Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?

The purpose of this retrospective study was to evaluate the changes in diabetes-related lower extremity amputations following the implementation of a multidisciplinary programme for prevention and treatment of diabetic foot ulcers in a 0.2 million population with a 2.4% prevalence of diabetes. All diabetes-related primary amputations from toe to hip from 1 January 1982 to 31 December 1993 were included. In 294 diabetic patients, 387 primary major (above the ankle) or minor (through or below the ankle) amputations were performed, constituting 48% of all lower extremity amputations. The annual number of amputations at all levels decreased from 38 to 21, equalling a decrease of incidence from 19.1 to 9.4/100,000 inhabitants (p = 0.001). The incidence of major amputations decreased by 78% from 16/1 to 3.6/100,000 inhabitants (p < 0.001). The absolute number of amputations with a final level below the ankle showed no increase, but their proportion increased from 28 to 53% (p < 0.001) and the reamputation rate decreased from 36 to 22% (p < 0.05) between the first and last 3-year period. Thus, a substantial long-term decrease in the incidence of major amputations was seen as well as a decrease in the total incidence of amputations in diabetic patients. Seventy-one per cent of the amputations were precipitated by a foot ulcer. These findings indicate that a multidisciplinary approach plays an important role to reduce and maintain a low incidence of major amputations in diabetic patients.

Effects of graded glutamine intake on liver protein metabolism following partial hepatectomy

OBJECTIVE

To elucidate whether glutamine can influence the rate of regeneration and protein metabolism in regenerating liver.

DESIGN

Liver regeneration rate, protein content and synthesis were measured in rats 7 days after a liver resection or sham operation. After the operation, the rats were fed three elementary isonitrogenous diets, one without and two including different levels of glutamine.

METHODS

Fifty-six rats were randomly assigned to either sham operation or liver resection. After the operation, they received an isonitrogenous, isocaloric elementary diet with a glutamine content of 0, 2 or 4%. The resected part of the liver was weighed and analysed for DNA and protein content. Seven days later, hepatic protein synthesis was measured by the flooding method using L-[3H]-phenylalanine, and the liver was analysed for DNA, RNA and protein content.

RESULTS

The regeneration rate was higher in the group receiving 2% glutamine but not in the group receiving 4% glutamine than in the 0% group. Total protein content was increased in regenerating liver in the 2 and 4% glutamine groups compared with the 0% group. Protein synthesis was higher 7 days after liver resection than in sham-operated rats. In the 2% group there was a tendency towards increased protein synthesis compared with the 0% group.

CONCLUSION

A diet with normal glutamine content improved liver regeneration rate, total protein content and protein synthesis in regenerating liver, but an excess of glutamine did not enhance this effect.

Hyperbaric oxygen treatment attenuates glutathione depletion and improves metabolic restitution in postischemic skeletal muscle

Glutathione serves as an important intracellular defence against reactive oxygen metabolites and has been shown to be depleted from a number of tissues upon oxidative stress. In the present study we have investigated the levels of total glutathione (reduced + oxidized) in skeletal muscle of the rat after prolonged ischemia and reperfusion with and without treatment with hyperbaric oxygen (HBO) for the initial 45 minutes immediately following reperfusion. A tourniquet model for temporary, total ischemia was used, in which one hind leg was made ischemic for 3 or 4 hours. Muscle biopsies were taken after 5 hours of reperfusion. In postischemic muscle there was a significant decrease of total glutathione compared to control muscle, but in the 3-hour-ischemia-groups the loss of total glutathione was less in HBO treated animals than in untreated. HBO treatment also preserved ATP and PCr and decreased edema formation in the postischemic muscle following 3 hours of ischemia and reperfusion when compared to untreated animals. However, after 4 hours of ischemia, HBO treatment failed to improve any of these parameters in the postischemic muscle. Thus, our results demonstrate that HBO treatment lessens the metabolic, ischemic derangements and improves recovery in postischemic muscle after 3 hours of ischemia followed by reperfusion.

