The Semmes-Weinstein monofilament as a potential predictor of foot ulceration in patients with noninsulin-dependent diabetes

Development of grading scales of pedal sensory loss using Mokken scale analysis on the Rotterdam Diabetic Foot Study Test Battery data

INTRODUCTION

Loss of sensation due to diabetes-related neuropathy often leads to diabetic foot ulceration. Several test instruments are used to assess sensation, such as static and moving 2-point discrimination (S2PD, M2PD), monofilaments, and tuning forks.

METHODS

Mokken scale analysis was applied to the Rotterdam Diabetic Foot Study data to select hierarchies of tests to construct measurement scales.

RESULTS

We developed 39-item and 31-item scales to measure loss of sensation for research purposes and a 13-item scale for clinical practice. All instruments were strongly scalable and reliable. The 39 items can be classified into 5 hierarchically ordered core clusters: S2PD, M2PD, vibration sense, monofilaments, and prior ulcer or amputation.

DISCUSSION

Guided by the presented scales, clinicians may better classify the grade of sensory loss in diabetic patients' feet. Thus, a more personalized approach concerning individual recommendations, intervention strategies, and patient information may be applied.

Prevalence of peripheral arterial disease among diabetic patients in Santo Domingo, Dominican Republic and associated risk factors

Introduction

Peripheral arterial disease (PAD) is a major risk factor of coronary artery disease and a major complication of atherosclerosis. Peripheral arterial disease can be diagnosed with simple and low cost techniques. There are major risk factors of PAD that have been studied for different countries. However, no such study has been done for the Dominican Republic. We conducted a cross-sectional study to determine the prevalence of PAD and the risk factors among patients with diabetes in Santo Domingo, Dominican Republic.

Material and methods

Six hundred randomly chosen patients with previously diagnosed diabetes were enrolled in our study. Their blood pressure and ankle brachial index were calculated and a questionnaire was provided to gather information regarding gender, age, weight, ethnicity, known duration of diabetes along with any history of smoking, hypertension and hyperlipidemia. A physical examination was also done to assess for any active diabetic ulcers, previous foot ulcers and non-traumatic amputation. A microfilament test was conducted to check for peripheral neuropathy.

Results

Eighty-four diabetic patients were diagnosed with PAD with a prevalence of 14% in Santo Domingo, Dominican Republic. Statistically significant associations (p < 0.05) was found for female gender, presence of active foot ulcers, history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia and peripheral neuropathy. Glycated hemoglobin (HbA_1c), age and smoking were not statistically significant in our study.

Conclusions

Diabetic patients who are either female, have active foot ulcers, a history of past foot ulcer, non-traumatic amputation, hypertension, hyperlipidemia or peripheral neuropathy are more at risk of developing PAD.

Recognizing the prevalence of changing adult foot size: an opportunity to prevent diabetic foot ulcers?

Ill-fitting shoes may precipitate up to half of all diabetes-related amputations and are often cited as a leading cause of diabetic foot ulcers (DFU), with those patients being 5 to 10 times more likely to present wearing improperly fitting shoes. Among patients with prior DFU, those who self-select their shoe wear are at a three-fold risk for reulceration at 3 years versus those patients wearing prescribed shoes. Properly designed and fitted shoes should then address much of this problem, but evidence supporting the benefit of therapeutic shoe programs is inconclusive. The current study, performed in a male veteran population, is the first such effort to examine the prevalence and extent of change in foot length affecting individuals following skeletal maturity. Nearly half of all participants in our study experienced a ≥1 shoe size change in foot length during adulthood. We suggest that these often unrecognized changes may explain the broad use of improperly sized shoe wear, and its associated sequelae such as DFU and amputation. Regular clinical assessment of shoe fit in at-risk populations is therefore also strongly recommended as part of a comprehensive amputation prevention program.

Diabetic Foot Complications: Diagnosis and Management

Foot complications in patients with diabetes mellitus are a challenge to the health care industry. A great deal of expenditure is due to the management of diabetic foot complications. This places a great burden on the health care industry. It also places a great burden on those diabetic patients with foot complications and their families. Therefore, their effective management in an efficient manner is crucial to our patients. To deal with these problems, a dedicated, knowledgeable, and experienced multidisciplinary team is key. Intervention at the earliest possible time yields the best outcome. Prevention is the focus for those with no ulcerations. For those with ulcerations, prompt recognition and treatment is key. The importance of classifying ulcerations according to size, depth, presence or absence of infection, and vascular status can not be overstated. Proper offloading is vital for those with neuropathic lesions. Recognition of patients with a component of ischemia and vascular intervention to increase perfusion will aid in wound healing. Of course deep infection requires immediate drainage. All efforts of those in the multidisciplinary team are directed at the restoration and maintenance of an ulcer-free foot which is important in enabling our patients to maintain their ambulatory status.

A Comparison of the Sensitivity of Brush Allodynia and Semmes-Weinstein Monofilament Testing in the Detection of Allodynia Within Regions of Secondary Hyperalgesia in Humans

BACKGROUND

Two of the most common Quantitative Sensory Techniques (QST) employed to detect allodynia include mechanical brush allodynia and Semmes-Weinstein monofilaments. However, their relative sensitivity at detecting allodynia is poorly understood. The purpose of this study was to compare the sensitivity of brush allodynia against Semmes-Weinstein monofilament technique for detecting allodynia within regions of secondary hyperalgesia in humans.

METHODS

Twenty subjects (10 males, 10 females; 21.1 ± 0.9 years) were recruited and randomly allocated to allodynia or monofilament groups. Topical capsaicin (Zostrix 0.075%) was applied to a target region defined by C4-C7 dermatomes. Allodynia testing was performed at 0- (baseline) and 10 minutes postcapsaicin. The Semmes-Weinstein group assessed changes in skin sensitivity 8 cm inferior to target region and 2 cm lateral to the spinous process, while brush allodynia was employed to detect the point inferior to the target region where subjects reported changes in skin sensitivity. The distance (cm) from this point to the inferior border of the target region was termed the Allodynia Score.

RESULTS

Statistically significant increases in the Allodynia Score were observed at 10 minutes postcapsaicin compared to baseline (P < 0.001). No differences in monofilament scores were observed between 10 minutes postcapsaicin and baseline (P = 0.125). Brush allodynia also demonstrated superior sensitivity, detecting allodynia in 100% of cases compared to 60% in the Semmes-Weinstein group.

