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Query: UMLS:C0011849 (diabetes)
 277,896 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

We report an infant of a diabetic mother (IDM) with in utero brachial artery thrombosis and neonatal gangrene to illustrate that there may be an increased risk for arterial as well as venous thrombosis in IDMs. The diagnosis of brachial artery thrombosis was made by using Doppler sonography flow studies and was confirmed with autopsy. The postnatal period was complicated by aortic and mesenteric artery thrombosis, with subsequent necrotizing enterocolitis, renal infarction, and death. Gangrene of a limb presenting at birth is rare, with 32 individuals reported in the literature, including this patient. Twenty-two percent (7/32) of the infants with peripartum limb gangrene were IDMs. This implies a marked increase in arterial thrombosis in IDMs over the general population. Changes in coagulation factors have been reported in newborn IDMs with poor control of maternal diabetes. Increased clotting and decreased fibrinolysis found in diabetics may lead to arterial thrombosis in IDMs in utero and postnatally. Use of anticoagulants in at-risk infants should be considered to prevent further thrombosis postnatally. Additionally, IDMs may be at increased risk for thrombotic complications from umbilical artery catheter. In utero thrombosis of the brachial artery may be one mechanism which leads to limb reduction defects in IDMs.
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PMID:In utero thrombosis and neonatal gangrene in an infant of a diabetic mother. 280 65

We placed 20 bypass grafts to the lateral plantar artery in 18 extremities to salvage feet with wet (12) or dry (six) gangrene; 15 grafts were implanted in men (75%), and five were implanted in women (25%). The median age was 65 years. All except two patients had diabetes; eight were treated with insulin. One patient had Buerger's disease, and another had vasculitis with chronic lymphocytic leukemia. History of smoking (65%), hypertension (53%), heart disease (71%), and osteomyelitis in the foot (35%), were noted. Cultures were positive in 15 gangrenous feet, 11 with gram-negative bacilli. Four long femoroplantar bypasses were placed. Ten short grafts were placed from the popliteal artery, and six jump grafts were placed distal to a femoropopliteal or tibial bypass. Hospital stay ranged from 8 to 38 days (median 16 days), and there were two in-hospital deaths. Transmetatarsal or button toe amputations were performed in nine feet. There were two below-knee amputations, one with a patent graft, for a foot salvage rate of 89% at 2 months. In four instances the gangrenous ulcers took longer than 6 months to heal; all other wounds healed within 6 months. The primary and secondary patency rates were 85% at 1 month, and 73% at 3 months and thereafter. Four of five graft failures occurred in the two legs with repeat bypass graftings. All patients with successful revascularization are able to walk, and seven returned to work full time.
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PMID:Lateral plantar artery bypass grafting: defining the limits of foot revascularization. 281 May 37

We present nine patients with necrotizing fasciitis. Two of them had Fourniers gangrene. Predisposing factors included diabetes mellitus, alcohol and drug abuse. Local signs were redness, swelling and pain rapidly followed by fever and deterioration in the patient's general condition. Soft tissue-gas was observed in all patients. It was found either clinically, on roentgenograms or by CT. Bacteria were found in blood cultures and/or necrotic tissues in all patients. The dominating treatment was radical surgical excision and early reexplorations. Antibiotics, intensive care support and early parenteral nutrition were given. Four patients were given hyperbaric oxygen treatment. The overall mortality rate was 11%. Amputation of one lower extremity became necessary in three patients. In these cases 4-8 days had elapsed between the onset and the first surgical excision. We find it important to underline early diagnosis and radical surgical excision in patients with necrotizing fasciitis.
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PMID:[Surgical treatment of necrotizing fasciitis]. 281 6

The importance of postoperative wound infection in major amputations was elucidated by recording the organisms isolated in preoperatively infected gangrene and in postoperatively infected wounds of patients undergoing lower-limb amputations for ischemia. Sixty-four amputations were performed on 61 patients. The frequency of coexisting diabetes mellitus was 34%. Postoperative infections occurred in nearly two-thirds of the 19 cases of infected gangrene, as compared with less than one-third of cases of noninfected gangrene. The presence of diabetes mellitus did not significantly influence the infection rate. Preoperatively as well as postoperatively, the most frequently isolated bacterium was Staphylococcus aureus. Clostridium perfringens was cultured in four cases. Postoperative wound infection following lower-limb amputation for ischemia is the main reason for reamputation, especially in patients with infected gangrene.
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PMID:Wound infection after lower extremity amputation because of ischemia. 286 53

