PubMed Health⌕ Search

Biomedical subjects

M E Edmonds

Publications and source records attributed to M E Edmonds.

At least 37 records · Page 2Linked to original sources
PubMed1995

Reduction of gangrene and amputations in diabetic renal transplant patients: the role of a special foot clinic.

This 4-year prospective study investigated the reasons for high levels of gangrene and major amputation in diabetic renal transplant patients and whether regular multidisciplinary foot care could reduce morbidity. All foot lesions were documented and investigated in 50 diabetic patients, mean age 49.2 +/- 11.0 (SD) years, duration of diabetes 25.3 +/- 9.0 years, time since renal transplantation 60.2 +/- 35.1 months, who attended a special foot clinic monthly for education, vascular and neurological assessment, podiatry and footwear. Foot lesions included: neuropathic ulcers, ischaemic ulcers, traumatic lesions, Charcot's arthropathy, pathological fracture. Treatment included antibiotics, podiatry, footwear, and angioplasty or distal bypass where appropriate. Only 13 patients were deemed ischaemic but peripheral neuropathy was a very common finding (mean VPT 24.8 +/- 12.9 V). Gangrene and major amputations showed a decrease on previous years and healing times for lesions were similar to those previously reported in diabetic patients without renal transplants. The majority of foot lesions, both in soft tissue and bone, were related to neuropathy and trauma and responded well to optimal foot care within the renal unit. Gangrene and major amputations were usually preventable.

Ambulatory Care Facilities↗
PubMed1995

Lower limb venous pressure in diabetic neuropathy.

OBJECTIVE: Distended turgid veins have been noted in the feet of patients with diabetic neuropathy. This study assessed the supine venous pressure and its correlation with diabetic neuropathy and arteriovenous (AV) shunting in the feet of type I and type II diabetic subjects. RESEARCH DESIGN AND METHODS: Seventeen patients with chronic Charcot joints, 11 patients with a history of neuropathic foot ulceration, 14 diabetic control subjects, and 11 normal control subjects were studied. Neuropathy was assessed by vibration and thermal thresholds and standard cardiovascular autonomic neuropathy tests. Supine venous pressure was measured by insertion of a 21-gauge needle connected to a strain gauge manometer into the veins on the dorsum of the foot. Venous PO2 was used as a measure of AV shunting. RESULTS: Venous pressure was raised in the group with chronic Charcot joints (18.9 +/- 4.2 mmHg, P < 0.001 vs. the diabetic control group [11.3 +/- 2.6 mmHg]), the normal control group (12.3 +/- 2.3 mmHg, mean +/- SD), and the diabetic group with a history of neuropathic foot ulceration (16.0 +/- 3.7 mmHg, P = 0.008 vs. diabetic control subjects and P = 0.04 vs. normal control subjects), with a maximum of 28 mmHg. Venous pressure was correlated with heart rate variation to deep breathing, r = -0.61 (P = 0.001), vibration threshold, r = 0.56 (P = 0.001), Valsalva ratio, r = -0.64 (P -= 0.001), warm threshold, r = 0.69 (P = 0.001), and venous PO2, r = 0.43 (P = 0.02). There was no correlation with skin temperature, duration of diabetes, age, HbA1c, random blood glucose, ankle/brachial Doppler index, height, or serum creatinine. CONCLUSIONS: Venous pressure is much higher in the neuropathic diabetic limb and is correlated with the severity of neuropathy and with AV shunting.

Adult↗
PubMed1994

Application of OpSite film: a new and effective treatment of painful diabetic neuropathy.

