****** DATA-MÉDICOS *********

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ULCERA DIABÉTICA (I) / DIABETIC ULCER (I)

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***** DERMAGIC-EXPRESS No 15 *********

****** 12 NOVIEMBRE 1.998 ******* 

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EDITORIAL ESPAÑOL:

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Saludos amigos dermágicos, el DR. Marcelo Errico (Argentina) la semana pasada me pidió una puesta al día sobre manifestaciones cutáneas de la Diabetes, el tema es bastante extenso en cuanto a BIBLIOGRAFÍA, para hoy les tengo 22 REFERENCIAS sobre la ulcera diabética bastante interesantes, en la próxima edición libero los nuevos productos para este tipo de ulceras encontrados en la WEB.

Hasta una próxima edición de DERMAGIC,,,, saludos.

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DERMAGIC/EXPRESS(15)

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ULCERA DIABÉTICA (I) / DIABETIC ULCER I

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1.) Promotion and acceleration of diabetic ulcer healing by

arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group. 

2.) Effects of electrical stimulation on wound healing in patients with

diabetic ulcers. 

3.) The use and abuse of wound care materials in the treatment of diabetic

ulcerations. 

4.) Relationship of microalbuminuria with the diabetic foot ulcers in type

II diabetes. 

5.) Choosing a practical screening instrument to identify patients at risk

for diabetic foot ulceration. 

6.) Effect of topical basic fibroblast growth factor on the healing of

chronic diabetic neuropathic ulcer of the foot. A pilot, randomized,

double-blind, placebo-controlled study. 

7.) Prognostic value of the clinical examination of the diabetic foot ulcer. 

8.) Wound healing. New modalities for a new millennium. 

9.) Is hyperbaric oxygen a useful adjunct in the management of problem

lower extremity wounds? 

10.) Adjunctive systemic hyperbaric oxygen therapy in treatment of severe

prevalently ischemic diabetic foot ulcer. A randomized study. 

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

12.) 1995 William J. Stickel Gold Award. High strain rate tissue

deformation. A theory on the mechanical etiology of diabetic foot

ulcerations. 

13.) A metabolically active human dermal replacement for the treatment of

diabetic foot ulcers. 

14.) Cavity foot ulcers in diabetic patients: a comparative study of

cadexomer iodine ointment and standard treatment. An economic analysis

alongside a clinical trial. 

15.) Power spectral analysis of heart rate variation in diabetic patients

with neuropathic foot ulceration. 

16.) [Prognostic factors in treatment of diabetic foot ulcers] 

17.) Total contact casting for diabetic neuropathic ulcers. 

18.) Electron microscopic investigation of the effects of diabetes mellitus

on the Achilles tendon. 

19.) New uses for benzoyl peroxide: a broad-spectrum antimicrobial agent.

20.) Topical therapy of leg ulcers with 20 percent benzoyl peroxide lotion.

21.) Treatment of cutaneous ulcers with benzoyl peroxide.

22.) Clinical evaluation of recombinant human platelet-derived growth

factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer

Study Group. 

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1.) Promotion and acceleration of diabetic ulcer healing by

arginine-glycine-aspartic acid (RGD) peptide matrix. RGD Study Group. 

=====================================================================

Author 

Steed DL; Ricotta JJ; Prendergast JJ; Kaplan RJ; Webster MW; McGill

JB; Schwartz SL 

Address 

Department of Surgery, University of Pittsburg, Pennsylvania 15213. 

Source 

Diabetes Care, 18(1):39-46 1995 Jan 

Abstract 

OBJECTIVE--To determine the effectiveness and safety of

arginine-glycine-aspartic acid

(RGD) peptide matrix in the treatment of diabetic foot ulcers.

RESEARCH DESIGN AND

METHODS--This randomized placebo-controlled investigator- and

patient-blinded

prospective multicenter investigation was conducted at three

institutional and three private

U.S. clinics providing ambulatory care. Sixty-five diabetic patients

with chronic full-thickness

neurotrophic foot ulcers were enrolled. Six discontinued the study

because of adverse

events. RGD peptide matrix (Argidene Gel; formerly Telio-Derm Gel) was

applied topically

twice weekly for up to 10 weeks in patients who otherwise received

standard care. Control

group patients received topical saline as a placebo plus standard

care. The primary method

of assessment was the incidence and rate of ulcer closure. All

patients enrolled were

included in the data analysis. RESULTS--The percentage of patients

whose ulcers healed

completely in the RGD peptide matrix group (35%; 14 of 40 patients)

was over fourfold

greater (P = 0.02) than that in the placebo group (8%; 2 of 25

patients). By the study end

point (either day of healing or week 10), 30 of 40 (75%) RGD peptide

matrix patients had

achieved > 50% ulcer closure compared with 12 of 25 (48%) placebo

patients (P = 0.03).

RGD peptide matrix also significantly (P = 0.03) increased the rate of

ulcer closure over the

10 weeks of the study. CONCLUSIONS--RGD peptide matrix treatment

promoted and

accelerated the healing of chronic diabetic foot ulcers to a significant 

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2.) Effects of electrical stimulation on wound healing in patients with

diabetic ulcers. 

