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The association between medical risk factors and the outcome of foot ulcers was evaluated in 208 consecutive diabetic patients with severe peripheral vascular disease (systolic toe blood pressure < or = 45 mm Hg). All patients were treated and followed by the same foot care team. Eighty patients healed primarily, 83 healed after a minor or major amputation, and 45 died. The systolic toe blood pressure was higher among primary healed (30 +/- 13 mm Hg) compared with amputated (22 +/- 15 mm Hg; p < 0.001) and deceased patients (20 +/- 14 mm Hg; p < 0.001). The patients were comparable regarding age, sex, and diabetes and wound duration. Only 41 (19%) patients had intermitten claudication, whereas 153 (77%) lacked palapble pedal pulses, 36% of whom healed primarily. Rest pain occurred in 72 (33%) patients, 38 (47%) of whom had an amputation and 18 (25%) who healed primarily (p < 0.01). Peripheral edema and proteinuria were more common among patients who healed after amputation compared with those who healed primarily (p < 0.001 and p < 0.01, respectively). Signs of sensory neuropathy were found in 158 (77%) patients. There were no differences concerning cardiovascular disease, smoking habits, or short-term metabolic control between patients who healed primarily or after an amputation. In conclusion, diabetic patients with foot ulcers and severe peripheral vascular disease with low systolic toe blood pressure were not excluded from the possibility of primary healing. The most important risk factors for amputation were a systolic toe pressure of less than 30 mm Hg, peripheral edema, rest pain, and proteinuria.
J Diabetes Complications
PMID:Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome. 147 42

Possible factors predisposing to peripheral vascular disease (PVD) in hypertensive subjects with Type 2 diabetes mellitus were studied. Details of age, sex, duration of diabetes, blood pressure, and smoking habit were recorded in 180 subjects of either White, West Indian Black or Asian ethnic origin. Glycosylated haemoglobin, fasting serum total cholesterol, total high density lipoprotein (HDL), HDL2, low density lipoprotein (LDL-cholesterol), and triglycerides were measured in all subjects. Peripheral vascular disease was defined as an ankle/brachial systolic pressure < 1.0 as measured by the Doppler technique. Multivariate analysis was performed and the following factors were identified as being strongly associated with the presence of PVD with a statistical significance of p < 0.001; LDL-cholesterol, total HDL-cholesterol, age, male sex, diet or oral hypoglycaemic therapy, diastolic blood pressure, and of p < 0.003; systolic blood pressure. When blood pressure was excluded from the analysis the other factors retained their predictive value. We conclude that hypertension and dyslipidaemia are important risk factors for peripheral vascular disease in Type 2 diabetes mellitus.
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PMID:Risk factors for peripheral vascular disease in hypertensive subjects with type 2 diabetes mellitus. 147 34

Cigarette smoking is the most preventable cause of cardiovascular morbidity and mortality. Smoking has been associated with a two-to fourfold increased risk of coronary heart disease, a greater than 70% excess rate of death from coronary heart disease, and an elevated risk of sudden death. These risks are compounded in the presence of hypertension, hypercholesterolemia, glucose intolerance, and diabetes, all of which exhibit a synergistic effect with smoking. The relationship between smoking and the risk of peripheral vascular disease has also been well documented. Smokers account for approximately 70% of patients with atherosclerosis obliterans and virtually all those with thromboangiitis obliterans. An association between smoking and cerebrovascular disease remains a matter of debate, although a higher risk of stoke and stroke-related mortality has been observed in smokers than in nonsmokers. Smoking has also been implicated in the development of cor pulmonale, but a direct association with congestive heart failure has not been established. Nicotine and carbon monoxide appear to play major roles in the cardiovascular effects of smoking. Both components adversely alter the myocardial oxygen supply/demand ratio and have been shown to produce endothelial injury, leading to the development of atherosclerotic plaque. Adverse effects on the lipid profile have been noted as well, but the relationship between these changes and the risk of cardiovascular disease remains to be confirmed. Notably, smoking cessation results in a dramatic reduction in the risk of mortality from both coronary heart disease and stroke. In light of the fact that the incidence of smoking has declined primarily among educated sectors of the U.S. population, future efforts must focus on providing effective education, including smoking cessation techniques, to the less-educated groups.
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PMID:Smoking and cardiovascular disease. 149 5