Effect of postoperative insulin-like growth factor I supplementation on protein metabolism in humans

Insulin-like growth factor I (IGF-I) has been shown experimentally to exert a nitrogen-sparing effect in both animals and humans. Its effects on protein metabolism during the first 5 days after radical large bowel resection were investigated. Nineteen patients were randomly allocated to receive either human recombinant IGF-I (2 x 80 micrograms/kg body weight subcutaneously, n = 10) or placebo (n = 9) starting on the morning of the first day after operation. All patients received parenteral nutrition (glucose 3 g and nitrogen 0.1 g/kg/day). The mean(s.e.m.) urinary nitrogen:creatinine ratio was significantly reduced in patients who received IGF-I compared with those given placebo (275.0(17.1) compared with 386.3(23.6), P < 0.01). The mean urinary 3-methylhistidine:creatinine ratio and nitrogen balance were lower in the IGF-I group, but not significantly so. Plasma IGF-I concentrations were four times higher in the treated group compared with those in the placebo group. Insulin-like growth factor binding protein 3 (IGFBP-3) increased significantly after the start of IGF-I treatment, compared with mean postoperative levels. The mean blood glucose concentration was significantly lower in the IGF-I group than the placebo group (P < 0.05) but no patient had a hypoglycaemic attack. The authors conclude that IGF-I does not significantly influence the nitrogen balance, but that results indicate a possible nitrogen-sparing effect in patients after major abdominal operations. IGF-I therapy is safe, and may be of value in catabolic patients after serious injury and major operations.

Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting

The purpose of this study was to analyze long-term costs for foot ulcers in diabetic patients. Patients were treated and followed prospectively by a foot care team. A retrospective economic analysis was performed of costs for 274 patients during 3 years from healing of an initial foot ulcer, with or without amputation. Costs were estimated for inpatient care, outpatient care, home care, and social service. The cost calculations include costs due to complications and disability related to the initial ulcer, costs related to recurrence of ulcer, and costs for prevention of new ulcers. Expected total present value cost per patient during 3 years of observation was $26,700 (U.S. dollars) for primary healed patients with critical ischemia and $16,100 for primary healed patients without critical ischemia. For patients who healed with an amputation, the corresponding costs were $43,100 after a minor amputation and $63,100 after a major amputation. When estimating the costs for diabetic foot ulcers, it is not sufficient to calculate short-term costs. Long-term costs are high, mainly due to the need for increased home care and social service, but also due to costs for recurrent ulcers and new amputations.

The effects of a new amino-acid dipeptide solution on nitrogen balance and humoral growth factors in the postoperative state in man

27 patients admitted for elective abdominal surgery were allocated to receive postoperative total parenteral nutrition supplemented with glutamine (glycyl-glutamine) and tyrosine (glycyl-tyrosine) containing dipeptides (DP-Gln 20; 0.16 g glutamine/kg BW/24 h) or isonitrogenous Vamin 18 for 5 days. The aim was to evaluate safety and effects on short-life plasma proteins, nitrogen balance, 3-methylhistidine excretion and alimentary growth factors in plasma. No differences in transthyretin or retinol binding protein levels, nitrogen balance or 3-methylhistidine excretion were found in patients receiving DP-Gln 20 compared to Vamin 18. There were higher plasma levels of peptide YY in the dipeptide group 5 days after surgery (p < 0.05). A correlation between insulin levels and nitrogen balance was found only in DP-Gln 20 treated patients day 6 (r = 0.91, p < 0.01). DP-Gln 20 is a glutamine dipeptide (Gly-Gln) containing amino acid solution which is considered safe in the postoperative state in man. No beneficial effects on whole body protein metabolism were found by adding DP-Gln 20 to total parenteral nutrition.