CONCLUSION

Brush allodynia is more sensitive than Semmes-Weinstein monofilaments for detecting mechanical allodynia in regions of secondary hyperalgesia. Brush allodynia may be preferred over Semmes-Weinstein monofilaments for clinical applications requiring reliable detection of allodynia.

Selecting a prospective test for early detection of diabetic polyneuropathy

Microneurolysis of entrapped peripheral nerve has the best chance of success when compression has not created significant axonal loss. The purpose of this study is to learn the best way to identify potential surgical candidates at the earliest time for intervention, by examining patients in a clinical setting using objective, electrodiagnostic nerve conduction studies (NCS), and subjective touch threshold studies, Semmes-Weinstein monofilaments (SWM) and Pressure-Specified Sensory Device™ (PSSD). Fifty-five patients with diabetic polyneuropathy over the age of 30 years were included. Neuropathy symptom score was the gold standard for statistical calculation, with a prevalence of 70%. In the symptomatic population, prevalence was 64% for NCS (n = 25), 59% for SWM (n = 43), and 88% for PSSD (n = 51). In the asymptomatic population, prevalence was 70% for NCS, 27% for SWM, and 92% for PSSD. It is concluded that the PSSD is the most sensitive device of those tested for identifying peripheral neuropathy in an at risk population of patients.

Comparison of the accuracy of monofilament testing at various points of feet in peripheral diabetic neuropathy screening

BACKGROUND

Diabetic Peripheral Neuropathy is one of the most prevalent complications of diabetes mellitus. The development and progression of such complications are responsible for much of the morbidity and mortality. The purpose of this study was to evaluate the effectiveness of Semmes-Weinstein monofilament ten gram in 3, 4, eight and ten points in the screening of diabetic peripheral neuropathy in patients with diabetes mellitus.

METHODS

In a descriptive correlational design, 150 patients with diabetes mellitus were selected using convenience sampling. All patients were evaluated for sensory neuropathy using ten gram Semmes-Weinstein Monofilaments and questionnaire on neuropathy symptoms. In the next phase, nerve conduction velocity was examined. The most common subjective symptoms were paresthesia of both feet, pain in feet, burning sensation in the extremities and numbness in the extremities.

RESULTS

The results showed that the sensitivity of Monofilament in three and four points were 35.9 to 53.8 present and 38.5 to 51.3 percent respectively. Specificity of Monofilament the same points, were 73.9 to 84.7 and 73 to 87.4 percent respectively. Monofilament sensitivity at eight and ten points were 38.5 to 61.5 and 64.1 to 30.8 percent respectively. Also, specificity of the same points were 77.5 to 95.5 and 64 to 89.2 percent respectively. It was revealed that the difference sensitivity and specificity of Monofilament in three and four points with sensitivity and specificity in eight and ten point is not statistically significant.

CONCLUSIONS

This study showed that Semmes-Weinstein monofilament can easily use as a simple and inexpensive device for screening. Since increasing the number of points it was not significantly difference. Therefore, we suggest that screening for diabetic peripheral neuropathy, especially in large populations to avoid wasting time on Monofilament application, areas like three or four points eight and ten points could be used.

Charcot arthropathy of the foot and ankle associated with rheumatoid arthritis

BACKGROUND

Diabetic peripheral neuropathy is now well recognized as the most common cause of Charcot arthropathy of the foot and ankle, but it may be associated with other peripheral neuropathies. While not well known, it is well documented that rheumatoid arthritis is correlated with peripheral neuropathy. However, despite rheumatoid neuropathy, Charcot arthropathy has never been associated with rheumatoid arthritis. We report a series of Charcot arthropathy patients with concomitant rheumatoid arthritis.

METHODS

The medical records of patients treated between 1986 and 2009 with Charcot arthropathy and rheumatoid arthritis were reviewed. Recorded data included neuropathy risk factors, medications, history of ulcerations, ambulatory status, shoe wear, and treatment course. Radiographs of Charcot joints were categorized according to the Brodsky anatomic classification. Patient care was based on published treatment algorithms, emphasizing accommodative, nonoperative treatment with selective surgical interventions. Surgery was indicated for recalcitrant, nonhealing lesions of the soft tissue and/or unbraceable, nonplantigrade feet. A successful outcome was considered an ambulatory patient without amputation and a closed skin envelope at last follow-up.

RESULTS

Four men and 16 women met the diagnostic criteria, resulting in 33 feet in the series. Average age was 61 years, and average follow-up was 4.3 years. In addition to rheumatoid arthritis, 4 patients (7 feet) had hypothyroidism, 4 patients (6 feet) had diabetes, 1 patient (2 feet) had megaloblastic anemia and diabetes, and 1 patient (1 foot) had hypothyroidism and diabetes; however, 17 feet (52%) had no known sources for neuropathy. Charcot involvement was type 1-midfoot in 21 feet (64%), type 2-hindfoot in 7 (21%), type 3a-ankle in 4 (12%), and type 3b-calcaneus in 1 (3%). Twenty-three feet (70%) were treated with conservative modalities. Ten feet (30%) required 15 surgeries, of which an exostectomy was the most common procedure. Of the 33 feet, 3 had persistent ulcerations and 1 underwent major amputation, representing 4 failures.

CONCLUSIONS

Raising awareness within the orthopaedic community, we report a Charcot arthropathy population with a concomitant rheumatoid arthritis diagnosis, emphasizing a relationship between the 2 diseases. Through a conservative treatment regimen combined with selective surgical interventions, satisfactory outcomes were achieved in 88% of the rheumatoid Charcot feet. While several patients had additional neuropathy sources which could cause Charcot arthropathy (eg, diabetes), the majority of feet had no etiologies accounting for neuropathy or neuroarthropathy except rheumatoid arthritis. Further study is required to expand on this relationship between the 2 diseases.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Nonarteriosclerotic vascular disease

Thromboangiitis obliterans, or Buerger disease, is a chronic nonatherosclerotic endarteritis manifesting as inflammation and thrombosis of distal extremity small and medium-sized arteries resulting in relapsing episodes of distal extremity ischemia. Takayasu arteritis is a rare syndrome characterized by inflammation of the aortic arch, pulmonary, coronary, and cerebral vessels, presenting with cerebrovascular symptoms, myocardial ischemia, or upper extremity claudication in young, often female, patients. Kawasaki disease is a small- and medium-vessel acute systemic vasculitis of young children, with morbidity and mortality stemming from coronary artery aneurysms. Microscopic polyangiitis, Churg-Strauss syndrome, and Wegener granulomatosis are systemic small-vessel vasculitides, affecting arterioles, capillary beds and venules, and each presenting with variable effects on the pulmonary, renal and gastrointestinal systems.