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Author 

Baker LL; Chambers R; DeMuth SK; Villar F 

Address 

Department of Biokinesiology and Physical Therapy, University of

Southern California, Los

Angeles 90033, USA. llbaker@hsc.usc.edu 

Source 

Diabetes Care, 20(3):405-12 1997 Mar 

Abstract 

OBJECTIVE: To evaluate the effects of two stimulation waveforms on

healing rates in

patients with diabetes and open ulcers. The hypothesis was that

stimulus waveforms with

minimal polar characteristics would provide significant healing for

this patient sample.

RESEARCH DESIGN AND METHODS: This was a prospective study that

enrolled 80

patients with open ulcers. Patients received stimulation with either

an asymmetric biphasic

(A) or symmetric biphasic (B) square-wave pulse. Amplitudes were set

to activate intact

peripheral nerves in the skin. Two other groups received either very

low levels of stimulation

current (MC), or no electrical stimulation (C). When combined these

groups were referred to

as the control group. Treatment was carried out daily until the wound

healed, the patient

withdrew from the study, or the physician changed the overall wound

management program.

Average healing rates were calculated from weekly measures of the

wound perimeter and

were used for statistical comparison through a one-way analysis of

variance. RESULTS:

Stimulation with the A protocol significantly increased the healing

rate, enhancing healing by

nearly 60% over the control rate of healing. Stimulation with the B

protocol did not increase

the healing rate when compared with control subjects. CONCLUSIONS:

Electrical

stimulation, given daily with a short pulsed, asymmetric biphasic

waveform, was effective for

enhancement of healing rates for patients with diabetes and open ulcers. 

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3.) The use and abuse of wound care materials in the treatment of diabetic

ulcerations. 

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Author 

Day MR; Fish SE; Day RD 

Address 

Nashville Family Foot Care, TN 37203, USA. 

Source 

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

Abstract 

With the ever-increasing availability of wound care materials for use

in diabetic foot

ulcerations, a thorough understanding of the indications and

applications of these materials

is important for wound-management success. The coupling of a lack of

understanding of the

interaction of wound care materials and the dynamic nature of

wound-healing physiology may

lead to a protracted healing course that may constitute an abuse of an

otherwise useful

adjunct to wound healing protocols. This article provides an overview

of wound care

products, their indications, and possible complications of

inappropriate use. 

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4.) Relationship of microalbuminuria with the diabetic foot ulcers in type

II diabetes. 

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Author 

Guerrero-Romero F; Rodr´iguez-Mor´an M 

Address 

Research Group on Diabetes and Chronic Illnesses, Mexican Social

Security Institute,

Durango. 

Source 

J Diabetes Complications, 12(4):193-6 1998 Jul-Aug 

Abstract 

Microalbuminuria is a significant risk factor associated with

nephropathy, retinopathy, and

cardiovascular disease; however, there are no previous reports on the

relationship of

microalbuminuria with diabetic foot ulcers or stroke, despite the fact

that microalbuminuria

is a marker of vascular damage. The purpose of this study was to

determine the relationship

of microalbuminuria with diabetic foot ulcers in type II diabetes

patients. In this,

cross-sectional clinical study, outpatients of the offices at first

level medical care in Durango,

Mexico, were included in one of two groups; (a) patients with diabetic

foot ulcers and (b)

control of group patients without diabetic foot ulcers. Diabetic foot

diagnosis was

established on the basis of clinical criteria and pletismography.

Patients diagnosed with renal

disease, urinary tract infection, acute febrile illness, or heart

failure and those receiving

angiotensin-converting enzyme inhibitors were excluded from the study.

Microalbuminuria

was measured, on a 24-h urine collection, by precipitation with

sulfasalicylic acid, and

turbidity was determined by measuring absorbance with a

spectrophotometer. The study

included 670 diabetic patients. Using both odds ratio and logistic

regression analyses,

diabetes duration, cigarette smoking, aging, and microalbuminuria

showed a strong

relationship with diabetic foot ulcers. Microalbuminuria should be

considered as an

independent risk factor for diabetic foot ulcers. 

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5.) Choosing a practical screening instrument to identify patients at risk

for diabetic foot ulceration. 

=====================================================================

Author 

Armstrong DG; Lavery LA; Vela SA; Quebedeaux TL; Fleischli JG 

Address 

Department of Orthopaedics, University of Texas Health Science Center,

San Antonio, Tex.,

USA. 

Source 

Arch Intern Med, 158(3):289-92 1998 Feb 9 

Abstract 

OBJECTIVE: To evaluate the sensitivity and specificity of 3 sensory

perception testing

instruments to screen for risk of diabetic foot ulceration. METHODS:

This case-control

study prospectively measured the degree of peripheral sensory

neuropathy in diabetic

patients with and without foot ulcers. We enrolled 115 age-matched

diabetic patients (40%

male) with a case-control ratio of approximately 1:3 (30 cases and 85

controls) from a

tertiary care diabetic foot specialty clinic. Cases were defined as

individuals who had an

existing foot ulceration or a history of a recently (< 4 weeks) healed

foot ulceration.

