In these patients, urinary albumin concentration had increased to 503 +/- 185 mg/L, compared to 16 +/- 1 mg/L in patients without nephropathy (P less than .01; means +/- SE), and the fractional albumin excretion rate was 0.21 +/- 0.07 X 10(-3), compared to 0.01 +/- 0.00 X 10(-3) (P less than .01). However, the activity of urinary NAG was not different in these patients compared with the patients without nephropathy (0.69 +/- 0.15 and 0.61 +/- 0.09 U/mmol creatinine, respectively). Furthermore, no increase in the activity of urinary NAG was seen during the observation period in either group. We concluded that the urinary activity of NAG is not related to the development of microalbuminuria and therefore cannot be used as a predictor for the development of diabetic nephropathy.

Lack of relationship between beta-hexosaminidase activity and retinopathy in insulin dependent diabetics

Beta-hexosaminidase activity in plasma and urine was measured and compared in insulin dependent diabetics (IDDM) with and without proliferative retinopathy. No difference in the activity of beta-hexosaminidase was found between the two groups indicating that this enzyme is not involved in the development of diabetic microangiopathy.

Platelet aggregation in type I diabetics with and without proliferative retinopathy

The cause of retinopathy in diabetes mellitus is unknown. Among factors suggested to be involved in the development of retinopathy is altered platelet function. In the present study, platelet aggregation was measured in vitro after stimulation with adenosine diphosphate (ADP) and collagen in patients with and without proliferative retinopathy. The results show that patients with proliferative retinopathy have an increased platelet aggregation in vitro after stimulation with collagen and ADP. However, the increased platelet aggregation was also found to be correlated to the duration of diabetes. Thus, the present study does not support the opinion that abnormal platelet function can be regarded as a primary cause of diabetic retinopathy. Increased platelet aggregation seems to be coupled to the duration of diabetes and to still unknown factors developing with prolonged duration of the disease.

Exercise stimulation in insulin-dependent diabetics, normal increase in albuminuria with abnormal blood pressure response

Increased urinary albumin excretion rate (AER), microalbuminuria, has been regarded as a sign of incipient nephropathy. The influence of exercise on AER was investigated in 10 male type I diabetics and in 12 age-matched male controls. The duration of diabetes was 7-31 years (median 14 years). The exercise tests were performed both as a combined submaximal workload-waterload test and as a maximal workload test. Urinary albumin was measured with an ELISA technique. During exercise in both tests, no difference was seen in the AER between diabetics and their controls. However, the increase in systolic blood pressure was significantly more marked in the diabetics. There was no correlation between the blood pressure response during exercise and the AER, neither in the diabetics, nor in their controls. It is concluded, that, increased blood pressure response during exercise does not necessarily result in increased AER in type I diabetics.

Retinopathy and nephropathy in insulin-dependent diabetics: an inconsistent relationship?

The association between retinopathy and nephropathy was investigated in a retrospective study of 52 insulin-dependent diabetics with preproliferative or proliferative retinopathy and in 48 patients without or with background retinopathy. The duration of diabetes was 23.2 +/- 1.0 years (mean +/- SEM) and 22.0 +/- 1.2 years in the two groups. Patients in the retinopathy group showed a higher frequency of detectable nephropathy and were more often treated with antihypertensive drugs. However, a high proportion (35%) of patients with proliferative retinopathy did not show any detectable signs of nephropathy. Furthermore, nephropathy did not seem to develop in patients with retinopathy during an observation period of up to 9 years. The data suggest that the factors underlying the development of retinal and renal microangiopathy might be of different origin.

Influence of treatment with diethylstilbestrol for carcinoma of prostate on platelet aggregation and plasma lipoproteins

Treatment of prostatic carcinoma with estrogens is accompanied by an increased risk for thromboembolic and cardiovascular complications. The underlying mechanisms are still unknown. Patients treated with diethylstilbestrol (DES) were compared with patients given no estrogen treatment regarding factors (platelet aggregation in vitro and plasma lipoproteins) that have been suggested to contribute to increased thrombogenesis and cardiovascular risk. The results do not show any increase in in vitro platelet aggregation in patients treated with DES compared with those given no treatment. This indicates that hyperaggregability does not contribute to the increased incidence in thromboembolic events seen in DES-treated patients. This is in contrast to the increased platelet aggregation previously described in patients treated with polyestradiolphosphate + etinylestradiol. The changes in plasma lipoproteins observed during DES-treatment are generally considered beneficial from an atherogenic point of view and do not appear to cause the elevated incidence of cardiovascular disease in these patients.