Topical treatment of diabetic foot ulcers: an economic analysis of treatment alternatives and strategies

In a prospective study, 314 patients with diabetic foot ulcers were followed and 40 patients died before healing occurred. In those patients who healed, a retrospective economic analysis of the costs for topical treatment was performed. The aim of the study was to analyse the costs and discuss how different treatment strategies influence total costs. Data collected for each patient were total time to healing, treatment time for each type of dressing, and the frequency of dressing changes. Material costs for the dressings, labour, and travelling costs were calculated separately. A formula for simulation of economic consequences of different treatment strategies including the introduction of new strategies was designed. The cost for topical treatment was strongly related to the severity of the ulcer and wound healing time. The average weekly cost per patient for topical treatment varied between 40.3 pounds and 385 pounds. The dominating costs for topical treatment were expenses for staff and transportation. The most important factor to reduce costs is the frequency of dressing changes. The study emphasizes the need for prospective comparative studies of cost effectiveness in topical treatment strategies.

Clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers: a prospective study of healing below or above the ankle in 187 patients

The aim of this study was to describe the clinical characteristics in relation to final amputation level in diabetic patients with foot ulcers. In a prospective series, 187 consecutively presenting patients were investigated. From admission until final outcome, the patients were treated by a multidisciplinary team both as in- and out-patients. All the patients had one or more signs of neuropathy and 171 had evidence of peripheral vascular disease. Healing with an amputation below the ankle occurred in 74 patients, 88 patients healed with an amputation above the ankle, and 25 patients died unhealed. Amputation above the ankle was associated with high age, living in an institution, a limited walking capacity, cerebrovascular disease, congestive heart failure, and a low hemoglobin level. Amputation below the ankle was associated with diabetes diagnosis before 30 years of age and diabetes duration. In conclusion, older age, history of cerebrovascular disease and low hemoglobin level are associated with above ankle amputation level in diabetic patients with foot ulcers. However, level selection cannot be based upon these factors only, since some patients at high age, with cerebrovascular disease or with a low hemoglobin value, healed with an amputation below the ankle. None of these factors per se should be taken as a cause to choose a primary amputation above the ankle, unless amputation is supported by the total clinical picture, including local characteristics, such as type and localization of ulcer, and signs of peripheral vascular disease. More attention should be paid to biological than to chronological age.

Enteral glutamine increases growth and absorptive capacity of intestinal mucosa in the malnourished rat

BACKGROUND

Glutamine is an important nutrient for the small intestine. Beneficial effects of glutamine could be related to restoration of optimal intestinal barrier functions.

METHODS

Thirty-eight Sprague-Dawley rats were allocated to three main groups. Experimental groups (n = 22) were malnourished and laparotomized. Sham groups (n = 11) were laparotomized without prior malnutrition. These groups were refed with or without oral glutamine for 3 days. The control group (n = 5) was given chow. Permeability was assessed by the 6-h urinary recovery of orally given polyethylene glycols, PEG 400/1000. Mucosal proliferation was estimated by DNA content and 1-h incorporation of 3H-thymidine intravenously.

RESULTS

In the malnourished groups glutamine resulted in higher thymidine incorporation (p < 0.05) and better absorption of small PEG molecules (p < 0.05).

CONCLUSION

The effects of oral glutamine on permeability after malnourishment and laparotomy are proposed to be related to an increase in absorptive area.

Nutritional assessment and muscle energy metabolism in severe chronic congestive heart failure--effects of long-term dietary supplementation

In order to investigate nutritional status in relation to the metabolic state of skeletal muscle in patients with severe congestive heart failure, and to explore the influence of long-term dietary supplementation, 22 patients were randomized in a double-blind study to receive either a placebo (n = 13) or high caloric fluid (n = 9). Before treatment, the muscle content of adenosine triphosphate (ATP), creatine and glycogen was lower than in healthy individuals, and muscle biopsies revealed an excess of water. Two patients were found to be malnourished according to nutritional assessment criteria. Following study treatment, no significant changes occurred, either within or between the two subgroups. Thus, patients with severe congestive heart failure displayed metabolic derangement in skeletal muscle which did not seem to be explained by malnutrition.