Controls were defined as subjects with no foot ulceration history.

Using receiver operating

characteristic analysis, we evaluated the sensitivity and specificity

of 2 commonly used

nephropathy assessment tools (vibration perception threshold testing

and the

Semmes-Weinstein 10-g monofilament wire system) and a 4-question

verbal neuropathy

score to evaluate for presence of foot ulceration. RESULTS: A

vibration perception

threshold testing using 25 V and lack of perception at 4 or more sites

using the

Semmes-Weinstein 10-g monofilament wire system had a significantly

higher specificity than

neuropathy score used. The neuropathy score was most sensitive when 1

or more answers

were affirmative. When modalities were combined, particularly the

monofilament wire system

plus vibration perception threshold testing and the neuropathy score

plus the monofilament

wire system, there was a substantial increase in specificity with

little or no diminution in

sensitivity. CONCLUSIONS: The early detection of peripheral neuropathy

or loss of

"protective sensation" is paramount to instituting a structured

treatment plan to prevent lower

extremity amputation. The results of our study suggest that all 3

sensory perception testing

instruments are sensitive in identifying patients at risk for

ulceration. Combining modalities

appears to increase specificity with very little or no diminution in

sensitivity. 

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6.) Effect of topical basic fibroblast growth factor on the healing of

chronic diabetic neuropathic

ulcer of the foot. A pilot, randomized, double-blind,

placebo-controlled study. 

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Author 

Richard JL; Parer-Richard C; Daures JP; Clouet S; Vannereau D; Bringer

J; Rodier M;

Jacob C; Comte-Bardonnet M 

Address 

Department of Dietetics and Diabetology, Centre Medical, Le Grau du

Roi, France. 

Source 

Diabetes Care, 18(1):64-9 1995 Jan 

Abstract 

OBJECTIVE--To assess the efficacy and safety of topical human

recombinant basic

fibroblast growth factor (bFGF) on the healing of diabetic

neurotrophic foot ulcers.

RESEARCH DESIGN AND METHODS--Seventeen diabetic patients suffering from

chronic neuropathic ulcer of the plantar surface of the foot entered a

pilot, randomized,

double-blind study comparing local application of bFGF with placebo.

Main inclusion criteria

were a typical neuropathic ulcer of Wagner grade I-III, more than 0.5

cm in the largest

diameter, with an abnormally high vibration perception threshold in

the absence of significant

peripheral vascular disease or wound infection. bFGF or placebo was

applied daily during

the 6 weeks as inpatients then twice a week for 12 weeks. Evolution of

ulcer size was

assessed through weekly clinical examination and computerized

photographs. RESULTS--In

the bFGF group, three of nine ulcers healed compared with five of

eight in the placebo

group (NS). The weekly reduction in ulcer perimeter and area was

identical in both groups,

as was the rate of linear advance from entry to the 6th week of

treatment (bFGF: 0.053 +/-

0.048 mm vs. placebo: 0.116 +/- 1.129 mm): the same result was

obtained at the 11th

week. Moreover, percent healed area at the end of the study did not

differ significantly. No

side effects were observed during bFGF application.

CONCLUSIONS--Topical application

of bFGF has no advantage over placebo for healing chronic neuropathic

diabetic ulcer of

the foot. Because diabetes causes significant wound-healing defects,

we hypothesized that

using a single growth factor might be insufficient to accelerate wound

closure of diabetic

ulcers. 

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7.) Prognostic value of the clinical examination of the diabetic foot ulcer. 

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Author 

Edelman D; Hough DM; Glazebrook KN; Oddone EZ 

Address 

Center for Health Services Research in Primary Care, Durham Veterans

Affairs Medical

Center, NC 27705, USA. 

Source 

J Gen Intern Med, 12(9):537-43 1997 Sep 

Abstract 

OBJECTIVE: To determine the value of the history, physical

examination, and magnetic

resonance imaging (MRI) in predicting successful primary healing of a

foot ulcer in a

diabetic patient. DESIGN: Prospective cohort study. SETTING: Durham

(NC) Veterans

Affairs Medical Center. PATIENTS: Sixty-four consecutive diabetic

patients with 78

dermal ulcers through the full thickness of the skin and at or distal

to the malleoli of the ankle.

MEASUREMENTS AND MAIN RESULTS: A structured clinical history and physical

examination were performed by two examiners, a physician participating

in the study and the

referring physician. Fifty of these patients with 63 ulcers underwent

MRI. Patients were

followed prospectively for 6 months after enrollment to ascertain

healing of the ulcer,

amputation, and death. During the 6-month follow-up period, 8 (13%) of

the patients died.