Normal eyes in type 1 diabetics stay normal after one year of treatment with continuous subcutaneous insulin pump

Seven patients with type 1 diabetes mellitus were restored to near normoglycaemia by treatment with continuous subcutaneous insulin infusion pumps (CSII). The patients were examined with ophthalmoscopy, fundus photography and fluorescein angiography before and one year after the start of CSII treatment. In addition, ophthalmoscopy was performed after 6 months of treatment. All 14 eyes were normal prior to the CSII treatment and none had developed any signs of retinopathy after 6 months or 1 year. It is concluded that metabolic control can be near normalized with CSII treatment without any risk for development of diabetic microangiopathy in type 1 diabetics with normal eyes.

The influence of plasma insulin concentrations on tissue insulin levels in rodents: a study of the diabetic Chinese hamster and the ob/ob mouse

Immunoreactive insulin was measured in acid-ethanol extracts of kidney, brain, liver, and heart from genetically diabetic Chinese hamsters and their nondiabetic controls and from obese (ob/ob) mice and their thin littermates. Selected samples were filtered on Sephadex G-50 columns and the insulin concentration determined. There was a good correlation between the insulin level measured in the acid-ethanol extracts of tissues and the insulin level after gel filtration, suggesting that the concentration measured in the whole extract is representative of the true insulin content. The present data demonstrate that different extrapancreatic organs contain characteristic amounts of insulin that are often (sometimes several-fold) higher than the insulin level of plasma. The tissue insulin concentrations also exhibit a wide range of values, with occasional high values. The data also show a direct correlation between plasma and kidney insulins but no relationship between plasma and brain insulins and a mixed correlation among plasma and liver and heart insulins.

Lack of relation between glycosylated haemoglobin concentrations and number of daily insulin injections: cross sectional study in care of ambulatory diabetes

Diabetic treatment aims at achieving a normal blood glucose concentration as reflected by the glycosylated haemoglobin concentration. Intensive treatment by insulin pump or multiple insulin injections is thought to achieve this. In an unselected group of outpatient diabetics metabolic control was the same after one, two, three, or more injections, which suggests that the mode of treatment was optimal for each group.

Diabetic control in community care. The use of clinical evaluation and hemoglobin A1

Diabetic control was evaluated in 50 consecutive patients attending a community care centre, either by clinical criteria or by determination of glycosylated hemoglobin (HbA1). Two methods used for the determination of HbA1 were found to give similar results, namely ion exchange chromatography and agar gel electrophoresis. On a group basis, good correlation was observed between HbA1 samples analysed prior to and following the elimination of the labile HbA1 fraction. When comparing three treatment modes (diet alone, hypoglycemic agents or insulin), no significant differences in HbA1 levels were noted. Patients considered to have satisfactory and poor control had significantly higher HbA1 levels than those considered to have good control, while no differences were seen between those considered to have satisfactory or poor control. It is concluded that the methods described for the determination of HbA1 yield similar results. Clinical evaluation of diabetic control is reliable in patients classified to have good or poor control. However, in many patients who are considered to have satisfactory control, regular determinations of HbA1 provide valuable additional information.

