The pressures and loads under the feet during walking have been compared in three groups of 41 patients each, using a microprocessor-controlled optical system. Group A consisted of patients with diabetic neuropathy, group B of non-neuropathic diabetic patients, and group C of nondiabetic controls. Thirteen patients in group A had a history of neuropathic foot ulceration. Other investigations in the diabetic patients included motor conduction velocity (MCV) in the median and peroneal nerves, vibration perception threshold (VPT) in the great toes, the valsalva response (VR), skin resistance (SR), and the ankle pressure index (API). Fifty-one percent of neuropathic feet had abnormally high pressures underneath the metatarsal heads compared with 17% of the diabetic controls and 7% of nondiabetic subjects. All those feet with previous ulceration had abnormally high pressures at the ulcer sites. Of the other investigations, the VPT correlated most significantly with the presence of foot ulceration. In addition, a low median and peroneal nerve MCV, an abnormal VR, a high API, and the absence of sweating all correlated with the presence of foot ulceration. We therefore conclude that simple bedside investigations, such as measurement of the VPT alone, may be useful in identifying those patients at risk of foot ulceration. Foot pressure studies may then be used in such patients as a predictive and management aid by determining specific areas under the foot that are prone to ulceration.
Forty-six diabetics treated with twice-daily insulin were seen every two weeks for six months in an intensive education programme aided by regular home urine glucose testing. Control was improved with a decrease in 24-hour urinary glucose excretion (median 138 mmol/ 24 h (24-8 g/24 h) falling to 70 mmol/24 h (12-6 g/24 h); p <0 002), glycosylated haemoglobin concentration (mean 114± SD 2-3% falling to 10-4±1-
Ten insulin-dependent C-peptide-negative diabetic subjects, whose control had been optimized on twice-daily injection therapy, were treated for periods of 10 wk in a crossover study, with either a thrice-daily subcutaneous insulin injection regimen (Actrapid + Ultratard) or by continuous subcutaneous insulin infusion (CSII). On CSII insulin dose stabilized at 51 +/- 5 U/day, compared with 80 +/- 9 U/day (P = 0.004) on the thrice-daily injection regimen, having been 60 +/- 6 U/day on twice-daily therapy. After 10 wk glycosylated hemoglobin was 11.7 +/- 0.6% on injection therapy and 10.0 +/- 0.7% (P = 0.026) on CSII. Mean blood glucose concentration and urinary glucose excretion were lower at most points during the study on CSII than on injection therapy. Patients on pumps gained weight compared with the thrice-daily injection regimen (P = 0.023 at 10 wk) and the previous twice-daily regimen, despite the reduction in insulin dose. Considering individual patients, four markedly improved on CSII compared with the previous twice-daily regimen and five compared with Actrapid + Ultratard. No patient showed impaired control on CSII compared with either injection regimen. The benefits of portable insulin infusion pumps over injection therapy are thus clearly demonstrable under outpatient conditions even with equal and intensive medical attention.
713 extremely low in advanced renal failure; the concentration is normal or increased, however, in patients with early to moderate renal failure, in whom hypocalcaemia, secondary hyperparathyroidism, and defective bone mineralisation are often present.4 Furthermore, treatment with 1 cx,25-dihydroxy or 1 oc-hydroxy vitamin D3 might alleviate skeletal pain, increase serum calcium concentration, suppress secondary hyperparathyroidism, and improve the skeletal lesions of osteitis fibrosa; results in patients with osteomalacia, however, were disappointing.5 The question remains, therefore, whether another metabolite of vitamin D, important for normal bone structure, is affected in renal failure. 24,25-Dihydroxy vitamin D may possibly play a part in normal bone formation.2 Our findings show that production of this metabolite is already impaired in early stages of renal failure. If low serum concentrations of 24,25-dihydroxy vitamin D are causally related to the osteomalacia of chronic renal failure, treatment with both 1,25-dihydroxy and 24,25-dihydroxy vitamin D may be needed to prevent and heal renal osteodystrophy. We thank Reuven Terdiman for his help in the statistical analysis. This study serves as part of the requirements for the MD degree for L Leib at the Technion,
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