Effects of cilostazol (OPC-13013, CAS 73963-72-1), a selective inhibitor of platelet cAMP-phosphodiesterase, on peripheral vascular disease in diabetes mellitus were studied. Cilostazol in a dose of 200 to 300 mg/d was administered to 5 diabetic patients with arteriosclerosis obliterans. Skin temperature of the finger and the toe, which reflects blood flow to the tissue, was selected as an objective index of cilostazol effects and measured by infra-red thermography at a constant temperature of 26 degrees C. Before administration, digital skin temperatures were low in 9 limbs of 5 patients. 200 mg/d of cilostazol significantly (p less than 0.001) increased the digital skin temperatures of 8 limbs, the increase (mean +/- SD) ranging from 29.9 +/- 1.4 degrees C to 33.2 degrees C +/- 1.2 degrees C for the average skin temperatures and from 28.7 +/- 2.1 degrees C to 33.1 +/- 1.5 degrees C for the lowest ones. An increase in the dose to 300 mg/d resulted in further elevation of skin temperatures of the digits. Cilostazol constantly elicited an increase in blood flow to the digits within the range of its therapeutic dose. This effect was observed about 1 month after initiation of administration and persisted while administration was continued. The measurement of digital skin temperatures by infrared thermography provided a noninvasive means to individualize the dosage of cilostazol and to monitor the cilostazol effect and patient complicance during long-term administration. It is concluded that cilostazol exerts a potent and steady vasodilatory effect on peripheral circulation in patients with diabetes mellitus.
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PMID:Effects of the anti-platelet agent cilostazol on peripheral vascular disease in patients with diabetes mellitus. 149 93

The Progetto Lombardo Atero-Trombosi (PLAT) Study was a prospective, multicenter, multidisciplinary study of the association among hemostatic variables, conventional risk factors, and atherothrombotic events in four groups of patients with preexisting vascular ischemic disease (335 myocardial infarction survivors, 123 patients with stable angina pectoris, 160 with transient ischemic attacks, and 335 with peripheral vascular disease). In the myocardial infarction group, univariate analysis showed that atherothrombotic events were associated with high fibrinogen (p = 0.001), factor VIII:C (p less than 0.001), and von Willebrand factor antigen (vWF:Ag) (p = 0.004) levels and with low high density lipoprotein cholesterol (p = 0.043), factor VII (p = 0.019), and protein C (p = 0.044) levels; multivariate analysis produced associations with high fibrinogen and factor VIII:C levels and low protein C levels. By both univariate and multivariate analysis, events in the angina pectoris group were associated with high vWF:Ag (p = 0.026) and leukocyte (p = 0.033) levels and the presence of carotid arterial stenosis (p = 0.063); associations with high leukocyte (p = 0.037) and factor VIII:C (p = 0.186) levels, family history (p = 0.031), and diabetes (p = 0.061) were also found in the group with transient ischemic attacks. In those with peripheral vascular disease, events were associated with Fontaine stage greater than or equal to IIB (p = 0.024), high factor VIII:C levels (p = 0.073), and low protein C (p = 0.028), fibrinogen (p = 0.030), antithrombin III (p = 0.054), and factor VII (p = 0.057) levels by univariate analysis and with Fontaine stage and low fibrinogen levels by multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:The PLAT Study: hemostatic function in relation to atherothrombotic ischemic events in vascular disease patients. Principal results. PLAT Study Group. Progetto Lombardo Atero-Trombosi (PLAT) Study Group. 152 21

Patients with diabetes mellitus are at increased risk of morbidity and mortality from macrovascular disease manifesting as coronary heart disease, cerebrovascular accidents, and peripheral vascular disease. Increased frequency of dyslipidemia, hyperglycemia, obesity, hypertension, and associated nephropathy may contribute to accelerated atherogenesis in diabetic patients. Therefore, besides intensive control of hyperglycemia, management of dyslipidemia, hypertension, and obesity should also be emphasized in diabetic patients. Those who smoke should be strongly encouraged to quit smoking. Besides attempts to achieve normal levels of plasma lipoproteins, consideration also should be given to normalization of compositional abnormalities of various lipoproteins in patients with diabetes mellitus. The therapeutic goals for cholesterol reduction should be lower in diabetic patients than nondiabetic subjects. The first step is to achieve good metabolic control of diabetes mellitus by diet, exercise, and weight reduction and, if needed, with sulfonylureas or insulin therapy. Because most of the patients with insulin-dependent diabetes mellitus achieve normal levels of plasma lipoproteins with intensive insulin therapy, lipid-lowering medications are rarely needed. In patients with non-insulin-dependent diabetes mellitus, however, dyslipidemia often persists despite good glycemic control. Lipid-lowering medications should be considered in such patients. Because nicotinic acid can cause marked deterioration in glycemic control, and bile acid-binding resins may accentuate hypertriglyceridemia, these agents are less desirable for use by diabetic patients. Inhibitors of hydroxymethylglutaryl coenzyme A reductase may be preferred in patients with elevated LDL cholesterol and mld hypertriglyceridemia. For diabetic patients with marked hypertriglyceridemia, however, fibric acid derivatives should be the drug of choice.
Diabetes 1992 Oct
PMID:Lipid-lowering therapy and macrovascular disease in diabetes mellitus. 152 29

