Ligia de Loiola Cisneros

Avaliação de um programa para prevenção de úlceras neuropáticas em portadores de diabetes

BACKGROUND Neuropathic foot ulcers are among the major health problems faced by patients with diabetes mellitus. OBJECTIVE To evaluate the preventive efficacy of a therapeutic education and protective footwear program in the incidence and recurrence of neuropathic ulcers due to diabetes. METHODS Fifty-three patients with diabetes and neuropathy from a public healthcare unit in Porto Alegre, Rio Grande do Sul, took part in a clinical trial for two years. The participants were randomly allocated to an intervention group (n=30) or a control group (n=23). Therapeutic education was provided in group sessions, and protective footwear was supplied in accordance with individual prescriptions. The nonparametric Mann-Whitney test was used to determine differences in incidence and recurrence of ulceration between the groups. Life-table analysis and the Kaplan-Meier method were used to measure the duration of ulcer-free survival. RESULTS In the intervention group, the ulcer incidence rate was 38.1% compared to 51.1% in the control group. Among the participants who presented ulcers, 83% were in the control group and 16.7% in the intervention group. After one year, the participants in the intervention group had a 75% chance of being ulcer-free, compared with 61% in the control group, and these percentages reduced to 60% and 52% respectively after two years. There was a tendency toward shorter survival among the control group participants. CONCLUSION Although the proposed program lowered recurrence rates and increased the duration of ulcer-free survival, it was unable to prevent occurrence and recurrence of neuropathic ulcers due to diabetes.

Mapping the association between back pain and type 2 diabetes: A cross-sectional and longitudinal study of adult Spanish twins

Background Back pain and type 2 diabetes often co-occur, resulting in greater impact on people’s health and complexity in their care. Plausible causal mechanisms for this association have been proposed, yet the nature of the link remains unclear. We therefore explored the direction of the association between type 2 diabetes and chronic back pain in twins, controlling for genetics and early environmental confounding. Methods 2,096 and 1,098 twins were included in the cross-sectional and longitudinal analyses, respectively. Any or severe (≥ 9) low back pain (LBP), neck pain (NP), and spinal pain (concurrent LBP and NP) and type 2 diabetes were investigated. Sequential analyses were performed using logistic regression. Firstly, twins were analysed unpaired (adjusted age and gender): total sample analyses. Then, to control for genetic and shared environmental factors, a co-twin case-control analysis was performed including monozygotic and dizygotic twin pairs discordant for back pain (cross-sectional only). Results In the cross-sectional total sample analyses, type 2 diabetes was associated with chronic spinal pain (OR 1.61; 95%CI 1.12 to 2.31), severe chronic spinal pain (OR 3.33; 95%CI 1.47 to 7.53), chronic NP (OR 1.37; 95%CI 1.01 to 1.85), severe chronic NP (OR 2.28; 95%CI 1.24 to 4.21), and severe chronic LBP (OR 1.63; 95%CI 1.00 to 2.64). After further adjustment for genetic and shared environmental factors, none of the associations remained significant. The longitudinal analyses indicated that the presence of type 2 diabetes did not increase the risk of future back pain, or vice-versa, after two to four years. Conclusions Chronic back pain (spinal pain, NP, or LBP) was associated with the prevalence of type 2 diabetes. Associations are stronger for severe cases of pain. Future research should investigate the temporal relationships between these conditions with longer follow up in twins.

Confiabilidade intra e interexaminador da análise por padrões de impressão de plantigrafias de pessoas diabéticas obtidas com o Harris Mat

INTRODUCTION High plantar pressure is a proven risk factor for ulceration among individuals with diabetes mellitus. The Harris and Beath footprinting mat is one of the tools used in screening for foot ulceration risk among these subjects. There are no reports in the literature on the reliability of footprint analysis using print pattern criteria. OBJECTIVE The aim of this study was to evaluate the inter- and intra-examiner reliability of the analysis of footprint patterns obtained using the Harris and Beath footprinting mat. METHODS Footprints were taken from 41 subjects using the footprinting mat. The images were subjected to analysis by three independent examiners. To investigate the intra-examiner reliability, the analysis was repeated by one of the examiners one week later. RESULTS The weighted kappa coefficient was excellent (K(w) > 0.80) for the inter- and intra-examiner analyses for most of the points studied on both feet. CONCLUSIONS The criteria for analyzing footprint patterns obtained using the Harris and Beath footprinting mat presented good reliability and high to excellent inter- and intra-examiner agreement. This method is reliable for analyses involving one or more examiners. Article registered in the Australian New Zealand Clinical Trials Registry (ANZCTR) under the number ACTRN12609000693224.

