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  • Kalani, Majid, et al. (författare)
  • Beneficial effects of dalteparin on haemostatic function and local tissue oxygenation in patients with diabetes, severe vascular disease and foot ulcers.
  • 2007
  • Ingår i: Thrombosis research. - 0049-3848. ; 120:5, s. 653-61
  • Tidskriftsartikel (refereegranskat)abstract
    • Introduction: A state of hypercoagulation and fibrinolytic dysfunction is present in individuals with diabetes, which may contribute to disturbed skin microcirculation and impaired ulcer heating. We have previously reported an improved outcome of chronic diabetic foot ulcers during treatment with dalteparin. In the present study we investigated the effects of dalteparin on skin microcirculation and haemostatic function. Materials and methods: 87 patients with diabetes, peripheral arterial obliterative disease and chronic foot ulcers were investigated in a prospective, randomised, double-blind and placebo-controlled study. They were randomised to treatment with subcutaneous injections of 5000 U dalteparin (n = 44) or placebo (n = 43), once daily until ulcer heating or for a maximum of six months. Plasma fibrinogen, fibrin get structure [permeability coefficient (Ks) and fiber mass/length ratio (mu)], prothrombin fragment 1 +2 (F1 +2) antigen, plasminogen activator inhibitor-1 (PAI-1) activity and tissue plasminogen activator (tPA) antigen were analysed before randomization (baseline value), and at the end of the treatment period. The skin microcirculation of the foot was investigated by transcutaneous oxygen tension (TcPO2) and laser Doppler ftuxmetry (LDF). Results: The changes (A-values) of Ks, mu, tPA and TcPO2 were higher (p<0.05) during treatment with dalteparin, as compared to the changes during treatment with placebo. At baseline, plasma fibrinogen and Ks were significantly correlated to TcPO2. Conclusions: Local skin oxygenation improved and a less thrombogenic fibrin get structure was formed in patients treated with dalteparin. Beneficial effects on haemostatic function are likely to contribute to the improved skin oxygenation observed during treatment with dalteparin. (C) 2007 Elsevier Ltd. All rights reserved.
  • Kalani, Majid, et al. (författare)
  • Effect of dalteparin on healing of chronic foot ulcers in diabetic patients with peripheral arterial occlusive disease: a prospective, randomized, double-blind, placebo-controlled study.
  • 2003
  • Ingår i: Diabetes care. - 0149-5992. ; 26:9, s. 2575-80
  • Tidskriftsartikel (refereegranskat)abstract
    • OBJECTIVE: Chronic foot ulcers are a common, severe, and expensive complication threatening life and limb in patients with diabetes. The aim of the present study was to investigate the effect of dalteparin on ulcer outcome in patients with diabetes, peripheral arterial occlusive disease, and chronic foot ulcers. RESEARCH DESIGN AND METHODS: A total of 87 patients were investigated in a prospective, randomized, double-blind, placebo-controlled trial. Participants were randomized to treatment with subcutaneous injection of 5000 units dalteparin (Fragmin, Pharmacia Corporation; n = 44) or an equivalent volume of physiological saline (n = 43) once daily until ulcer healing or for a maximum of 6 months. Ulcer outcome was investigated by evaluating the number of patients 1). who healed with intact skin; 2). in whom the study ulcer was improved, unchanged, or impaired; or 3). who were amputated above or below the ankle level, as compared with control subjects. RESULTS: Two patients, one on dalteparin and one on placebo, dropped out of the study. Ulcer outcome was significantly better (P = 0.042, two-sided chi(2) test for trend) in the dalteparin group (n = 43) compared with the placebo group (n = 42). A total of 29 patients healed with intact skin (n = 14) or decreased the ulcer area >or=50% (n = 15) in the dalteparin group compared with 20 (n = 9 and 11, respectively) in the placebo group. Five patients in each group showed impaired ulcer healing, i.e., the ulcer area increased >or=50%. Two patients in the dalteparin group were amputated compared with eight in the placebo group. Time to healing with intact skin was 17 +/- 8 weeks in the dalteparin group compared with 16 +/- 7 weeks in placebo group (NS). CONCLUSIONS: The results of the present study indicate that dalteparin improves the outcome of chronic foot ulcers in diabetic patients with peripheral arterial occlusive disease.
  • Torffvit, Ole, et al. (författare)
  • Increased Urine IgM and IgG(2) Levels, Indicating Decreased Glomerular Size Selectivity, Are Not Affected by Dalteparin Therapy in Patients with Type 2 Diabetes.