The effect of mannitol on reperfusion after severe induced subtotal ischemia of the leg. A hemodynamic, biochemical and metabolic study in a pig hind limb model

Revascularization of acutely ischemic muscle tissue is followed by edema, decreased oxygen utilization, increased vascular resistance and massive efflux of intracellular compounds indicating loss of cellular integrity, with resultant irreversible damage. In this pig hindlimb study, 8 pigs were submitted to standardized subtotal ischemia of one leg and mannitol was administered i.v. prior to and during 2.5 hours of reperfusion. Compared to 9 controls, the mannitol treated pigs had increased blood flow to the legs, increased oxygen consumption and decreased release of intracellular compounds (CK). This indicates that mannitol attenuates the ischemia/reperfusion syndrome. Muscle energy metabolic parameters showed a similar response to ischemia for both mannitol-treated pigs and controls and no differences in recovery were detected during 2.5 hours of reperfusion between the groups.

Local signs and symptoms in relation to final amputation level in diabetic patients. A prospective study of 187 patients with foot ulcers

Local signs and symptoms were evaluated in 187 consecutively presenting diabetic patients undergoing amputation for foot ulcers. From admission until final outcome the patients were treated by the same multidisciplinary team both as in- and out-patients. At the time of amputation, the types of lesions were superficial/deep ulcer (n 17), ulcer with deep infection, but without gangrene (n 40), and gangrene with or without infection (n 130). Healing after a minor amputation (below the ankle) occurred in 74 patients, while 88 patients healed after a major amputation (above the ankle), and 25 patients died before healing had occurred. Deep infection and presence of popliteal or pedal pulses were associated with healing after minor amputation and so were ulcers on the small toes, metatarsal head area and midfoot. Pain, progressive gangrene, intermittent claudication, and decubital and multiple ulcers were related to healing after major amputation. In a logistic regression analysis, pain, progressive gangrene and intermittent claudication remained. However, none of these factors excluded healing of a minor amputation and thus selection of amputation level in diabetic patients with foot ulcers cannot be based upon these factors exclusively.

Protein synthesis in regenerating rat liver during malnutrition

To examine the effect of malnutrition on liver protein metabolism and synthesis during liver regeneration, 104 rats were allocated to semi-starvation or ordinary food intake for 1 week. Half of each group was sham operated and the other half was partially hepatectomized. Specimens were taken from the liver at the time of liver resection and from animals killed 24, 48 and 72 h after the primary operation. Liver samples were analysed for DNA and protein, and in the 48-h groups RNA and protein synthesis were also analysed. Protein synthesis was measured by the flooding method using L[4-3H] phenylalanine. The liver weight during regeneration increased very rapidly in the well-nourished animals, but when expressed as percent of body weight or as proportional increases, the difference between well-nourished and malnourished animals disappeared. The fractional rate of protein synthesis was not changed in sham-operated malnourished or well-nourished animals. During regeneration, protein synthesis in well-nourished animals was elevated compared to sham-operated controls, but a lesser stimulation was seen in malnourished rats. It was concluded that the mechanism of liver regeneration depends on nutritional state, involving an increase in protein synthesis in well-nourished animals, but relying more on a decrease in protein degradation or cessation of secretory protein synthesis in malnourished animals.

Surgical management of pure pancreatic fistulas

This paper reports on 13 patients with pure pancreatic fistulas defined as persistent lesions originating directly from the gland tissue and not from a pancreatico-intestinal or pancreatico-gastric anastomosis. Six fistulas were external and seven internal. All external fistulas were postoperative whereas all the internal ones were due to chronic pancreatitis. Conservative treatment of 2 to 36 months duration was unsuccessful, so that all patients underwent surgery. To establish a proper surgical strategy, preoperative mapping of the fistula by endoscopic retrograde cholangiopancreaticography (ERCP), fistulography and/or computerized tomography proved of value. In eleven patients, pancreatic fistula flow was surgically redirected into the gastrointestinal tract, while the remaining two were submitted to a pancreatic left resection. There were no hospital deaths and the complication rate was low. During the follow-up time of 6 to 96 months no recurrent fistulas were seen.