A novel robotic monofilament test for diabetic neuropathy

OBJECTIVE

The use of the Semmes-Weinstein (SW) monofilament test is recommended as a screening method for diabetic neuropathy. It offers an important chance to prevent further complications of diabetic foot. We aimed to develop a prototype Robotic Monofilament Inspector that can be used as a standard machine for screening of diabetic neuropathy.

METHODS

Development was divided into three parts: computer software, control box, and Robotic Monofilament Inspector. The examiner conducted the SW test (by hand and by robotic inspector), vibration perception threshold, and Toronto Clinical Scoring System without knowledge of patient information. The unpaired t test or Wilcoxon rank-sum test was used to determine the differences between independent groups in terms of continuous outcomes, while the χ(2) test was used to determine categorical outcomes. Agreement between the various diabetic neuropathy tests was measured using the kappa statistic.

RESULTS

The SW test and vibration perception threshold were more valid tests for neuropathy than the Toronto test. The robotic test was in excellent agreement with the two former tests and appeared to be valid (kappa statistic, 0.35-0.81). Another indirect evidence for the validity of the robotic test was the finding that diabetic patients with foot ulcers had a higher prevalence of neuropathy (77%vs. 38%). This might indicate that the robotic test was more valid than the manual test.

CONCLUSION

The Robotic Monofilament Inspector could be used as a simple screening machine. This prototype may be developed further for routine clinical use.

Prediction of incident diabetic neuropathy using the monofilament examination: a 4-year prospective study

OBJECTIVE

To determine the specific monofilament examination score that predicts the subsequent 4-year incidence of diabetic neuropathy with the highest degree of diagnostic accuracy.

RESEARCH DESIGN AND METHODS

Longitudinal follow-up of 175 of 197 (89%) participants in the Toronto Diabetic Neuropathy Cohort without baseline neuropathy for incident neuropathy. We examined the baseline monofilament examination score (and other simple sensory screening tests) by receiver operating characteristic (ROC) curve analysis.

RESULTS

Incident diabetic neuropathy developed in 50 (29%) participants over a mean follow-up of 4.1 years (interquartile range 2.6-7.1 years). Although male sex, longer diabetes duration, taller height, and higher blood pressure at baseline were associated with incident neuropathy, the strongest association was with a lower baseline monofilament score (score out of 8 was 3.7 +/- 2.5 for incident neuropathy vs. 5.7 +/- 2.3 for those who did not develop neuropathy; P < 0.001). The optimal threshold score for risk of incident neuropathy was <or=5 sensate stimuli out of 8, with 72% sensitivity, 64% specificity, positive and negative likelihood ratios of 2.5 and 0.35, and positive and negative predictive values of 87 and 46%, respectively (chi(2) = 20.7, P < 0.001). Area under the ROC curve was significantly greater for the monofilament examination compared with that for other simple sensory tests.

CONCLUSIONS

A simple threshold of <or=5 sensate stimuli out of 8 discriminates 4-year risk of diabetic neuropathy with acceptable operating characteristics. Although there are limitations in its specificity for prediction of future neuropathy onset, the monofilament examination is appropriate as a simple diabetic neuropathy screening instrument generalizable to the clinical setting.

Leg symptom categories and rates of mobility decline in peripheral arterial disease

OBJECTIVES

To determine whether asymptomatic lower extremity peripheral arterial disease (PAD) and leg symptoms other than intermittent claudication (IC) in PAD are associated with faster functional decline than in people with both PAD and IC.

DESIGN

Prospective, observational study.

SETTING

Chicago-area medical center.

PARTICIPANTS

Four hundred fifteen people with PAD followed annually for up to 7 years.

MEASUREMENTS

At baseline, patients with PAD were categorized into symptom categories, including IC; leg pain on exertion and rest; participants who could walk through exertional leg pain (pain/carry on); and participants who never experienced exertional leg pain, even during the 6-minute walk (always asymptomatic). Outcomes included mobility loss (becoming unable to walk one-quarter of a mile or walk up and down one flight of stairs without assistance) and becoming unable to complete the 6-minute walk without stopping. Analyses adjusted for age, sex, comorbidities, ankle brachial index, and other confounders.

RESULTS

Always-asymptomatic participants (hazard ratio (HR)=2.94, 95% confidence interval (CI)=1.39-6.19, P=.005) and those with leg pain on exertion and rest (HR=2.89, 95% CI=1.47-5.68, P=.002) had greater mobility loss than participants with IC. Participants with PAD with leg pain/carry on were less likely (P=.047) to become unable to walk for 6 minutes continuously without stopping than participants with IC.

CONCLUSION

The ABI identifies patients with asymptomatic PAD and those with atypical leg symptoms who are at risk for greater mobility decline than participants without PAD and participants with PAD with IC.

Clinical factors associated with a conservative gait pattern in older male veterans with diabetes

Background

Patients with diabetes and peripheral neuropathy are at higher risk for falls. People with diabetes sometimes adopt a more conservative gait pattern with decreased walking speed, widened base, and increased double support time. The purpose of this study was to use a multivariate approach to describe this conservative gait pattern.

Methods

Male veterans (mean age = 67 years; SD = 9.8; range 37–86) with diabetes (n = 152) participated in this study from July 2000 to May 2001 at the Veterans Affairs Medical Center, White River Junction, VT. Various demographic, clinical, static mobility, and plantar pressure measures were collected. Conservative gait pattern was defined by visual gait analysis as failure to demonstrate a heel-to-toe gait during the propulsive phase of gait.

Results

Patients with the conservative gait pattern had lower walking speed and decreased stride length compared to normal gait. (0.68 m/s v. 0.91 m/s, p < 0.001; 1.04 m v. 1.24 m, p < 0.001) Age, monofilament insensitivity, and Romberg's sign were significantly higher; and ankle dorsiflexion was significantly lower in the conservative gait pattern group. In the multivariate analysis, walking speed, age, ankle dorsiflexion, and callus were retained in the final model describing 36% of the variance. With the inclusion of ankle dorsiflexion in the model, monofilament insensitivity was no longer an independent predictor.

Conclusion

Our multivariate investigation of conservative gait in diabetes patients suggests that walking speed, advanced age, limited ankle dorsiflexion, and callus describe this condition more so than clinical measures of neuropathy.

Clinical screening and diagnosis of diabetic polyneuropathy: the North Catalonia Diabetes Study

BACKGROUND

To evaluate the prevalence of diabetic polyneuropathy (DPN) and develop a simple and accurate method for the evaluation of DPN risk in primary care settings.