  • 2012
  • Ingår i: Biochemistry Research International. - Hindawi Publishing Corporation. - 2090-2247. ; 2012
  • Tidskriftsartikel (refereegranskat)abstract
    • Fifty-four type 2 diabetic patients with neuroischemic foot ulcers were randomised to treatment with 5000 IU of dalteparin, (n = 28), or physiological saline, (n = 26), once daily until ulcer healing or for a maximum of 6 months. Thirty-three patients had normo-, 15 micro-, and 6 macroalbuminuria. The urinary levels of IgM and IgG(2) were elevated in 47 and 50 patients, respectively. Elevated urinary levels of IgM and IgG(2) indicate decreased glomerular size selectivity. Urine IgM levels were associated with IGF-1/IGFBP-1 and IGFBP-1 levels. Dalteparin treatment increased urinary levels of glycosaminoglycans (P < 0.001) and serum IGFBP-1 (P < 0.05) while no significant effects were seen in any of the other studied parameters. In conclusion, dalteparin therapy in patients with type 2 diabetes had no effects on urinary levels of albumin, IgM, or IgG(2) despite significantly increased glycosaminoglycans in urine. Elevated urinary levels of IgM and IgG(2) might be more sensitive markers of renal disease than albuminuria in patients with type 2 diabetes and antihypertensive therapy.
  • Annersten Gershater, Magdalena, et al. (författare)
  • Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers : a cohort study
  • 2009
  • Ingår i: Diabetologia. - Springer. - 0012-186X .- 1432-0428. ; 52:3, s. 398-407
  • Tidskriftsartikel (refereegranskat)abstract
    • <p>AIMS/HYPOTHESIS: We sought to identify factors related to short-term outcome of foot ulcers in patients with diabetes treated in a multidisciplinary system until healing was achieved. METHODS: Consecutively presenting patients with diabetes and worst foot ulcer (Wagner grade 1-5, below ankle) (n = 2,511) were prospectively followed and treated according to a standardised protocol until healing was achieved or until death. The number of patients lost to dropout was 31. The characteristics of the remaining 2,480 patients were: 1,465 men, age 68 +/- 15 years (range 18-96), type 1 diabetes 18%, type 2 diabetes 82% and insulin-treated 62%. RESULTS: The healing rate without major amputation in surviving patients was 90.6% (n = 1,867). Sixty-five per cent (n = 1,617) were healed primarily, 9% (n = 250) after minor amputation and 8% after major amputation; 17% (n = 420) died unhealed. Out of 2,060 surviving patients, 1,007 were neuroischaemic (48.8%). In a multiple regression analysis, primary healing was related to co-morbidity, duration of diabetes, extent of peripheral vascular disease and type of ulcer. In neuropathic ulcers, deep foot infection, site of ulcer and co-morbidity were related to amputation. Amputation in neuroischaemic ulcers was related to co-morbidity, peripheral vascular disease and type of ulcer. Age, sex, duration of diabetes, neuropathy, deformity and duration of ulcer or site of ulcer did not have an evident influence on probability of amputation. CONCLUSIONS/INTERPRETATION: Patients with diabetic foot ulcer suffer from multi-organ disease. Factors related to outcome are correspondingly complex.</p>
  • Apelqvist, Jan, et al. (författare)
  • Diabetikers fotproblem : Rätt prevention och behandling kan halvera risken för amputation
  • 1999
  • Ingår i: Läkartidningen. - Swedish Medical Association. - 0023-7205. ; 96:1-2, s. 37-41
  • Tidskriftsartikel (övrigt vetenskapligt)abstract
    • Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases, amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education, footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual costs for the management of diabetic foot in Sweden would be reduced by SEK 400 million (the value of improved quality of life not taken into consideration).
  • Apelqvist, Jan, et al. (författare)
  • Factors related to outcome of neuroischemic/ischemic foot ulcer in diabetic patients.
  • 2011
  • Ingår i: Journal of vascular surgery : official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter. - Mosby. - 1097-6809. ; 53, s. 1582-1588
  • Tidskriftsartikel (refereegranskat)abstract
    • OBJECTIVES: Peripheral vascular disease (PVD) is an important limiting factor for healing in neuroischemic or ischemic diabetic foot ulcer. The purpose of this study was to identify factors related to healing in patients with diabetes with foot ulcers and severe PVD. METHODS: Patients with diabetes with a foot ulcer, consecutively presenting at a multidisciplinary foot center with a systolic toe pressure <45 mm Hg or an ankle pressure <80 mm Hg were prospectively included, followed according to a preset program, and with the exception of specified exclusions, subjected to angiography offered vascular intervention when applicable. All patients had continuous follow-up until healing or death irrespective of the type of vascular intervention. RESULTS: One thousand one hundred fifty-one patients were included. Eighty-two percent had a toe pressure <45 mm Hg and 49% had an ankle pressure <80 mm Hg. Eight hundred one patients (70%) underwent an angiography. Out of these, 63% had vascular intervention, either percutaneous transluminal angioplasty (PTA; 39%) or reconstructive surgery (24%). Nine percent of the patients had one or more complications after angiography. PTA was multisegmental in 46% and to the crural arteries in 46%. Reconstructive surgery was distal in 51%. Age (P < .001), renal function impairment (P = .005), congestive heart failure (P = .01), number and type of ulcer (P < .001), and severity of PVD (P = .003) affected the outcome of ulcers. PTA and reconstructive vascular surgery increased the probability of healing without amputation (odds ratio [OR], 1.77 and 2.05, respectively). CONCLUSION: Probability of ulcer healing is strongly related to comorbidity, extent of tissue involvement, and severity of PVD in patients with diabetes with severe PVD.