Seventeen (22%) of the ulcers were amputated, 17 (22%) of the ulcers

failed to heal, and

36 (47%) healed primarily. Univariate predictors of healing at 6

months included age less

than 65 years, diagnosis of diabetes within the last 15 years,

painless ulcer, palpable ankle

pulse, anklebrachial index greater than 0.5, and the physician's

assessment of the overall

likelihood of osteomyelitis. In a multivariable logistic regression

model, predictors of healing

included the presence of an audible pulse on Doppler examination (p =

.01) and a painless

ulcer (p = .04). The diagnosis of osteomyelitis on MRI did not predict

healing in these

patients. CONCLUSIONS: Foot ulcers in patients with diabetes

frequently have poor

outcomes; fewer than half the patients in this study healed their

ulcers within 6 months. The

vascular components of the clinical examination are the best

predictors of healing in patients

with a diabetic foot ulcer. 

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8.) Wound healing. New modalities for a new millennium. 

=====================================================================

Author 

Williams RL; Armstrong DG 

Address 

Department of Anesthesia, University of Texas Health Science Center,

San Antonio, USA. 

Source 

Clin Podiatr Med Surg, 15(1):117-28 1998 Jan 

Abstract 

Common to all studies of wound healing modalities is the need to

convert the chronic wound

into an acute wound and to maintain the wound in an acute state while

subsequently using

adjunctive therapy. Hence, precise control and documentation of wound

care is extremely

important in order to avoid contamination of the effects of a specific

modality with the effects

of good wound care. Falanga has noted that neuropathy of diabetes has

been given wide

support as the primary pathogenic component of diabetic ulcers,

whereas less recognition

has been made of the wound-healing failure component. The therapies

discussed in this article

considered the wound-healing failure component. Oxygen is a drug. The

use of oxygen under

normobaric conditions at higher than normal inspired partial pressures

is standard operating

procedure when clinicians are faced with patients with respiratory

embarrassment or heart

failure. The use of oxygen under hyperbaric conditions, however,

remains estranged from the

mainstream thoughts of most clinicians. Abnormally hypoxic wounds may

benefit from

specific oxygen therapy in hyperbaric dosage ranges. However,

correction of abnormal

wound oxygen tension alone does not guarantee healing. Hyperbaric

studies have been

criticized for the lack of well-defined wound care protocols, the

absence of precise wound

healing measures, and poorly defined wound healing endpoints. Studies

with growth factors

and human skin equivalents exclude patients typically referred for

hyperbaric therapy.

Patients referred for hyperbaric therapy often have larger wounds with

greater severity of

peripheral vascular disease with ABIs < 0.7 and TcPO2 < 30 to 40 mm

Hg, are often on

medications known to inhibit wound healing (e.g., steroids), or have

concomitant medical

disorders (collagen vascular disease, renal failure) associated with

poor healing. No

hyperbaric study has controlled stringently for all of these factors.

Nevertheless, HBO2 is

more specific and successful for the intended purpose of correction of

abnormal tissue

oxygen tensions than are growth factors for the intended purpose of

growth. Similarly, skin

substitutes are limited in their application and have not been tried

in patients with ABIs < 0.7

or TcPO2 values < 30 mm Hg. In our view, hyperbaric therapy probably

can be combined

successfully with allogenic grafts and human skin equivalents in this

group of patients.

Hyperbaric therapy can generate a sufficient granulation base in which

these products should

be able to close properly selected wounds successfully. No studies of

this combined modality

approach exist. Finally, regardless of the modality used to aid in

wound closure, long-term

outcomes probably depend more on neuropathy and large vessel disease

than on

microangiopathy and local wound-healing defects. The modalities

presented in this article

must prove to be both cost effective and practical before they are

widely disseminated.

Nevertheless, the ability to manipulate the local wound environment is

no longer inviolate as

was once presumed, and current investigations continue to advance

therapeutic options in this

most fascinating and challenging discipline. 

Language 

Eng 

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9.) Is hyperbaric oxygen a useful adjunct in the management of problem

lower extremity wounds? 

=====================================================================

Author 

Ciaravino ME; Friedell ML; Kammerlocher TC 

Address 

Department of Surgical Education, Orlando Regional Medical Center, FL

32806, USA. 

Source 

Ann Vasc Surg, 10(6):558-62 1996 Nov 

Abstract 

Hyperbaric oxygen (HBO) is currently being used in the treatment of

nonhealing or "problem"

wounds of the lower extremities. In an attempt to evaluate the

efficacy of HBO in problem

wounds, a retrospective study of the HBO experience at Orlando

Regional Medical Center

was conducted. From 1989 to 1994, fifty-four patients with nonhealing

lower extremity

wounds resulting from underlying peripheral vascular disease and/or

diabetes mellitus were

treated with HBO. Wounds were grouped into the following five

categories: (1) diabetic

ulcers (n = 17 [31%]); (2) arterial insufficiency (n = 8 [15%]); (3)

gangrenous lesions (n = 6

[11%]); (4) nonhealing amputation stumps (n = 13 [24%]); and (5)

nonhealing operative

wounds (n = 10 [19%]). Each patient received an average of 30

treatments. Outcomes for all

54 patients treated with HBO in this study were dismal. None of the

patients experienced

complete healing, six (11%) showed some improvement, 43 (80%) showed

no improvement,

and in five cases (9%) results were inconclusive because these

patients underwent

concomitant revascularization or amputation. Thirty-eight of the 43

patients who showed no

improvement (88%) ultimately required at least one surgical procedure

to treat their wounds.