Sixty-five lower-extremity amputations were performed as a result of sepsis in diabetic patients during a 3-year period. Chronic plantar ulcer was the most frequent cause of infection. Other causes of infection included ischemic gangrene, trauma, and web space fissures. Advanced ischemia was infrequent; only 21 (32.3%) had ankle-brachial indices (ABI) less than 0.5. Eight (23.5%) deaths and 12 (35.3%) stump failures followed 34 amputations where the stump was closed, compared with no deaths and 4 (12.9%) stump failures when open amputations were done (p less than 0.02). Partial foot amputations with aggressive local debridement resulted in healing in 10 (71.4%) of 14 cases with revision or grafting. Guillotine transmalleolar amputation is advised when foot salvage is not possible, because only 1 (5.9%) of 17 such procedures could not be revised to the below-knee (B-K) level, whereas 8 (33.3%) of 24 definitive, closed B-K amputations were unsuccessful (p less than 0.02). Infections were polymicrobial, with 5.8 bacterial isolates and 2.3 anaerobes recovered per patient. Anaerobic antibiotic coverage, however, failed to alter outcome. Sepsis, often without advanced ischemia, is an important cause of limb loss in patients with diabetes. Open amputations are recommended, with foot salvage possible in many cases.
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PMID:The septic foot in patients with diabetes. 290 97

Twenty-two patients who had diabetes mellitus and had needed an amputation for gangrene in an upper extremity at an average age of fifty-one years were identified and followed. The five patients who were still living at the latest follow-up had been followed for an average of 50.6 months. The other seventeen patients survived for an average of only 20.6 months after the amputation. All of the patients were in poor health; eighteen had needed an amputation in a lower extremity, and sixteen received hemodialysis. The results of amputation in an upper extremity were unsatisfactory; the site of the initial amputation healed in only two of the twenty-two patients. In the remaining twenty patients, a total of sixty-three additional operations were performed on an upper extremity, and five of the twenty patients died before the wound had healed.
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PMID:Gangrene of the upper extremity in diabetic patients. 291 10

Cholesterol embolization is a puzzling event that may be increasingly iatrogenic in origin. Diagnosis is difficult and requires a high index of suspicion, an appropriate clinical picture, and usually, confirmation by biopsy. Certain laboratory abnormalities may be helpful; the elevated sedimentation rate and relative eosinophilia found in our patients concurs with other cases reported in the literature. Prognosis is related to the extent of systemic involvement, but renal disease is particularly threatening and gangrene and infection can be lethal. Multiple therapeutic regimens have been generally unsuccessful in altering the course of the disease process. The most significant impact on the disease can be made by its prevention. Cholesterol emboli occur spontaneously, but also after invasive aortic procedures such as diagnostic angiography or cardiovascular surgery. In addition, cardiac catheterization and percutaneous transluminal coronary angioplasty have the potential for arterial trauma and consequent cholesterol embolization. Although the apparent increasing numbers of cholesterol emboli may be a reflection of the increased use of arterial invasive procedures, they are being performed on an older, more severely ill population, with other risk factors for the development of embolic phenomena, i.e., age, smoking history, diabetes mellitus, hypertension, and peripheral vascular disease. Our observed cases and review of the literature do not furnish information concerning the comparative incidences of embolization as related to the suggested etiologies. Careful documentation of the clinical situation preceding the event, the type of procedure, the site of arterial entry, and the duration, difficulty, and extent of the intravascular invasion (i.e., above or below the left subclavian artery) are necessary for this purpose. Such data should help to develop guidelines for patient and procedure selection in order to minimize the possibility of cholesterol embolization.
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PMID:Cholesterol emboli after cardiac catheterization. Eight cases and a review of the literature. 305 19