Angiotensin-converting enzyme (ACE) inhibitors and calcium antagonists are important classes of antihypertensive agents. Within their respective classes, ACE inhibitors and calcium antagonists share common pharmacokinetic properties, but in contrast to ACE inhibitors, some calcium antagonists may cause a significant increase in plasma digoxin concentrations. Clinically, both classes of agents have been shown to be safe and effective in large-scale, long-term clinical trials. ACE inhibitors appear to be very well tolerated and may be associated with fewer adverse effects than some calcium antagonists. ACE inhibitors appear to blunt diuretic-induced hypokalemia, hypercholesterolemia, hyperuricemia, and hyperglycemia. Both classes of agents can be used safely in patients with renal disease, diabetes mellitus, peripheral vascular disease, and chronic obstructive pulmonary disease. They may also be used in the elderly. While ACE inhibitors are particularly useful in hypertension accompanied by congestive heart failure, calcium antagonists can be very useful when angina pectoris is present in the hypertensive patient.
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PMID:Comparative pharmacokinetic and clinical profiles of angiotensin-converting enzyme inhibitors and calcium antagonists in systemic hypertension. 154 35

Diabetes mellitus and hypertension are common diseases that coexist at a greater frequency than chance alone would predict. Hypertension in the diabetic individual markedly increases the risk and accelerates the course of cardiac disease, peripheral vascular disease, stroke, retinopathy, and nephropathy. Our understanding of the factors that markedly increase the frequency of hypertension in the diabetic individual remains incomplete. Diabetic nephropathy is an important factor involved in the development of hypertension in diabetics, particularly type I patients. However, the etiology of hypertension in the majority of diabetic patients cannot be explained by underlying renal disease and remains "essential" in nature. The hallmark of hypertension in type I and type II diabetics appears to be increased peripheral vascular resistance. Increased exchangeable sodium may also play a role in the pathogenesis of blood pressure in diabetics. There is increasing evidence that insulin resistance/hyperinsulinemia may play a key role in the pathogenesis of hypertension in both subtle and overt abnormalities of carbohydrate metabolism. Population studies suggest that elevated insulin levels, which often occurs in type II diabetes mellitus, is an independent risk factor for cardiovascular disease. Other cardiovascular risk factors in diabetic individuals include abnormalities of lipid metabolism, platelet function, and clotting factors. The goal of antihypertensive therapy in the patient with coexistent diabetes is to reduce the inordinate cardiovascular risk as well as lowering blood pressure.
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PMID:Diabetes mellitus and hypertension. 156 57

In developing countries diabetes in the elderly is thought to be uncommon and is consequently ignored by health planners. We assessed the prevalence of complications of diabetes mellitus and frequency of hospital admissions in patients aged 60 and over in a hospital diabetic clinic in Sri Lanka. Elderly diabetic patients, though comprising only 23% of clinic patients, accounted for 46% of admissions. The prevalence of coronary artery disease, peripheral vascular disease, cerebrovascular disease, hypertension and visual handicap was increased in the diabetic patients when compared to age and gender matched controls. We conclude that diabetes in the elderly is a significant cause of morbidity in Sri Lanka.
Diabetes Res Clin Pract 1992 Mar
PMID:Diabetes in the elderly in a developing country. 157 24

Twelve patients who had a large ulceration over the heel were managed with a partial calcanectomy, in lieu of a below-the-knee amputation, after unsuccessful non-operative treatment of the ulcer. Only patients who had an ankle-arm index (the ratio of blood pressure at the ankle to the brachial blood pressure) of more than 0.45, a transcutaneous PO2 of more than twenty-eight millimeters of mercury (3.7 kilopascals), a level of albumin of more than 3.0 grams per deciliter (thirty grams per liter), and a total lymphocyte count of more than 1500 were managed with a partial calcanectomy. The primary diagnosis was diabetes in seven patients, peripheral vascular disease in three, quadriplegia in one, and myelodysplasia in one. The duration of follow-up averaged thirty-three months and ranged from seven to sixty-four months. The wound healed after the partial calcanectomy in ten of the twelve patients. Nine of these ten patients maintained the level of mobility that they had had preoperatively. (One patient was unable to walk because he was quadriplegic before the operation). The wound did not heal in two patients, and those patients ultimately had a below-the-knee amputation and a decrease of one grade on the scale that was used to evaluate walking ability.
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PMID:Partial calcanectomy for the treatment of large ulcerations of the heel and calcaneal osteomyelitis. An amputation of the back of the foot. 158 52


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