The aim of the study was to assess the effect of application of OpSite dressings on the pain and quality of life in 33 patients with chronic diabetic neuropathy. The effect of OpSite was compared with no treatment. After a run-in period of 2 weeks, OpSite was applied to one of the painful legs for 4 weeks. This was followed by another period of 4 weeks when OpSite was switched to the opposite leg. Pain was assessed by visual analogue scale and the primary analysis variable was within patient difference in pain between OpSite leg and no treatment leg at week 4 corrected for baseline. Secondary variables were paracetamol pill ingestion and the quality of life dimensions, sleep, mobility, contact discomfort, appetite, and mood. Changes in these variables from baseline to weeks 4 and 8 were analysed. There was a significantly greater reduction in pain in the OpSite treated limbs than the control limbs (p < 0.001). By week 4 paracetamol intake also declined significantly (p = 0.034) and patients experienced a significant improvement in contact discomfort, sleep, mood, appetite, and mobility (p < 0.002 for all 5 variables). OpSite appeared to alleviate the pain associated with diabetic painful neuropathy and thus improved patients' quality of life.

Adult↗
PubMed1994

The value of the Neurometer in assessing diabetic neuropathy by measurement of the current perception threshold.

The Neurometer is a relatively new device for assessing neuropathy by measuring current perception threshold (CPT). The study aim was to assess the ability of the Neurometer to distinguish between different types of nerve fibre damage by using different frequencies (2000 Hz, 250 Hz, and 5 Hz) of electric stimulus (high frequencies for large fibres and low frequencies for small fibres) and comparing the results with standard sensory tests of vibration perception threshold (VPT) and thermal perception threshold (TPT). CPT was determined on index finger and great toe of 51 patients with diabetic neuropathy and 28 non-diabetic control subjects, age and sex matched. CPT in neuropathic patients could be distinguished from controls at all three frequencies in both feet and hands (p < 0.05). The best correlation was found between CPT at 2000 Hz and VPT (r = 0.48, p < 0.001) in the feet suggesting a degree of neuroselectivity. Internal correlations between CPT at the three frequencies showed the weakest correlation between CPT at 2000 Hz and 5 Hz (r = 0.27, p < 0.005), suggesting also that possibly different types of fibres were examined. CPT reproducibility was better in control (CV = 6.4-27.7%), than in neuropathic subjects (CV = 28.4-52.3%), although the coefficient of variation was comparable to that of standard tests of sensory function, VPT and TPT. The Neurometer is a simple instrument to use in clinical practice. It has a degree of neuroselectivity but like all subjective sensory tests has a large variability.

Adult↗
PubMed1993

Abnormal digital pressure measurements in diabetic neuropathic foot ulceration.

The diabetic neuropathic ulcer is typically slow to heal and recurrent. Macrovascular insufficiency is usually excluded as foot pulses are present and ankle:brachial pressure ratios are not decreased. These assessments cannot however exclude more distal vascular disease. Digital pressure measurements enable a reliable assessment of the distal peripheral vascular status to be made. The aim of this study was therefore to use toe pressures to assess the contribution of distal ischaemia in the pathogenesis of the neuropathic ulcer. Sixteen diabetic patients with recurrent neuropathic foot ulceration had their toe pressures compared to 10 neuropathic patients without a history of foot ulceration, 10 diabetic control subjects, and 11 normal subjects. Four non-diabetic patients with neuropathy and foot ulceration were also assessed. All subjects had ankle:brachial pressure indices > or = 1. Toe pressure was assessed using laser Doppler flowmetry to record the return of skin blood flow. The toe:brachial pressure index (TBI) was then calculated. The diabetic patients with a history of recurrent neuropathic ulceration, had the lowest mean TBI, 0.63 +/- 0.14 (SD), compared to the non-ulcerated diabetic neuropathy patients, the diabetic control subjects, and the normal subjects. 0.84 +/- 0.11, 0.82 +/- 0.1, and 0.81 +/- 0.07, p < 0.01, respectively. Three of the four non-diabetic patients with neuropathic foot ulceration also had an abnormally low TBI. Reduced toe pressure measurements are thus found to be associated with neuropathic foot ulceration. The contribution of distal ischaemia in the pathogenesis of the diabetic neuropathic foot ulcer needs to be evaluated.