MATERIALS AND METHODS

Cross-sectional descriptive study in a random sample (N = 307) of type 2 diabetes mellitus participants. DPN was diagnosed by both clinical neurological examination and simplified DPN Selection Method in each patient. Correlation between the two methods was obtained.

RESULTS

Prevalence of DPN was 23.13% (confidence interval,18.38-27.87) according to clinical neurological examination. Noteworthy, clinical neurological evaluation scores were related to nerve conduction studies (r = 0.882; P < 0.0005). DPN presence was positively related to age, metabolic control (HbA1c levels), known duration of diabetes, diabetic retinopathy, cardiovascular disease, peripheral ischemia and systolic and diastolic blood pressure, but was negatively related to current high-density lipoprotein cholesterol (HDL-C) levels (P < 0.0001). The sensitivity and specificity of our DPN Selection Method (using four clinical parameters: age, retinopathy, HbA1c and HDL-C plasma levels) for diagnosis of DPN was 74.20% and 74.90%, respectively.

CONCLUSIONS

The expected prevalence of DPN was observed. The sensitivity of the DPN Selection Method correlated well with formal clinical neurological exam in detection of the condition. We therefore conclude the DPN Selection Method is a useful tool in primary care settings in the evaluation and diagnosis of DPN.

The management of ankle fractures in patients with diabetes

Patients with diabetes mellitus have higher complication rates following both open and closed management of ankle fractures. Diabetic patients with neuropathy or vasculopathy have higher complication rates than both diabetic patients without these comorbidities and nondiabetic patients. Unstable ankle fractures in diabetic patients without neuropathy or vasculopathy are best treated with open reduction and internal fixation with use of standard techniques. Patients with neuropathy or vasculopathy are at increased risk for both soft-tissue and osseous complications, including delayed union and nonunion. Careful soft-tissue management as well as stable, rigid internal fixation are crucial to obtaining a good outcome. Prolonged non-weight-bearing and subsequently protected weight-bearing are recommended following both operative and nonoperative management of ankle fractures in patients with diabetes.

Does Lower-Extremity Arterial Disease Predict Future Falling Among Older Men and Women?

The purpose of this study was to determine whether lower-extremity peripheral arterial disease (PAD) is an independent risk factor for falls among older persons. Men and women 55 years old and older participated. Subjects with PAD (n = 86) were identified from a noninvasive vascular laboratory and a general medicine practice. Randomly selected controls without PAD (n = 82) were identified from the same medicine practice. Subjects were categorized into PAD (ankle brachial index, <0.90) or controls (ankle brachial index, 0.90 to 1.50). Subjects underwent a comprehensive baseline evaluation for fall risk. Prospective fall data were obtained using monthly mail-in postcards and structured telephone interviews over a mean follow-up of 9.6 ± 2.9 months. Two independent investigators blinded to PAD status reviewed each fall incident for its eligibility. A total of 37 subjects (22%) had at least 1 eligible fall. In an unadjusted Cox regression model, the relative risk of falling was lower among PAD subjects than among controls (relative risk, 0.54; 95% confidence interval, 0.28 to 1.06). After adjustment for age, gender, history of frequent falls in the last year, number of comorbidities, and balance and gait abnormalities, PAD was significantly associated with a lower risk of falling (relative risk, 0.43; 95% confidence interval, 0.21 to 0.87) as compared with controls. PAD is associated with a lower risk of falling as compared with persons without PAD among older men and women. Future study is needed to determine whether reduced levels of physical activity among patients with PAD account for the lower rate of falling observed here.

Which diabetic patients should receive podiatry care? An objective analysis

INTRODUCTION

Diabetes is the leading cause of lower limb amputation in Australia. However, due to limited resources, it is not feasible for everyone with diabetes to access podiatry care, and some objective guidelines of who should receive podiatry is required.

METHODS

A total of 250 patients with neuropathy (Biothesiometer; Biomedical Instruments, Newbury, Ohio, USA) ( > 30, age < 65)) but no active foot lesion, and 222 without neuropathy matched for age, type of diabetes, gender and duration, was followed prospectively for 2 years. Sensation was also tested using a 10 g Semmes Weinstein monofilament (Royal Prince Alfred Hospital Diabetes Centre). After the baseline examination, patients were contacted at 6 months and thereafter yearly to determine ulcer status. Incidence of foot ulceration across different risk categories was calculated using Kaplan-Meier survival curve. Log-rank test and Cox's proportional model were used to compare groups. The Number Needed to Treat (NNT) to prevent one ulcer per year was calculated using the standard formulae.

RESULTS

During the follow-up period, 34 new ulcers occurred in the neuropathy group and three ulcers in the control group (chi2 (1df) = 21.3; P < 0.0001), equating to an annual incidence of 6.3% and 0.5%, respectively. Fifty-four per cent of the ulcers were due to trauma from footwear. Further stratification of the neuropathy group showed annual incidence of ulceration to be 4% for those with abnormal biothesiometer reading, but who could still feel the monofilament, 10% for those who cannot feel the monofilament and 26% for those with previous ulceration or amputation. Predictors of ulceration were past history of ulceration/amputation (chi2 = 27.8; P < 0.0001) and the presence of neuropathy (chi2 = 4.7; P = 0.03). Assuming a 55% relative risk reduction in ulceration from podiatry care (mean of estimates from 10 reports), the NNT to prevent one foot ulcer per year was: no neuropathy (vibration perception threshold (VPT) < 30)), NNT = 367; neuropathy (VPT > 30) alone, NNT = 45; +cannot feel monofilament, NNT = 18; +previous ulcer/amputation, NNT = 7.

CONCLUSION

Provision of podiatry care to diabetic patients should not be only economically based, but should also be directed to those with reduced sensation, especially where there is a previous history of ulceration or amputation.

Technology literature review: quantitative sensory testing

The development of the personal computer has simplified the process of quantitating sensory thresholds using various testing algorithms. We reviewed the technical aspects and reproducibility of different methods to determine threshold for light touch-pressure, vibration, thermal, and pain stimuli. Clinical uses and limitations of quantitative sensory testing (QST) were also reviewed. QST is a reliable psychophysical test of large- and small-fiber sensory modalities. The results of QST are highly dependent on methodology and the full cooperation of the subject. QST has been shown to be reasonably reproducible over a period of days or weeks in normal subjects. The use of QST in research and patient care should be limited to instruments and their corresponding methodologies that have been shown to be reproducible. Literature data do not allow conclusions regarding the relative merits of individual QST instruments.