Thirty-four patients (63%) developed complications, most commonly

barotrauma to the ears,

which occurred in 23 patients (43%). The average cost of 30 HBO

treatments was $14,000

excluding daily inpatient charges. Based on the experience with HBO

therapy at Orlando

Regional Medical Center and the paucity of good supporting literature,

it is difficult to justify

such an expensive, ineffective complication-prone treatment modality

for problem extremity

wounds. 

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10.) Adjunctive systemic hyperbaric oxygen therapy in treatment of severe

prevalently ischemic diabetic foot ulcer. A randomized study. 

=====================================================================

Author 

Faglia E; Favales F; Aldeghi A; Calia P; Quarantiello A; Oriani G;

Michael M; Campagnoli

P; Morabito A 

Address 

Diabetology Center, Niguarda Hospital, Milan, Italy. 

Source 

Diabetes Care, 19(12):1338-43 1996 Dec 

Abstract 

OBJECTIVE: To evaluate the effectiveness of systemic hyperbaric oxygen

therapy (s

HBOT) in addition to a comprehensive protocol in decreasing major

amputation rate in

diabetic patients hospitalized for severe foot ulcer. RESEARCH DESIGN AND

METHODS: From August 1993 to August 1995, 70 diabetic subjects were

consecutively

admitted into our diabetologic unit for foot ulcers. All the subjects

underwent our

diagnostic-therapeutic protocol and were randomized to undergo s-HBOT.

Two subjects,

one in the arm of the treated group and one in the arm of nontreated

group, did not complete

the protocol and were therefore excluded from the analysis of the

results. Finally, 35 subjects

received s-HBOT and another 33 did not. RESULTS: Of the treated group

(mean session =

38.8 +/- 8), three subjects (8.6%) underwent major amputation: two

below the knee and one

above the knee. In the nontreated group, 11 subjects (33.3%) underwent

major amputation:

7 below the knee and 4 above the knee. The difference is statistically

significant (P = 0.016).

The relative risk for the treated group was 0.26 (95% CI 0.08-0.84).

The transcutaneous

oxygen tension measured on the dorsum of the foot significantly

increased in subjects treated

with hyperbaric oxygen therapy: 14.0 +/- 11.8 mmHg in treated group,

5.0 +/- 5.4 mmHg in

nontreated group (P = 0.0002). Multivariate analysis of major

amputation on all the

considered variables confirmed the protective role of s-HBOT (odds

ratio 0.084, P = 0.033,

95% CI 0.008-0.821) and indicated as negative prognostic determinants

low ankle-brachial

index values (odds ratio 1.715, P = 0.013, 95% CI 1.121-2.626) and

high Wagner grade

(odds ratio 11.199, P = 0.022, 95% CI 1.406-89.146). CONCLUSIONS:

s-HBOT, in

conjunction with an aggressive multidisciplinary therapeutic protocol,

is effective in decreasing

major amputations in diabetic patients with severe prevalently

ischemic foot ulcers. 

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

=====================================================================

Author 

Jarde O; Filloux V; Filloux JF; Remond A; Vives P 

Address 

Service d'orthop´edie-taumatologie, H^opital Nord, AMIENS, France. 

Source 

Acta Orthop Belg, 63(3):156-64 1997 Sep 

Abstract 

The authors report a series of thirty-six perforating ulcers of the

foot in diabetic patients,

evaluated using M.R.I. M.R.I. showed osteomyelitis in 16 cases,

cellulitis in 15 cases,

osteoarthropathies in 21 cases, tenosynovitis of flexor tendons in 2

cases, oedema in 2 cases

and abscess in one case. In 19 cases, M.R.I. was used to improve

diagnostic accuracy. The

medical treatment made use of thermo-moulded soles allowing for the

recovery of walking,

with a hole facing the perforating ulcer of the foot. The application

of insulin-soaked sponges

in the event of clean perforating ulcer of the foot and iodized

solution in the event of infected

perforating ulcer of the foot promoted healing. The treatment was only

conservative, when

the lesions were limited to the soft tissues. Surgical treatment was

performed in 19 cases due

to a global involvement of soft and osteoarticular tissues. In

fourteen cases the surgical

treatment was limited and was performed through the perforating ulcer.

Resection of

metatarsal heads or metatarso-phalangeal joints was performed in 10

cases, with resection of

surrounding pathologic tissue. The surgical treatment was limited to

the soft tissues in 6 cases.

In 4 cases, M.R.I. findings resulted into a transmetatarsal amputation

because the vascular

plexus was of poor quality and infection spread from the perforating

ulcer to the dorsal

aspect of the foot. In our opinion, dorsal infectious involvement in a

perforating ulcer of the

foot, is a factor of poor prognosis. A below-knee amputation has been

performed in one

patient. 

=====================================================================

12.) 1995 William J. Stickel Gold Award. High strain rate tissue

deformation. A theory on the mechanical etiology of diabetic foot

ulcerations. 