Adult↗
PubMed1992

Selective neuropathy and preserved vascular responses in the diabetic Charcot foot.

Charcot arthropathy is a disabling complication of diabetic neuropathy. It is however, unclear why it occurs in only a small number of neuropathic patients. We have studied 12 diabetic patients (10 insulin-dependent) with an acute Charcot arthropathy, and compared their neuropathy and vascular responsiveness with 12 diabetic patients (10 insulin-dependent) with recurrent neuropathic foot ulceration, 12 diabetic control subjects (9 insulin-dependent) and 10 normal non-diabetic subjects. The Charcot arthropathy patients demonstrated a preservation of warm perception, 6 (5.5) degrees C, but complete loss of peripheral cold perception, 10 (0) degrees C, p less than 0.001 (median (interquartile range)). This contrasted with the ulcerated neuropathy patients, who had equally severe impairement of both warm and cold sensory thresholds, 10(0.5) degrees C vs 10(1) degrees C, respectively, the diabetic control subjects who were able to detect a 2 (1.3) degrees C warm stimulus and 3 (3.5) degrees C cold stimulus and the normal subjects, whose warm threshold was 2 (1) degrees C and cold was 2 (1) degrees C. Light touch perception at the foot was preserved in the Charcot patients 4 (4) g vs 100 (50) g, p less than 0.0002, in the ulcerated neuropathy patients. Vibration perception at the great toe and cardiovascular autonomic function tests (heart rate variability, Valsalva ratio and postural systolic blood pressure fall) were abnormal in both the Charcot patients and ulcerated neuropathy group, with no differences seen between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Arthropathy, Neurogenic↗
PubMed1991

Influence of neuropathy on the microvascular response to local heating in the human diabetic foot.

1. The diabetic neuropathic foot exhibits excess arteriovenous anastomotic shunt flow due to a reduced sympathetic vasoconstrictor tone. Local axon reflexes (mediating postural vasoconstriction, for example) are preserved even in severe diabetic neuropathy. This excess shunt flow and its local neurogenic control may be important in the development of complications of the neuropathic limb. 2. The response of arteriovenous anastomoses to local heating was assessed in 13 diabetic patients with neuropathy (12 insulin-dependent), 10 diabetic control patients (seven insulin-dependent) and 10 normal control subjects. The aim was to study the local reflex control of arteriovenous flow when central sympathetic tone had been largely removed. 3. The change in skin blood flow on local heating to 44 degrees C was measured by using a laser Doppler flowmeter in standard environmental conditions with the foot at heart level. Two sites were assessed: (i) the plantar surface of the great toe (a site in which skin blood flow is dominated by arteriovenous shunt flow) and (ii) the dorsum of the foot (a site without anastomotic flow). 4. It was found that when heat was applied to the plantar surface of the great toe in the diabetic patients with neuropathy a paradoxical decrease in flow through arteriovenous anastomoses occurred, flow declining to 65% (P less than 0.05) of its resting value. This could be compared with an increase in flow over the same time period of 262% and 228% (P less than 0.01) in diabetic control patients and normal subjects, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Disabling postural hypotension complicating diabetic autonomic neuropathy.

A 35-year-old Type 1 diabetic man with severe disabling postural hypotension was studied for physiological abnormalities, precipitating factors, and effect of current treatment. A 24-h blood pressure profile indicated a diurnal variation in systolic blood pressure with the lowest values recorded between 0100 and 0600 h, during which the patient often lost consciousness on standing (mean standing systolic pressure 78 mmHg at night vs 105 mmHg in the afternoon, p less than 0.001). Food induced a profound fall in systolic pressure, both while supine and while standing erect. The systolic pressure fall during euglycaemia was 49 mmHg vs 3 mmHg during hypoglycaemia. Plasma noradrenaline and adrenaline levels were low during euglycaemia, but increased during hypoglycaemia. Therapeutic manoeuvres aimed at increasing heart rate (by atrial tachypacing) and reducing the peripheral pooling of blood (vasoconstricting drugs and gravity suit), together with the somatostatin analogue octreotide, proved ineffective. These observations demonstrate the phenomenon of post-prandial exacerbation of postural hypotension in a Type 1 diabetic patient, and indicate that despite failure of conventional methods of treatment, hypoglycaemia increased plasma catecholamines and was effective in abolishing the blood pressure fall on standing.