Peripheral Arterial Disease in African Americans: Clinical Characteristics, Leg Symptoms, and Lower Extremity Functioning

OBJECTIVES

The describe peripheral arterial disease (PAD) in African Americans, and compare findings in African Americans and whites with PAD.

DESIGN

Cross-sectional.

SETTING

Three academic medical centers.

PARTICIPANTS

Three hundred sixty-six whites and 76 African Americans with PAD (as defined by an ankle brachial index (ABI) <0.90) aged 55 and older identified from lower extremity arterial studies performed between 1996 and the fall of 1999.

MEASUREMENTS

Comprehensive medical interview, body mass index, and neuropathy score. Functional measurements included the 6-minute walk distance, 4-m walking velocity, and the summary performance score.

RESULTS

Age- and sex-adjusted results showed that African Americans had a lower mean ABI than whites (0.60 vs 0.66, P=.001), were less likely to be college graduates (13.7% vs 44.4%, P<.001), and had nearly twice the prevalence of diabetes mellitus (46.8% vs 28.0%, P=.001). After adjusting for age, sex, education level, and ABI, African Americans had a higher prevalence of no exertional leg pain (28.0% vs 18.2%, P=.044) and leg pain with exertion and rest (30.0% vs 17.3%, P=.023). African Americans had a shorter 6-minute walk distance (989 vs 1,156 ft, P<.001), a slower normal-pace 4-m walking velocity (0.79 vs 0.89 m/s, P<.001), a slower fast-pace 4-m walking velocity (1.12 vs 1.20 m/s, P=.012), and a lower summary performance score (8.8 vs 9.6, P=.018) than whites. These differences in functioning were attenuated after adjusting for age, sex, ABI, education, and leg symptoms.

CONCLUSION

Poorer lower extremity functioning in African Americans was largely explained by differences in leg symptoms and, to a somewhat lesser degree, lower ABI levels and poorer education in African Americans than in whites. Further study is needed to determine whether these findings affect racial treatment disparities and poorer outcomes previously reported in African Americans than in whites with PAD.

4.5-gram monofilament sensation beneath both first metatarsal heads indicates protective foot sensation in diabetic patients

BACKGROUND

Loss of protective plantar foot sensation is the major cause of diabetic foot ulcerations and ultimate limb loss. Identification of patients without protective sensation can reduce the risk of unrecognized foot injury. The current recommended screening protocol requires 10-g monofilament testing of ten foot sites with use of a forced-choice paradigm. The objective of the present study was to determine whether testing of fewer than ten sites could provide accuracy comparable with that obtained by testing all ten sites.

METHODS

A cross-sectional comparative study of plantar sensory levels in diabetic subjects with and without plantar ulceration was conducted in a tertiary-care teaching hospital setting. We examined forty-seven diabetic subjects with a history of foot ulceration and forty-five diabetic subjects with no history of foot ulceration. Plantar sensory threshold values at five sites on the sole of each foot were measured with a quasi-continuous range of applied forces, and receiver operating characteristic analysis techniques were applied.

RESULTS

Screening on the basis of only the maximum force threshold for the left and right first metatarsal head sites provided comparable or better performance at high levels of sensitivity than did either the mean or the maximum force threshold across all ten sites. A sensory threshold of 4.5 g for both the left and right first metatarsal head sites predicted the risk of ulceration with a sensitivity of 100% and a specificity of 67%.

CONCLUSIONS

Testing of diabetic patients for protective sensation may be simplified to testing under both first metatarsal heads with a 4.5-g monofilament. If a patient cannot sense the application of a 4.5-g monofilament under either first metatarsal head, he or she probably has lost protective sensation and should be considered to be at risk for undetected injury.

Restoration of sensation, reduced pain, and improved balance in subjects with diabetic peripheral neuropathy: a double-blind, randomized, placebo-controlled study with monochromatic near-infrared treatment

OBJECTIVE

Diabetic peripheral neuropathy (DPN) has been thought to be progressive and irreversible. Recently, symptomatic reversal of DPN was reported after treatments with a near-infrared medical device, the Anodyne Therapy System (ATS). However, the study was not controlled nor was the investigator blinded. We initiated this study to determine whether treatments with the ATS would decrease pain and/or improve sensation diminished due to DPN under a sham-controlled, double-blind protocol.

RESEARCH DESIGN AND METHODS

Tests involved the use of the 5.07 and 6.65 Semmes Weinstein monofilament (SWM) and a modified Michigan Neuropathy Screening Instrument (MNSI). Twenty-seven patients, nine of whom were insensitive to the 6.65 SWM and 18 who were sensitive to this filament but insensitive to the 5.07 SWM, were studied. Each lower extremity was treated for 2 weeks with sham or active ATS, and then both received active treatments for an additional 2 weeks.

RESULTS

The group of 18 patients who could sense the 6.65 SWM but were insensitive to the 5.07 SWM at baseline obtained a significant decrease in the number of sites insensate after both 6 and 12 active treatments (P < 0.02 and 0.001). Sham treatments did not improve sensitivity to the SWM, but subsequent active treatments did (P < 0.002). The MNSI measures of neuropathic symptoms decreased significantly (from 4.7 to 3.1; P < 0.001). Pain reported on the 10-point visual analog scale decreased progressively from 4.2 at entry to 3.2 after 6 treatments and to 2.3 after 12 treatments (both P < 0.03). At entry, 90% of subjects reported substantial balance impairment; after treatment, this decreased to 17%. However, among the group of nine patients with greater sensory impairment measured by insensitivity to the 6.65 SWM at baseline, improvements in sensation, neuropathic symptoms, and pain reduction were not significant.

CONCLUSIONS

ATS treatments improve sensation in the feet of subjects with DPN, improve balance, and reduce pain.

Improvement of Sensory Impairment in Patients with Peripheral Neuropathy

OBJECTIVE

To report the findings in 27 patients with peripheral neuropathy (21 with lower extremity sensory impairment associated with diabetic peripheral neuropathy and 6 with other causes), who received treatment with monochromatic near-infrared photoenergy (890 nm) delivered by the Anodyne Therapy System (ATS).

METHODS

All enrolled patients exhibited abnormal sensory perception (either hyperesthesia or hypoesthesia) based on a qualifying examination with the Neurometer CPT (current perception threshold) (baseline CPT). The patients received 10 ATS treatments (each lasting 40 minutes) during a 2-week period and then underwent CPT retesting to determine the extent of improvement of sensory impairment in myelinated and unmyelinated sensory fibers of the peroneal nerve.