Unique features of the insulin receptor in rat brain

We examined the structure of the affinity-labeled insulin receptors in rat brain, rat liver, and human IM-9 lymphocytes using sodium dodecyl sulfate-polyacrylamide gel electrophoresis. In gels run under reducing conditions, the alpha-subunit of the insulin receptor in brain had an apparent Mr of 127,000 distinctly lower than that seen in both rat liver and human lymphocytes (apparent Mr = 136,000). Exposure to neuraminidase increased the electrophoretic mobility of the liver receptor, but had no effect on the insulin receptor in brain. The carbohydrate moieties of the insulin receptors in rat brain and liver were further examined by chromatography on wheat-germ agglutinin agarose. The receptors in both tissues adsorbed to the wheat-germ agglutinin; elution with 0.3 M N-acetyl glucosamine resulted in slightly better recovery of the brain than of the liver receptor. Exposure to neuraminidase virtually abolished the interaction of the liver receptor with the lectin, whereas adsorption of the brain receptor was unaffected by neuraminidase. These results indicate that the insulin receptor in brain is distinguished from those in peripheral tissues by structural alterations, including changes in the carbohydrate moiety of the receptor. Such alterations contrast sharply with the previously observed similarities in insulin binding properties between insulin receptors in brain and other tissues. The implications of such structural alterations for the program of insulin action expressed by the receptors in brain remain to be explored.

The influence of treatment with estrogens and estramustine phosphate on platelet aggregation and plasma lipoproteins in non-disseminated prostatic carcinoma

The treatment of prostatic carcinoma with estrogens is associated with an increased risk of cardiovascular as well as thromboembolic complications. In the present study, patients harboring highly or moderately differentiated prostatic carcinoma without signs of metastases were treated with either polyestradiolphosphate + etinylestradiol, estramustine phosphate or given no treatment. Subsequently, these patients were investigated regarding factors (platelet aggregation, plasma and platelet phospholipid composition and lipoprotein patterns) that might contribute to increased thrombogenesis and cardiovascular risk. The results indicate the presence of increased in vitro platelet aggregation in patients treated with polyestradiolphosphate + etinylestradiol compared to those treated with estramustine phosphate or given no treatment. A possible relationship between the availability of arachidonic acid in platelet membrane phospholipids and in vitro platelet aggregation is suggested. On the other hand the alterations in plasma lipoproteins observed during treatment are generally considered positive from an atherogenic point of view and do not seem relevant to the elevated incidence of cardiovascular disease in these patients.

Persistent vegetative state with high cerebral blood flow following profound hypoglycemia

A persistent vegetative state (severe dementia) developed in a 30-year-old man following hypoglycemic coma. Despite the poor clinical outcome, sensory evoked response recovered between 6 and 34 months after the insult. The cerebral blood flow level at rest after 34 months was slightly above the normal range. This finding contrasts with the low cerebral blood flow regularly reported in patients who are comatose or stuporous following severe brain hypoxia-ischemia.

The influence of total hepatectomy on cerebral energy state, ammonia-related amino acids of the brain and plasma amino acids in the rat

The influence of total hepatectomy on cerebral energy state, ammonia-related amino acids of the brain tissue and plasma amino acids was studied in anaesthetized rats after total hepatectomy. The hepatectomy was performed with the aid of a microsurgical three-stage procedure. In the first stage, division of the inferior vena cava was performed. In the second stage 4 weeks later a porta-caval anastomosis was constructed, followed after 1 week by a total hepatectomy. The brain energy state, defined as the concentrations of phosphocreatine, ATP, ADP and AMP, was unchanged 4 h after the hepatectomy. Plasma amino acids did not differ significantly between hepatectomized and shunted control rats. On the other hand, clear-cut increases in the concentrations of glutamine, and decreases in the concentrations of glutamate and aspartate, were observed in the fronto-parietal part of the cerebral cortex and the brain stem. These changes might explain the minor manifestations of cerebral dysfunction in the early phase of the hepatectomized state.

Desensitisation as a means of preventing untoward reactions to ionic contrast media

Patients with a previous history of anaphylactic reactions to ionic iodinated contrast media were desensitised before a second radiologic examination was performed. The tolerance to the contrast medium was raised by repeated intravenous injections in increasing doses and concentrations. No serious side effects were noted when the examinations with contrast medium was repeated within a few days after the desensitisation. The positive effect of the desensitisation may depend on a successive consumption of complement proteins, probably responsible for the allergic reactions. Therefore, the available amount of complement for some days may be too low for the occurrence of a complement reaction.