=====================================================================

Author 

Landsman AS; Meaney DF; Cargill RS 2nd; Macarak EJ; Thibault LE 

Address 

Dr. William M. Scholl College of Podiatric Medicine, Chicago, IL

60610, USA. 

Source 

J Am Podiatr Med Assoc, 85(10):519-27 1995 Oct 

Abstract 

Foot ulcerations are one of the most common and dangerous

complications associated with

chronic diabetes mellitus. Many studies have focused on neuropathy, in

conjunction with

elevated ground reactive forces, as the principal cause of these

ulcerations. The authors

discuss the mechanical cause of diabetic ulcerations at the cellular

level. It is hypothesized

that increased rate of tissue deformation associated with foot slap

secondary to progressive

motor neuropathy is the actual culprit, and not the magnitude of local

pressure applied. The

authors present a cellular model that shows that high rates of tissue

deformation may result in

elevated intracellular calcium concentrations, which may lead to

cellular death, while

comparable loads gradually applied do not. Furthermore, there is no

significant difference in

the response observed at 5 psi and 10 psi. Based on these findings, it

is hypothesized that

techniques such as ankle foot orthoses, which control the velocity of

foot strike, may be

useful in treating diabetic foot ulcerations. 

=====================================================================

13.) A metabolically active human dermal replacement for the treatment of

diabetic foot ulcers. 

=====================================================================

Author 

Naughton G; Mansbridge J; Gentzkow G 

Address 

Advanced Tissue Sciences, Inc., La Jolla, California 92037, U.S.A. 

Source 

Artif Organs, 21(11):1203-10 1997 Nov 

Abstract 

Tissue engineering, the science of growing living human tissues for

transplantation, promises

to revolutionize aspects of medical care. Ulcers of the skin of the

feet of diabetic patients

are a serious health problem and a major cause of amputations.

Dermagraft, a

tissue-engineered, living human dermal tissue, which provides normal

growth factors and

matrix proteins, has been implanted to replace a patients' destroyed

dermises and heal these

ulcers. Large-scale clinical studies and in vitro experiments have

demonstrated the

importance of controlling specific product parameters, especially the

metabolic activity of the

tissue, to provide, upon implantation into the wound bed, a living

tissue that facilitates healing.

Implanting tissue within a defined therapeutic range of metabolic

activity dramatically

improves healing of diabetic foot ulcers, with significantly more

ulcers healed completely in

a shorter time. In this new, rapidly moving science, such elucidation

of the mechanism of

action is vital to ensure that tissues will provide their intended

benefit. 

=====================================================================

14.) Cavity foot ulcers in diabetic patients: a comparative study of

cadexomer iodine ointment and standard treatment. An economic analysis

alongside a clinical trial. 

=====================================================================

Author 

Apelqvist J; Ragnarson Tennvall G 

Address 

Department of Internal Medicine, University Hospital of Lund, Sweden. 

Source 

Acta Derm Venereol, 76(3):231-5 1996 May 

Abstract 

Diabetic foot ulcers with exposure of tendon, muscle, or bone imply a

high probability for

deep infections and amputations. Delayed healing times are often

described. The aim of this

study was to compare the clinical effect and economic cost of

cadexomer iodine with

standard treatment in diabetic feet with cavity ulcers. Patients with

deep, exudative foot

ulcers were included in a 12-week open, randomised, comparative study.

When ulcers

stopped exudating, vaseline gauze was used in both groups until the

end of the study. Costs

were estimated for dressing material, staff and transportation.

Clinically relevant improvement

was seen in 12 patients treated with cadexomer iodine and in 13

patients treated with

standard treatment. The average weekly cost was SEK 903 and SEK 1,421,

respectively, of

which the major part was costs for staff and transportation related to

frequency of dressing

changes. Treatment with cadexomer iodine ointment (Iodosorb) showed no

clinical difference

compared to topical treatment consisting of gentamicin solution,

streptodornase/streptokinase, or dry saline gauze but was associated

with considerably lower

weekly treatment costs. 

=====================================================================

15.) Power spectral analysis of heart rate variation in diabetic patients

with neuropathic foot ulceration. 

=====================================================================

Author 

Aso Y; Fujiwara Y; Inukai T; Takemura Y 

Address 

Department of Medicine, Koshigaya Hospital, Dokkyo University School

of Medicine,

Saitama, Japan. 

Source 

Diabetes Care, 21(7):1173-7 1998 Jul 

Abstract 

OBJECTIVE: To evaluate the relationship between diabetic autonomic

neuropathy and

diabetic neuropathic foot ulceration, we used power spectral analysis

(PSA) of heart rate

variation, which provides the accurate simultaneous quantification of

parasympathetic and

sympathetic activities, to assess autonomic function in diabetic

patients. RESEARCH

DESIGN AND METHODS: We studied 55 NIDDM patients including 10 diabetic

patients

without neuropathy, 23 diabetic patients with neuropathy and no

history of foot ulceration,

and 22 diabetic patients with neuropathic foot ulceration. We

performed PSA of 100 R-R

intervals at rest and analyzed the results by fast Fourier

transformation. RESULTS: The low

frequency (LF) power, which reflects sympathetic activity, and the

high frequency (HF)

power, which reflects parasympathetic (vagal) activity, were inversely

correlated with the

duration of diabetes and the fasting plasma glucose (FPG) levels. By

multiple regression

analysis, the FPG remained with significant influence on both LF and

HF powers. The LF

and HF powers were positively correlated with motor nerve conduction

velocity (MCV) and

sensory nerve conduction velocity (SCV) in the upper and lower limbs

and the coefficient of

variation of R-R intervals. The LF and HF powers were significantly

reduced in patients with

neuropathy and patients with foot ulceration compared with patients

without neuropathy.