The role of percutaneous transluminal angioplasty in treating advanced peripheral vascular disease is unknown. The authors therefore reviewed the experience of Sunnybrook Medical Centre in Toronto with 85 consecutive patients who had rest pain, ulceration, pregangrene or gangrene as a result of peripheral vascular disease and who underwent percutaneous transluminal angioplasty. Seventy-four percent were smokers and 91% were at increased risk due to one or more of the following: coronary or cerebral ischemic disease, diabetes mellitus, obesity and hypertension. Thirty-six patients underwent dilatation of iliac lesions, 46 of superficial femoral or popliteal and 3 of more distal lesions. In nine patients angioplasty was repeated on the same lesion. In 16 patients, the procedure was technically unsatisfactory. The morbidity and 30-day mortality were 5% and 2%, respectively. When the procedure was technically satisfactory, surgery was avoided and the limb was salvaged at 1, 2 and 5 years in 69%, 62% and 54% of cases, respectively (life-table analysis). The authors conclude that percutaneous transluminal angioplasty is acceptable treatment for patients with advanced peripheral vascular disease, because the morbidity and mortality are low and the long-term results are good.
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PMID:Transluminal angioplasty: results in high-risk patients with advanced peripheral vascular disease. 315 87

CSAD provides a challenge for the vascular surgeon. Patients are older, sicker, and at greater risk than are patients with unisegmental disease. Similarly, symptoms are more severe and limb loss is more frequent. A multitude of different reconstructive techniques are available, but their injudicious or untimely use can not only fail to improve the patient but can also cause limb loss or death. Their use must be predicated by a differentiation of which arterial segments are hemodynamically involved, yet this determination may not be possible even after extensive noninvasive and invasive investigation. To optimize the approach to these patients, the following principles should be employed. First, incapacitating claudication is a valid indication for a suprainguinal inflow procedure in a good-risk patient. However, indications for surgery should usually be limited to limb salvage, especially if an infrainguinal procedure is contemplated. Medical conditions such as heart failure and diabetes should be improved before arteriography. The latter should delineate the entire infrarenal arterial system, with special attention to the iliac, deep femoral, and pedal arteries. Oblique views may be of critical importance. Noninvasive hemodynamic tests should be used to confirm the need for arterial reconstruction and help delineate areas of functional stenosis. Direct pull-through pressure measurements may be required for ultimate confirmation. If proximal disease is thus defined, as proximal inflow operation should usually be sufficient unless there is extensive gangrene of the foot, in which case synchronous distal grafts may be required. If the proximal graft alone is performed, the patient must be followed closely since approximately 10% of patients may need subsequent distal reconstructions. The role of the "runoff" segments such as the deep femoral artery, popliteal trifurcation, and pedal arteries may be critical. Every effort should be made to ensure flow through these vessels. Profundoplasty alone is seldom indicated but is often a valuable adjunct to other reconstructive procedures. Lumbar sympathectomy is seldom required. PTA is becoming a valuable adjunct to treatment of CSAD, and intraoperative dilatation also has potential attributes. If such an approach is followed, lasting limb salvage with minimal morbidity should be achieved in most patients with CSAD.
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PMID:Combined segment arterial disease. 315 27

A 10-year review of specimens of aortofemoral graft infection sent to the microbiology laboratory for cultures of anaerobic bacteria revealed the presence of these organisms in 13 of 16 specimens. Nineteen organisms (1.5 per patient) were isolated: 16 anaerobes and 3 aerobes. The predominant bacteria were anaerobic gram-positive cocci (six isolates), Propionibacterium acnes (five), and Bacteroides fragilis group (four). Polymicrobial infection was present in three patients, all with decubitus ulcers. Conditions predisposing to the infections were present in nine patients and included the presence of preoperative infections in the form of ulcer or toe gangrene in four, decubitus ulcer in three, reoperation in two, and diabetes mellitus in one. These data illustrate the potential importance of anaerobic bacteria in aortofemoral graft infection.
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PMID:Role of anaerobic bacteria in aortofemoral graft infection. 318 99


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