  • Apelqvist, Jan, et al. (författare)
  • Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome
  • 1992
  • Ingår i: Journal of Diabetes and its Complications. - Elsevier. - 1873-460X. ; 6:3, s. 167-174
  • Tidskriftsartikel (refereegranskat)abstract
    • 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.
  • Apelqvist, Jan, et al. (författare)
  • The Diabetic Foot Syndrome Today : A Pandemic Uprise
  • 2017
  • Ingår i: The Diabetic Foot Syndrome. - Karger. - 0251-5342. - 978-3-318-06145-1 ; 26, s. 1-18
  • Bokkapitel (refereegranskat)abstract
    • Diabetes mellitus is growing at epidemic proportions worldwide; currently 415 million adults are estimated to have diabetes and by 2040, this number is estimated to increase to 642 million. As a consequence, the prevalence of diabetes-related complications is bound to increase. Diabetic foot disorders are common throughout the world, resulting in major medical, social and economic consequences for the patients, and a public health problem. The risk for ulceration and amputation is much higher in individuals with diabetes compared to that of the non-diabetic population: it is estimated that every 20 s an amputation is performed on an individual with diabetes somewhere in the world. Foot ulceration is the commonest major end point among diabetic complications. More than 5% of diabetic patients have a history of foot ulceration and the cumulative lifetime incidence may be as high as 25%. Incidence and prevalence figures related to both foot ulcerations and lower extremity amputations have been reported worldwide. There is a substantial global variation in the incidence and prevalence of amputation and diabetic foot ulcer (DFU). The variation may be partially explained by differences in the measurement of amputation and DFU, as well as the ascertainment of diabetes, demographic factors, setting or other confounders. There is an urgent need to determine a standardized way to report the incidence and prevalence of diabetes-related amputation and foot ulcer in order to be able to be used as a marker of quality of care.
  • Apelqvist, Jan, et al. (författare)
  • The influence of external precipitating factors and peripheral neuropathy on the development and outcome of diabetic foot ulcers
  • 1990
  • Ingår i: Journal of Diabetic Complications. - Elsevier. - 0891-6632. ; 4:1, s. 21-25
  • Tidskriftsartikel (refereegranskat)abstract
    • The influence of external precipitating factors and the presence of peripheral neuropathy on the development and outcome of foot ulcers were evaluated in 314 consecutive diabetic patients. All patients were treated by the same foot care team. Each patient was represented by one ulcer, and primary healing was defined as intact skin for at least six months. External precipitating factors were identifiable in 264 of 314 patients. The most common factors were ill fitting shoes/socks, acute mechanical trauma, stress ulcer, and paronychia. The highest primary healing rates were seen in lesions caused by paronychia (84%) and stress ulcer (76%). Clinical signs of sensory and muscular disturbances were seen in the majority of patients (96%). Sensory neuropathy, evaluated with a biothesiometer, was more common among patients who had had amputations or, died subsequently compared to those who healed. This study suggests that a majority of diabetic foot ulcers might have been prevented, since a precipitating external factor was identified in four of five patients, stressing the importance of preventive foot care.
  • Elgzyri, Targ, et al. (författare)
  • Outcome of Ischemic Foot Ulcer in Diabetic Patients Who Had no Invasive Vascular Intervention.
  • 2013
  • Ingår i: European Journal of Vascular and Endovascular Surgery. - Elsevier. - 1532-2165. ; 46:1, s. 110-117
  • Tidskriftsartikel (refereegranskat)abstract
    • OBJECTIVE/BACKGROUND: There is limited information regarding outcome in patients not available for revascularisation. Our aim was to identify factors related to ulcer healing in diabetic patients with severe peripheral arterial disease who were not available for revascularisation. METHODS: Diabetic patients with a foot ulcer, consecutively presenting at a multidisciplinary foot centre with systolic toe pressure <45 mmHg or an ankle pressure <80 mmHg were prospectively included. Patients who received revascularisation were excluded. All patients had continuous follow-up until healing or death. RESULTS: Out of 602 patients (median age: 76 years) included in this study, 50% healed either primarily (76%) or with a minor amputation (24%). Seventeen percent of patients healed after major amputation and 33% died unhealed. By regression analysis, rest pain, impaired renal function, ischemic heart disease, cerebral vascular disease, extent of tissue destruction, and ankle pressure >50 mmHg affected the outcome of the ulcers. CONCLUSION: Diabetic patients with ischemic foot ulcers not available for revascularisations are not excluded from healing without major amputation. Factors strongly related to outcome were co-morbidity, severity of peripheral arterial disease, and extent of tissue destruction. Our findings reinforce the need for a classification system considering these factors at decision-making for vascular intervention.
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