RESULTS

All patients obtained improvement in sensory impairment in comparison with baseline CPT measures, and 16 of the 27 patients achieved normal sensory responses in all nerve fiber subpopulations. Ten patients had been tested previously (initial CPT) and did not exhibit spontaneous improvement in sensory impairment during a mean period of 27 months before baseline CPT. After receiving the ATS treatments, however, this group of patients showed improvement in comparison with both initial CPT results and baseline CPT.

CONCLUSION

On the basis of the data from this study, the ATS seems to be a safe and effective treatment to improve sensory impairment associated with peripheral neuropathy due to diabetes and other causes.

How should peripheral neuropathy be assessed in people with diabetes in primary care? A population-based comparison of four measures

AIMS

To test the accuracy of four measures of peripheral diabetic neuropathy in a primary care population.

METHODS

Type 2 diabetic (n = 544) and 544 non-diabetic participants aged 45-76 years were randomly selected from general practice registers. Neuropathy was assessed using vibration threshold (VT) and scores for light touch, thermal sense and modified Michigan Neuropathy Screening Instrument questionnaire. These measures were assessed for variation with diabetes status, age, diabetes duration, HbA1c, and presence of retinopathy and nephropathy. Light touch, thermal sense and questionnaire scores were assessed against VT using ROC curve analysis.

RESULTS

Only VT and light touch were different between diabetic and non-diabetic groups (P = 0.02 and < 0.0001, respectively). All measures were significantly associated with diabetes duration and retinopathy, and all except questionnaire score (P = 0.14) with age. None was associated with nephropathy and only questionnaire score was associated with HbA1c (P = 0.033). VT varied as expected across scores of light touch (chi2 = 41.65, P = 0.0001), thermal sense (chi2 = 15.86, P = 0.015) and questionnaire (chi2 = 21.22, P = 0.047). Area under the curve values for light touch, thermal and questionnaire scores were 0.72 (95% confidence interval (CI) 0.63, 0.82), 0.63 (95% CI 0.52, 0.73) and 0.64 (95% CI 0.53, 0.74), respectively.

CONCLUSIONS

All measures had associations with risk factors for neuropathy, but light touch score (monofilament) had the strongest association with vibration threshold (the chosen gold standard) and thus appeared the most appropriate tool for use in primary care, because of its validity and simplicity of use.

Diagnosis and management of diabetic neuropathy

Diabetic sensorimotor polyneuropathy (DSP) remains the most common microvascular complication of both type I and type 2 diabetes, and poses a unique set of management challenges in the prevention of foot complications. Although different quantitative tests are available, the preliminary diagnosis of DSP can be reliably made using simple and rapid screening tests in the family physician's office or in the diabetes clinic. The Semmes-Weinstein 10-g monofilament examination is a popular, simple clinical modality for the prediction of early DSP, foot ulceration, and amputation, and, in turn, a predictor of mortality in patients with diabetes. The management of DSP is centered on optimal glycemic control, diligent foot care, and pain control as a means of preventing the progression of DSP and reducing the morbidity associated with foot complications.

Plasma catecholamines in Buerger's disease: effects of cigarette smoking and surgical sympathectomy

OBJECTIVES

to study the influence of tobacco exposure and sympathectomy on basal sympathoadrenal function of patients with Buerger's disease.

DESIGN

plasma catecholamines were measured before and after smoking, in patients with Buerger's disease (n=13), in patients with Buerger's disease submitted to surgical bilateral lumbar sympathectomy (n=13), and in healthy volunteers (n=16).

MATERIALS AND METHODS

venous blood samples were collected before and 2h after smoking one cigarette (0.9mg nicotine). Plasma concentrations (pg/ml) of dihydroxiphenylalanine (pL-DOPA), noradrenalin (pNA), adrenalin (pAD) and 3,4-dihydroxiphenylacetic acid (pDOPAC) were determined.

RESULTS

Buerger's patients have low basal plasma catecholamines compared to volunteers: pNA (501 (196-927) vs 1858 (968-3663)) and pAD (71 (31-109) vs 193 (116-334)). Sympathectomy increased pL-DOPA, pAD and pDOPAC, but not pNA. After smoking, pNA only decreased in volunteers (1858 (968-3663) vs 1064 (535-2393)). In Buerger+sympathectomy group, smoking lowered pAD (700 (58-3379) vs 278 (54-429)).

CONCLUSIONS

in Buerger's disease there is an impairment of sympathoadrenal function with an altered peripheral adrenergic response to cigarette smoking. Patients submitted to sympathectomy have high pAD, but this benefit is reversed after smoking. This might be clinically relevant given the association between cigarette smoking and the manifestations of Buerger's disease and the controversy on the effectiveness of sympathectomy in the management of the disease.

Peripheral artery disease, diabetes, and reduced lower extremity functioning

OBJECTIVE

To characterize lower extremity function and dysfunction in peripheral artery disease (PAD) patients with and without diabetes.

RESEARCH DESIGN AND METHODS

In this cross-sectional study, 460 men and women with PAD (147 with diabetes) were recruited from three academic medical centers. Assessments included ankle brachial index (ABI), neuropathy score, 6-min walk distance, 4-m walking velocity, Walking Impairment Questionnaire (0-100 scale, 100 = best), and summary performance score (SPS) (0-12 scale, 12 = best).

RESULTS

The mean ABI was similar in PAD patients with and without diabetes. PAD patients with diabetes were younger, had a higher BMI, had a worse neuropathy score, and had a greater number of cardiovascular comorbidities compared with those without diabetes. Participants with diabetes were less likely to report classical symptoms of intermittent claudication and more likely to report exertional leg pain, which sometimes started at rest. After adjusting for age, those with diabetes had a shorter mean 6-min walk distance (1,040 vs. 1,168 feet, P < 0.001), slower fast-pace 4-m walk velocity (0.83 vs. 0.90 m/sec, P < 0.001), and a lower SPS (7.3 vs. 8.6, P < 0.001) than those without diabetes. Patients with diet-controlled diabetes performed better than those on diabetes medications. Differences in lower extremity functioning between patients with and without diabetes were largely attenuated but not abolished for SPS and fast-pace 4-m walk velocity after adjustment for type of exertional leg pain, neuropathy score, and number of cardiovascular comorbidities.

CONCLUSIONS

Subjects with PAD and diabetes have poorer lower extremity function than those with PAD alone. This difference in functioning appears to be largely explained by diabetes-associated neuropathy, differences in exertional leg symptoms, and greater cardiovascular disease in patients with diabetes.