Although the median MCV and SCV were similar between diabetic patients

with

neuropathy and patients with foot ulceration, both the LF and HF

powers were significantly

decreased in patients with foot ulceration compared with patients with

neuropathy. There

was no difference in the value of the LF:HF ratio, an index of

sympathovagal balance, among

three subgroups. We observed a positive correlation between LF and HF

power in all

subjects; however, the LF and HF powers were not correlated in the

subgroups of patients

with foot ulceration. CONCLUSIONS: These results showed that diabetic

patients with

neuropathic foot ulceration have a greater impairment in spectral

indexes of autonomic

activity obtained by PSA than patients with neuropathy and no history

of foot ulceration,

whereas no difference was present in nerve conduction velocities. 

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16.) [Prognostic factors in treatment of diabetic foot ulcers] 

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Author 

Coerper S; Flesch I; Becker HD; K¨oveker G 

Address 

Abteilung f¨ur Allgemeine Chirurgie, Chirurgische Universit¨atsklinik

T¨ubingen. 

Source 

Langenbecks Arch Chir Suppl Kongressbd, 114():566-8 1997 

Abstract 

138 patients with nonhealing diabetic foot ulcers were treated between

1994 and 1996.

Sixty-nine percent of these foot ulcers healed within 17 weeks. Heel

ulcers had a

significantly lower healing rate, probably because of the difficulty

of taking weight-bearing off

this zone. Ischemia also correlated well with low healing rates,

underlining the importance of

vascular diagnosis and surgery. Since compliance is the most

significant factor for success, it

is mandatory to educate the patient about his disease and prevent

further complications. 

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17.) Total contact casting for diabetic neuropathic ulcers. 

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Author 

Sinacore DR 

Address 

Program in Physical Therapy, Washington University School of Medicine,

St. Louis, MO

63110, USA. 

Source 

Phys Ther, 76(3):296-301 1996 Mar 

Abstract 

Despite its limited therapeutic use, several research reports indicate

that TCC is currently the

most rapid and effective technique for healing diabetic neuropathic

ulcers. Skilled

application and careful follow-up of the wound are necessary to avoid

complications and

minimize the risks for reulceration. As more clinicians adopt this

form of therapy, the

successful treatment of neuropathic ulcers using TCC should result in

a lower incidence of

infection, hospitalization and lost income in patients with chronic

sensory neuropathies. 

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18.) Electron microscopic investigation of the effects of diabetes mellitus

on the Achilles tendon. 

=====================================================================

Author 

Grant WP; Sullivan R; Sonenshine DE; Adam M; Slusser JH; Carson KA;

Vinik AI 

Address 

Tidewater Foot and Ankle Center, Virginia Beach, Virginia, USA. 

Source 

J Foot Ankle Surg, 36(4):272-8; discussion 330 1997 Jul-Aug 

Abstract 

Fine structural changes in the Achilles tendons of patients with

long-term diabetes mellitus

were investigated. All patients had clinical and electrophysiological

evidence of diabetic

neuropathy and had ulceration and/or Charcot neuroarthropathy. Several

differences

between tendons of diabetic (n = 12) and nondiabetic (n = 5)

individuals were observed by

electron microscopy. In diabetics, these differences included

increased packing density of

collagen fibrils, decreases in fibrillar diameter, and abnormal fibril

morphology. In one

diabetic patient, individual collagen fibrils were tightly apposed so

that many areas of tendon

appeared as a single mass of closely adhering fibrillae. In addition,

foci in which collagen

fibrils appeared twisted, curved, overlapping and otherwise highly

disorganized were

common in specimens from most patients (11 of 12). These morphologic

abnormalities in the

Achilles tendons of diabetics appear to reflect a poorly known process

of structural

reorganization that may be the result of nonenzymatic glycation

expressed over many years.

Such structural changes could contribute to the tightening of the

Achilles tendor a

phenomenon consistent with clinical observations of extreme shortening

of the Achilles

tendon-gastrocnemius-soleus complex common in advanced diabetic

neuropaths. In patients

with diabetic neuropathy, tendon shortening causes severe equinus that

may precipitate

serious ulceration, stress fractures, and Charcot collapse of the

foot. However, in

nondiabetics, the fine structure of the Achilles tendon appears

normal, consistent with the

finding that the ultrastructural changes result from diabetes rather

than neuropathy. 

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19.) - New uses for benzoyl peroxide: a broad-spectrum antimicrobial agent.