Diabetic foot ulcer carries high amputation and mortality rates, particularly in the presence of advanced age, peripheral artery disease and anemia

INTRODUCTION Foot ulcer is also a clinical marker for limb amputation and for death in diabetic patients. The purpose of this study was to determine amputation and mortality rates and its associated factors in patients with diabetic foot ulcerations in a tertiary hospital in Brazil. METHODS Retrospective medical records from 654 diabetic foot patients were reviewed. The risk factors were determined using the conditional logistic regression model analysis. RESULTS The mean patient age was 63.1 years (SD 12.20). Peripheral arterial disease was present in 160 patients (24.5%). Major amputations were performed in 135 (21%). The in-hospital mortality rate was 12% and the mortality rate of the amputees was 22.2%. The lowest hemoglobin level, the median value was 9.50g/dL, (4.0-17.0). Anemia was detected in 89.6% of patients submitted to amputation and in 82,1% of those who died. Hemoglobin <11g/dL was the most significant risk factor for major amputation (odds ratio 5.57, p<0.0001). The presence of peripheral arterial disease and old age were also a risk for major amputation (odds ratio 1.84, p=0.007 and 1.02, p=0.028, respectively). Factors associated with increased risk for death were hemoglobin <11g/dL (odds ratio 4.04, p<0.001), major amputation (1.79, p=0.03) and old age (1.05, p<0,001). CONCLUSIONS Diabetic foot ulcer is associated with high amputation and mortality rates. Old age, peripheral arterial disease and low hemoglobin level are risk factor for major amputation. Old age, major amputation and low hemoglobin level are risk factors for death.

Hydrotherapy improves pain and function in older women with knee osteoarthritis: a randomized controlled trial

Highlights • Elderly women with knee osteoarthritis are at risk of developing limitations physical.• Hidrotherapy improves pain, function, muscle power and strength in older women with knee osteoarthritis.• Hydrotherapy is likely to be an effective treatment option for these patients.

Anatomical Principles of the Circulatory System

The circulatory system comprises two interrelated systems: the cardiovascular and the lymphatic vascular systems. The cardiovascular system is composed by the heart and its distribution network: arteries, veins, and capillaries [Color textbook of histology, Philadelphia, 2007]. Its ramifications are depicted inside this chapter. In parallel, the lymphatic system consists of an extensive network of vessels similar to veins that are spread throughout the body. These plexuses contain nodes in its path that are responsible for filtering and carrying back to the blood stream fluids from organs and tissues that did not return to the blood capillaries [Color textbook of histology, Philadelphia, 2007; Gray’s anatomy: the anatomical basis of clinical practice, Edinburgh, 2008]. For a better understanding of the main problems and diseases related to this system it is extremely important to review the anatomy of the vessels and the heart before going to the next chapters.

Epidemiology and outcomes of 655 diabetic foot patients in a Brazilian university hospital

Results Sixty seven percent (442) were males; the age ranged from 21 to 102 years (median 63 years). Arterial ischemia was present in 28% of the patients. Among these diabetic patients 73% had hypertension and 30% were active smokers. The in-hospital mortality rate was 12%, and there was no statistically difference between patients with ischemic and non-ischemic lesions (P=0.16). Of the 576 patients alive, 61% were not readmitted, 21% were readmitted once and 18% were readmitted twice or more times. The minor amputation rate was 48% while major amputations were performed in 21% of the subjects (28% below the knee amputation and 72% above the knee amputation). The major amputation free survival rate was 72%. After discharge 47% of the patients required special home-care for dressings and for parenteral drug administration. Independent risk factor for amputation were age (OR: 1.02; 95%CI: 1.0011.035; P=0.041) and arterial ischemia (OR 2.20; 95%CI 1.46-3.31; P<0.0001). Independent risk factors for death were age (OR 1.06; 95% CI 1.03 – 1.08; P<0.01) and major amputations (OR 2.38; 95% CI 1.41 – 3.99; P=0.01).

Functional status after major amputation in diabetic foot patients from a tertiary hospital

Objective The purpose of this study was to verify functional status of diabetic foot patients submitted to lower limb major amputation after the discharge of a university hospital, reference in vascular surgery. A cohort of 31 diabetic foot patients was identified from the electronic medical records. Data were retrospectively collected from each patients chart including age, gender, peripheral arterial disease, level of amputation and number of readmissions. Patients were contacted by phone. A questionnaire investigated the survival, functional and ambulatory status: prosthesis use, reason for non-implantation of prosthetics, other hospitalization and amputation, mobility, selfperformance of activities of daily living such as dressing and personal hygiene.

Quality of life of people with diabetes mellitus pre revascularization surgery and post amputation: an exploratory study

Background Diabetic foot complications are the most serious and costly problem of Diabetes Mellitus affecting substantially the quality of life of these patients. People with diabetic foot ulcers experience severe restrictions on daily life as a result of the ulcer. They face social isolation due to reduced mobility, they require frequent clinical treatment and constant caution to ensure that effective care is taken of the feet.