Diabetic foot care: developing culturally appropriate educational tools for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Australia

Evidence shows that Aboriginal and Torres Strait Islander people have the highest national percentage of morbidity in relation to diabetes. Aboriginal and Torres Strait Islander people also suffer the greatest risk of amputation as a complication of diabetes. This participatory action research project sought to discover the opinions of a range of people, including registered nurses, general practitioners, Aboriginal health workers, cross-cultural liaison officers and Aboriginal and Torres Strait Islander people with diabetes. Focus groups provided valuable information regarding relevant issues of foot care education in the Northern Territory. The emergent themes included communication issues, educational resources, changing behaviour and other practical resources required for health education. The themes provided evidence of the inherent issues of foot care for Aboriginal and Torres Strait Islander people and guidance for the development of a visual educational tool. The results have lead to the development of a foot care educational tool that will be used by health-care professionals and clients in urban, community, rural and remote areas. The use of a participant action research process will ensure that the educational tool will be owned by Aboriginal and Torres Strait Islander People and health-care professionals.

[Buerger's disease or thromboangiitis obliterans]

The Buerger's disease or thromboangiitis obliterants (TAO) is a non atheromatous inflammatory disease which alters medium and small-sized arteries and veins. It can be found world-wide, but it is more frequent in Eastern Europe, Middle East, Asia and Southeast Asia. Young men and smokers are the most affected. The incidence of this disease is increasing among women. The cause of this disease is unknown yet. The most striking fact is the relationship between TAO and tobacco. The diagnostic is most often late in front of a digital leg ischemia. Complementary exams help to its diagnostic and management but none of them are specific out of the pathology. The affection is evolving towards distal gangrene with amputation in 5 to 10% of cases. Prostacyclin demonstrated its efficiency. Revascularization surgery is difficult but sometimes possible. Sympathectomy, medular stimulation must be suggested. The patient survival is not at stake and the prognosis is above all functional. The most important element in the treatment is stop smoking definitively.

Simple screening tests for peripheral neuropathy in the diabetes clinic

OBJECTIVE

The utility of rapid and reliable sensory tests appropriate for the diagnosis of neuropathy in the diabetes clinic, rather than as prognostic tools for the prediction of foot complications, has been unclear because of limitations inherent in previous studies. Although clinical practice guidelines recommend annual screening for neuropathy, they are unable to support specific recommendations for screening maneuvers because of a lack of evidence for the validity of screening tests in the medical literature. The objective of this study was to assess the operating characteristics of four simple sensory screening maneuvers as compared with standardized electrophysiological tests in the diagnosis of distal symmetrical polyneuropathy.

RESEARCH DESIGN AND METHODS

We assessed four simple tests (the 10-g Semmes-Weinstein monofilament examination [SWME], superficial pain sensation, vibration testing by the on-off method, and vibration testing by the timed method) in 478 subjects with independent blinded evaluations compared against the criterion standard of nerve conduction studies. We present receiver-operating characteristic (ROC) curves, positive and negative likelihood ratios, and sensitivity and specificity values for each test.

RESULTS

The four simple screening maneuvers reveal similar operating characteristics. Cutoff points by ROC curve analyses reveal that a positive or abnormal test is represented by five incorrect responses of eight stimuli applied. A negative or normal test is represented by one or fewer incorrect responses of eight stimuli applied. By these criteria, the point estimates of the positive likelihood ratios for vibration testing by the on-off method, vibration testing by the timed method, the SWME, and superficial pain sensation test are 26.6, 18.5, 10.2, and 9.2, respectively. The point estimates of the negative likelihood ratios are 0.33, 0.51, 0.34, and 0.50, respectively The screening tests showed comparable sensitivity and specificity results. The 10-g SWME, superficial pain test, and vibration testing by the on-off method are rapid, each requiring approximately 60 s to administer. The timed vibration test takes longer, and the interpretation is more complicated. The combination of two simple tests (e.g., the 10-g SWME and vibration testing by the on-off method) does not add value to each individual screening test.

CONCLUSIONS

Annual screening for diabetic neuropathy should be conducted using superficial pain sensation testing, SWME, or vibration testing by the on-off method. The reported operating characteristics for each sensory modality can be applied to positive findings on the physical examination of individual patients to predict the likelihood of neuropathy.

Sensory thresholds of normal human feet

HYPOTHESES/PURPOSE

Although several studies in the literature have evaluated the abnormal sensory thresholds of diabetic feet to Semmes-Weinstein monofilament testing, there is very limited data on the sensory thresholds of individuals without diabetes or peripheral neuropathy. The purpose of this study was to assess the dorsal and plantar sensation of the feet from 40 healthy, college-aged volunteers using Semmes-Weinstein monofilaments.

CONCLUSIONS/SIGNIFICANCE

Semmes-Weinstein testing is a useful tool in predicting which diabetic patients may be at risk for ulceration of the feet. Several studies have determined 5.07 to be the threshold for protective sensation. Based on the normal values derived in this study, the inability to feel a Semmes-Weinstein monofilament of 5.07 (as in diabetic neuropathy) represents a sensory threshold that is more than 50 times greater than normal. This means that roughly 98% of the sensory ability has been lost.

METHODS

20 male and 20 female volunteers between the ages of 18 to 22 years old were selected. None had a history of any significant injury or previous surgery to the foot or ankle. There were no known medical conditions associated with decreased foot sensation, (e.g.- diabetes, syphilis, leprosy, myelomeningocele, syringomyelia, or hereditary neuropathy). Volunteers were also questioned regarding participation in athletic activities. The subjects were blindfolded with the leg resting comfortably on a chair as 14 plantar and 5 dorsal locations were tested on each foot. The right foot was always tested first. Each site on the foot had the Semmes-Weinstein monofilaments applied to it first, in an order of increasing stiffness, then repeated in decreasing order, using all twenty monofilaments in the set. A positive threshold response was recorded when the subject could feel the filament and could accurately locate where on the foot the stimulus had been applied. The left foot was then tested in an identical fashion.

RESULTS

The mean sensitivity for all sites was 3.63 (0.0075 SEM). There were significant differences between sites, between using increasing or decreasing monofilament stiffness, between subjects, and in some instances, between right foot and left foot values. When testing was performed from the higher to lower monofilament stiffness, subjects were found to have significantly better sensitivity, which indicates the importance of a consistent testing protocol (either all up or all down). Sensation in the lesser toes and the arch were the most sensitive followed by the hallux and the plantar metatarsal heads. The least sensitive site was the heel, with 1/6th the sensitivity of the most sensitive toes.