=====================================================================

SO - Int J Dermatol 1977 Jun;16(5):413-7

AU - Kligman AM; Leyden JJ; Stewart R

MJ - Benzoyl Peroxide [therapeutic use]; Peroxides [therapeutic use];

Tinea [drug therapy]

MN - Tinea Pedis [drug therapy]; Tinea Versicolor [drug therapy]

MT - Human

PT - JOURNAL ARTICLE

AB - Benzoyl peroxide is a useful agent in the treatment of acne, chronic

ulcers, tinea pedis, and tinea versicolor, probably because of its

antimicrobial power. 2.5% concentration is almost as active as 5%. Although

potential irritancy and allergic reaction have not been a problem on the

face, benzoyl peroxide should be used judiciously in chronically inflamed

or ulcerated skin. Several potential uses are mentioned.

=====================================================================

20.) Topical therapy of leg ulcers with 20 percent benzoyl peroxide lotion.

=====================================================================

SO - Cutis 1978 Apr;21(4):491-4

AU - Colman GJ; Roenigk HH Jr

MJ - Benzoyl Peroxide [therapeutic use]; Leg Ulcer [drug therapy];

Peroxides [therapeutic use]

MN - Administration, Topical; Benzoyl Peroxide [administration & dosage];

Leg Ulcer [pathology]

MT - Human

PT - JOURNAL ARTICLE

AB - Preliminary clinical observations suggest that benzoyl peroxide

lotion (20%) may be a useful topical treatment for various types of leg

ulcers. Further studies utilizing patients as their own controls (treating

half of the ulcer surface with 20% benzoyl peroxide) are now underway.

=====================================================================

21 - Treatment of cutaneous ulcers with benzoyl peroxide.

=====================================================================

SO - Can Med Assoc J 1976 Dec 4;115(11):1101-6

AU - Pace WE

MJ - Benzoyl Peroxide [therapeutic use]; Peroxides [therapeutic use]; Skin

Ulcer [drug therapy]

MN - Administration, Topical; Adult; Aged; Benzoyl Peroxide

[administration & dosage] [adverse effects]; Child, Preschool; Child;

Methods; Middle Age; Skin Ulcer [pathology]

MT - Case Report; Female; Human; Male

PT - JOURNAL ARTICLE

AB - Benzoyl peroxide, a powerful organic oxidizing agent, was applied

topically according to a carefully developed technique to cutaneous ulcers

of different types. The healing time was shortened greatly by the rapid

development of healthy granulation tissue and the quick ingrowth of

epithelium. Exceptionally large pressure ulcers with deep cavities,

undercut edges and sinus tracts were sucessfully treated, as were stasis

ulcers of long duration resistant to all other therapy. There were only 13

treatment failures among the 133 cases. The slow, sustained release of

oxygen by benzoyl peroxide was though to be responsible for the success.

The only complications were contact irritant dermatitis in 3% and contact

allergic dermatitis in 2% of patients treated.

=====================================================================

22.) Clinical evaluation of recombinant human platelet-derived growth

factor for the treatment of lower extremity diabetic ulcers. Diabetic Ulcer

Study Group. 

=====================================================================

Author 

Steed DL 

Address 

University of Pittsburgh, Presbyterian University Hospital, PA 15213. 

Source 

J Vasc Surg, 21(1):71-8; discussion 79-81 1995 Jan 

Abstract 

PURPOSE: The purpose of this study was to investigate the efficacy and

safety of

recombinant human platelet-derived growth factor (rhPDGF-BB) in a

double-blind,

placebo-controlled, multicenter study of patients with chronic

diabetic ulcers. METHODS:

Patients with chronic, full-thickness, lower-extremity diabetic

neurotrophic ulcers of at least

8 weeks' duration, free of necrotic and infected tissue after

debridement, and with

transcutaneous oxygen tensions of 30 mm Hg or greater were studied. A

total of 118 patients

were randomized to receive either topical rhPDGF-BB (2.2

micrograms/cm2 of ulcer area)

or placebo until the ulcer was completely resurfaced or for a maximum

of 20 weeks,

whichever occurred first. RESULTS: Twenty-nine (48%) of 61 patients

randomized to the

rhPDGF-BB group achieved complete wound healing during the study

compared with only

14 (25%) of 57 patients randomized to the placebo group (p = 0.01).

The median reduction

in wound area in the group given rhPDGF-BB was 98.8% compared with

82.1% in the

group given placebo (p = 0.09). There were no significant differences

in the incidence or

severity of adverse events between the rhPDGF-BB and placebo groups.

CONCLUSIONS: Once-daily topical application of rhPDGF-BB is safe and

effective in

stimulating the healing of chronic, full-thickness, lower-extremity

diabetic neurotrophic

ulcers. 

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DATA-MÉDICOS/DERMAGIC-EXPRESS No(15) 12/11/98 DR. JOSE LAPENTA R. DERMATÓLOGO

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Produced by Dr. José Lapenta R. Dermatologist
Venezuela 1.998-2.024

Producido por Dr. José Lapenta R. Dermatólogo Venezuela 1.998-2.0024

Tlf: 0414-2976087 - 04127766810