糖尿病足部溃疡的预防

Context:Among persons diagnosed as having diabetes mellitus, the prevalence of foot ulcers is 4%to 10%, the annual population-based incidence is 1.0%to 4.1 %, and the lifetime incidence may be as high as 25%. These ulcers frequently b ecome infected, cause great morbidity, engender considerable financial costs, an d are the usual first step to lower extremity amputation. Objective:To systemat ically review the evidence on the efficacy of methods advocated for preventing d iabetic foot ulcers in the primary care setting. Data Sources, Study Selection, and Data Extraction:The EBSCO, MEDLINE, and the National Guideline Clearinghous e databases were searched for articles published between January 1980 and April 2004 using database-specific keywords. Bibliographies of retrieved articles wer e also searched, along with the Cochrane Library and relevant Web sites. We revi ewed the retrieved literature for pertinent information, paying particular atten tion to prospective cohort studies and randomized clinical trials. Data Synthesi s:Prevention of diabetic foot ulcers begins with screening for loss of protecti ve sensation, which is best accomplished in the primary care setting with a brie f history and the Semmes-Weinstein monofilament. Specialist clinics may quantif y neuropathy with biothesiometry, measure plantar foot pressure, and assess lowe r extremity vascular status with Doppler ultrasound and ankle-brachial blood pr essure indices. These measurements, in conjunction with other findings from the history and physical examination, enable clinicians to stratify patients based o n risk and to determine the type of intervention. Educating patients about prope r foot care and periodic foot examinations are effective interventions to preven t ulceration. Other possibly effective clinical interventions include optimizing glycemic control, smoking cessation, intensive podiatric care, debridement of c alluses, and certain types of prophylactic foot surgery. The value of various ty pes of prescription footwear for ulcer prevention is not clear. Conclusions:Sub stantial evidence supports screening all patients with diabetes to identify thos e at risk for foot ulceration. These patients might benefit from certain prophyl actic interventions, including patient education, prescription footwear, intensi ve podiatric care, and evaluation for surgical interventions.

脂肪和红细胞膜脂质与由ELOVL4基因突变引起的显性Stargardt黄斑营养不良病情严重程度的相关性

Objective: To determine whether adipose and red blood cell membrane lipids,particularly long-chain polyunsaturated fatty acids such as docosahexaenoic acid and eicosapentaenoic acid,are significantly correlated with phenotype in a family with autosomal dominant Stargardt macular dystrophy (gene locus STGD3). Amutation in the ELOVL4 gene is responsible for the macular dystrophy in this family,and its disease-causing mechanism may be its possible involvement in fatty acid elongation in the retina. Methods: The subjects in this study included 18 adult family members known to have a 2-base pair deletion in the ELOVL4 gene. Control subjects included 26 family members without the mutation. Each subject received a complete eye examination including fundus photographs,the results of which were used to grade the severity of macular dystrophy on a 3-tier scale. Red blood cell membrane and adipose tissue lipids were analyzed as an indication of short-term and long-term dietary fatty acid intake. Results: When adipose lipids were analyzed,there was a significant inverse relationship between phenotypic severity and the level of eicosapentaenoic acid (r=-0.54; P =.04). When red blood cell lipids were analyzed,there were significant inverse relationships between phenotypic severity and levels of eicosapentaenoic acid (r=-0.55; P=.02) and docosahexaenoic acid (r=-0.48; P=.04). Conclusions: These results indicate that the phenotypic diversity in this family may be related to differences in dietary fat intake as reflected by adipose and red blood cell lipids. Clinical Relevance: This study demonstrates that dietary factors can influence the severity of an inherited human macular dystrophy.

有和无阻塞性冠状动脉疾病患者对硝酸甘油的头痛反应

Objectives: To examine the hypothesis that glyceryl trinitrate(GTN) may cause headache in patients with normal coronary arteries more often than in patients with obstructive coronary artery disease(CAD). This simple assessment may aid clinicians in the initial evaluation of chest pain syndrome and possible CAD. Patients and methods: 118 patients(66 men and 52 women) with new onset of chest pain were enrolled in this study. Patients were excluded from the study if they had a history of chronic headache, long term nitrates use, or any coronary artery procedures. Mean age of the patients was 62.5 years. Coronary angiography was performed within one month of GTN administration with the usual clinical indications such as recurrent chest pain, abnormal ECG, or abnormal results of stress tests. Thirty patients had normal coronary arteries or minimal or non-obstructive CAD. Eighty eight patients had obstructive CAD defined as luminal narrowing greater than 50%in any one or more of the left or right coronary arteries or their major branches. All the patients had a varying degree of relief of chest pain with GTN administration within 10 minutes. 36%of patients reported significant headache after GTN administration. Results: In patients with normal coronary arteries or minimal CAD, 73%had significant headache caused by sublingual GTN. In patients with obstructive CAD, only 23%had significant headache after GTN use(p< 0.001). There were no differences in patientssex and vascular risk factors concerning the frequency of headache in patients with or without obstructive CAD. Conclusions: GTN causes significantly more frequent headache episodes in patients with normal coronary arteries or minimal CAD than in patients with obstructive CAD. This unique finding may provide clinicians with an additional tool for the differential diagnosis of patients with chest pain syndrome.