Adult↗
PubMed1988

Direct measurement of capillary blood flow in the diabetic neuropathic foot.

The two major components of the microcirculation in the diabetic neuropathic foot have been examined in detail. Nutritive capillary blood flow was measured directly using the non-invasive technique of television microscopy, applied to the toe nailfold. Arteriovenous shunt flow was assessed using the technique of laser Doppler flowmetry, applied to the toe pulp. Fourteen diabetic patients with peripheral and autonomic neuropathy, 11 with no clinical evidence of neuropathy and 14 normal subjects were studied. Laser Doppler flowmetry (predominantly arteriovenous shunt flow) was increased more than three-fold (p less than 0.01) in the diabetic patients with neuropathy compared to control subjects, (median 3.57, interquartile range 2.00-5.32 volts vs median 0.93, interquartile range 0.47-2.36 volts, respectively). There was no evidence of skin capillary closure. The calculated capillary blood flow (erythrocyte flux) was significantly increased in the diabetic neuropathic patients compared to control subjects (median 76.4, interquartile range 34.4-109.8 picolitres/s vs median 23.2, range 8.0-44.8 picolitres/s, p less than 0.01). This study demonstrates that foot skin capillary blood flow is increased in diabetic patients with neuropathy. There is, therefore, no evidence to support the supposition that capillary ischaemia, either secondary to a "capillary steal phenomenon" or "advanced microangiopathy", is a feature of diabetic neuropathy under resting conditions.

Adult↗
PubMed1986

The diabetic foot: pathophysiology and treatment.

The diabetic foot can be classified into the neuropathic foot, characterized by the neuropathic ulcer, the Charcot joint and neuropathic oedema associated with a good circulation, in which neuropathy predominates, and the ischaemic foot in which atherosclerosis is the dominant factor leading to a reduction in blood flow with absent pulses. In the neuropathic foot, blood flow is increased, the vessels are still and dilated as a result of medial wall calcification and there is evidence for arteriovenous shunting. The neuropathic ulcer characteristically develops on the plantar surface following inflammatory autolysis and haematoma formation under neglected callosities. Chiropody is therefore the mainstay of treatment and recurrence is prevented by redistribution of weight bearing forces by moulded insoles in special footwear. Charcot osteoarthropathy is often preceded by fracture which is a further complication of diabetic neuropathy and which precipitates the rapid bone and joint destruction of the Charcot joint. Neuropathic oedema responds to ephedrine with a reduction in peripheral flow and an increase in urinary sodium excretion. The ischaemic foot is characterized by rest pain, ulceration and gangrene. Medical management can be successful in up to 72%, the remainder needing arteriography to assess suitability for arterial reconstruction or angioplasty. In the diabetic leg, atherosclerosis is predominant in the branches of the popliteal artery making arterial reconstruction difficult. Optimum care of the diabetic foot is provided in a diabetic foot clinic where the skills of chiropodist, shoe-fitter and nurse receive full support from physician and surgeon. Many lesions of the diabetic foot are avoidable and thus patient education is the cornerstone of prevention.

Arthropathy, Neurogenic↗
PubMed1986

Autonomic neuropathy and diabetic foot ulceration.