Clinical examination for the detection of protective sensation in the feet of diabetic patients. International Cooperative Group for Clinical Examination Research

OBJECTIVE

We compared the reproducibility and accuracy of conventional clinical examination of the diabetic foot to monofilament examination. We also sought to simplify the monofilament examination by reducing it to fewer touch points.

METHODS

In a cross-sectional study at 10 centers in the United States, Canada, and Switzerland, general internists and residents performed a structured history and physical examination for neuropathy on the feet of diabetic patients. Independent examination by two observers included monofilament sensation, pinprick, vibration, position sense, and ankle reflexes.

MAIN RESULTS

A total of 304 patients were examined by at least one practitioner, and 200 received duplicate examinations. Monofilament examination and ankle reflexes had the best reproducibility, with moderate agreement (kappa = 0.59); pinprick, position, and vibration sense had fair agreement (kappa = 0.28-0.36). No component of the history or physical examination, singly or in aggregate, was both sensitive and specific for identifying a patient with an abnormal monofilament examination. A simplified monofilament examination using only 4 sites per foot (total 8 sites) detected 90% of patients with an abnormal 16-site monofilament evaluation.

CONCLUSIONS

Conventional clinical examination had low reproducibility and correlated poorly with monofilament examination for the identification of the at-risk patient. The Semmes-Weinstein monofilament examination, a reproducible, valid, and generalizable test of foot sensation, is recommended as the screening procedure of choice for examining diabetic feet.

Diabetic neuropathy: pathophysiology and prevention of foot ulcers

Diabetic neuropathy, which affects 60% to 70% of those with diabetes mellitus, is one of the most troubling complications for persons with diabetes, often leading to foot ulcers and potentially to lower limb amputations, both of which are preventable. The physiologic, structural, and functional changes associated with diabetic neuropathy and foot ulcers are discussed. Advanced practice nurses are in a unique position to implement strategies for the prevention of serious and debilitating complications from diabetic neuropathy, including foot assessment, education, and specialist referrals. Research evidence is given to support the use of the Semmes-Weinstein monofilaments to evaluate decreased plantar sensation, a common precursor to ulceration. Ongoing patient and family education can emphasize the importance of preventive self-care measures. Referrals for specialist care and therapeutic footwear can be made by advanced practice nurses. If begun early, these interventions can prevent foot ulcers from diabetic neuropathy, thereby improving the quality of life and reducing healthcare costs for this chronic disease.

Buerger's disease at the 'San Juan De Dios' Hospital, Santa Fe De Bogota, Colombia

OBJECTIVES

To know the clinical characteristics in the presentation of Buerger's disease in San Juan de Dios Hospital, Bogota, Colombia, between 1986 and 1996, and compare them with a previous series from the same Hospital and another reported in international literature; To determine the changes in the form of appearance of the disease.

METHODS

We reviewed the clinical information of 22 patients with diagnosis of Buerger's disease, observed between 1986 and 1993, and we added the information of the clinical histories of eight other patients with equal diagnosis, observed between 1994 and 1996 in our Unit.

RESULTS

We observed 30 patients: 28 men (93%) and two women (7%), with a ratio M:F of 14:1, with an average age of 39+10 years (range from 18 to 52 years). Sixty percent were younger than 40 years and only the 10% were older than 50 years. The most frequent reasons for consultation were: pain in rest in the affected extremity, gangrene and ulceration in more than 50%. Raynaud's phenomenon in 30%, and the related surgical history in 40%. The pedal pulse was the most compromised followed by popliteal, poster or tibial and femoral. We did not observe the presence of thrombophlebitis. Eighty percent showed compromise of more than one extremity. All of them were active smokers. Three patients showed IgG anticardiolipine antibodies at high level.

CONCLUSIONS

The clinical characteristics are similar to those reported, we find also a reduction of the disease diagnosis. It calls to our attention that no thrombophlebitis was found in the present series and the less compromise of the upper extremities with a frequent femoral compromise. All this points toward a change in the natural history of the disease.

Antiendothelial cell antibodies in thromboangiitis obliterans

The occurrence of autoimmune phenomena in 28 patients with thromboangiitis obliterans (Buerger's disease) was determined. The following were sought: antineutrophil cytoplasmic antibodies against proteinase 3 (cANCA) and myeloperoxidase (pANCA), antinuclear antibodies, anti-Ro antibodies, anticardiolipin antibodies, and antiendothelial cell antibodies (AECA). For the last, an enzyme-linked immunosorbent assay was developed which verified the presence of the AECA phenomenon with immunofluorescence and confocal microscopy. Seven patients with active disease had AECA titers of 1,857 +/- 450 arbitrary units (AU) compared with 126 +/- 15 AU in 30 normal control subjects (P < 0.001) and 461 +/- 41 AU in 21 patients in remission (P < 0.01). Antibodies from the sera of patients with active disease reacted not only with surface epitopes but also with sites within the cytoplasm of human endothelial cells. AECA may be useful in following disease activity and may play a role in the pathogenesis of thromboangiitis obliterans.

Buerger's disease in Hong Kong: a review of 89 cases

BACKGROUND

A retrospective analysis of 103 case records from 1978 to 1996 with a provisional diagnosis of Buerger's disease was undertaken at the Department of Surgery, University of Hong Kong, Queen Mary Hospital. The aim of the study was to elucidate the clinical course and evaluate the results of surgical intervention of Buerger's disease in Hong Kong Chinese people.

METHODS

Fourteen patients were subsequently excluded from the study because of inability of fulfil our diagnostic criteria. Data on clinical presentation, investigations, indications and results of surgical intervention were reviewed. Sympathectomies and arterial reconstructions were performed on 42 and four patients, respectively, for critical ischaemia or rest pain. Outcome was analysed with respect to the rate of ulcer healing, pattern of recurrence and limb loss.

RESULTS

The patients were all young male heavy smokers with a mean age of 36.5 years. The majority of patients (80%) presented with ischaemic ulceration or gangrene. Vascular reconstruction was undertaken in four patients and satisfactory long-term results were obtained in three patients. Sympathectomy was able to relieve symptoms in 87% of operated patients and ischaemic ulceration healed in 2.6 (mean) +/- 1.7 (SD) months after the operation. If the patient continued to smoke, surgical intervention did not exempt the patient from a relapse or amputation.

CONCLUSION

Sympathectomy provides short-term pain relief and promotes ulcer healing in patients with Buerger's disease but carries no long-term benefit. Complete abstinence from smoking is the only means of arresting the progression of the disease.