Autonomic function was studied in three groups of insulin-dependent diabetic patients. Heart rate changes during deep breathing and on standing were significantly less in 28 patients with a recent history of foot ulceration compared with 40 patients with peripheral neuropathy but without ulceration (p less than 0.001) and 54 patients without neuropathy (p less than 0.001). Sympathetic function was assessed in 36 of these patients from peripheral arterial diastolic flow patterns obtained by Doppler ultrasound measurements and expressed as the pulsatility index (PI). Patients with a history of ulceration (n = 10) showed considerably increased diastolic flow (PI = 4.28 +/- 0.53, mean +/- S.E.M.) compared with 12 neuropathic patients with no history of ulceration (PI = 7.80 +/- 0.68, p less than 0.002) and 14 patients without neuropathy (PI = 9.55 +/- 0.89, p less than 0.002). Severely abnormal autonomic function occurs in association with neuropathic foot ulceration, but patients without ulcers have lesser degrees of autonomic neuropathy, thus a causal relationship has not been established.

Adult↗
PubMed1986

Improved survival of the diabetic foot: the role of a specialized foot clinic.

A specialized foot clinic for diabetic patients has made a detailed analysis of the presentation of diabetic foot ulcers and from this a new, organised approach to treatment has been derived. Over three years it has achieved a high rate of ulcer healing and reduced the number of major amputations. It has brought together the skills of chiropodist, shoe-fitter, nurse, physician and surgeon to manage the distinctive lesions of the neuropathic and ischaemic diabetic foot. The neuropathic ulcer was invariably associated with callus, whereas the ischaemic ulcer presented as areas of necrosis often from localised pressure of tight shoes. Essential aspects of management are specially constructed shoes, intensive chiropody and precise antibiotic treatment. Healing was achieved in 204 out of 238 (86 per cent) neuropathic ulcers and 107 out of 148 (72 per cent) ischaemic ulcers. Relapse rate in special shoes was 26 per cent compared with 83 per cent who preferred to wear their own shoes. In the two years before the establishment of the clinic, there were 11 and 12 major amputations yearly. This rate has now been reduced to seven, seven and five amputations yearly.

Aged↗
PubMed1985

Osteopenia and metatarsal fractures in diabetic neuropathy.

Radiographs of the hands and feet of 19 diabetic patients with severe neuropathy were compared to those of 22 control patients without neuropathy. The two groups were matched for age, sex, and duration of diabetes. Cortical bone mass, measured by x-ray morphometry, was significantly lower in both the hands (p less than 0.002) and the feet (p less than 0.001) of those with neuropathy. The osteopenia was worse in the feet than the hands and also worse in women. Serum alkaline phosphatase levels were also significantly higher in the neuropathy group (p less than 0.005). Metatarsal fractures were a frequent finding in the neuropathic patients, but were not seen in controls. The presence of metatarsal fractures was strongly associated with the subsequent development of diabetic osteopathy (p less than 0.001). We conclude that cortical bone mass in the feet and hands is reduced in severe diabetic neuropathy. This may contribute to the predisposition to metatarsal fracture and diabetic osteopathy.

Adult↗
PubMed1985

Increased uptake of bone radiopharmaceutical in diabetic neuropathy.

Uptake of radiopharmaceutical was markedly abnormal in all phases of the bone scan in the feet of patients with diabetic neuropathy. Bone scans were performed in three groups of patients; diabetics with neuropathic osteoarthropathy (Charcot joints); diabetics with neuropathy but no evidence of osteoarthropathy and non-diabetic controls. Uptake was monitored in three phases; during the first 2 min after injection, then at 4 min and finally at 4 h. Uptake in all three phases was markedly increased in the neuropathic subjects, not only in those with osteoarthropathy but also in those with no radiological abnormalities. Increased uptake at 2 and 4 min indicates increased blood flow which can also result in increased uptake at 4 h. Increased blood flow secondary to peripheral neuropathy may lead to excessive bone resorption, susceptibility to fracture and finally the development of neuropathic osteoarthropathy of the diabetic foot.

Adult↗