The gastric acid pocket is attenuated in H. pylori infected subjects

Objective Gastric acid secretory capacity in different anatomical regions, including the postprandial acid pocket, was assessed in Helicobacter pylori positive and negative volunteers in a Western population. Design We studied 31 H. pylori positive and 28 H. pylori negative volunteers, matched for age, gender and body mass index. Jumbo biopsies were taken at 11 predetermined locations from the gastro-oesophageal junction and stomach. Combined high-resolution pH metry (12 sensors) and manometry (36 sensors) was performed for 20 min fasted and 90 min postprandially. The squamocolumnar junction was marked with radio-opaque clips and visualised radiologically. Biopsies were scored for inflammation and density of parietal, chief and G cells immunohistochemically. Results Under fasting conditions, the H. pylori positives had less intragastric acidity compared with negatives at all sensors >1.1 cm distal to the peak lower oesophageal sphincter (LES) pressure (p<0.01). Postprandially, intragastric acidity was less in H. pylori positives at sensors 2.2, 3.3 and 4.4 cm distal to the peak LES pressure (p<0.05), but there were no significant differences in more distal sensors. The postprandial acid pocket was thus attenuated in H. pylori positives. The H. pylori positives had a lower density of parietal and chief cells compared with H. pylori negatives in 10 of the 11 gastric locations (p<0.05). 17/31 of the H. pylori positives were CagA-seropositive and showed a more marked reduction in intragastric acidity and increased mucosal inflammation. Conclusions In population volunteers, H. pylori positives have reduced intragastric acidity which most markedly affects the postprandial acid pocket

Biofilm is a major virulence determinant in bacterial colonization of chronic skin ulcers independently from the multidrug resistant phenotype

Bacterial biofilm is a major factor in delayed wound healing and high levels of biofilm production have been repeatedly described in multidrug resistant organisms (MDROs). Nevertheless, a quantitative correlation between biofilm production and the profile of antimicrobial drug resistance in delayed wound healing remains to be determined. Microbial identification, antibiotic susceptibility and biofilm production were assessed in 135 clinical isolates from 87 patients. Gram-negative bacteria were the most represented microorganisms (60.8%) with MDROs accounting for 31.8% of the total isolates. Assessment of biofilm production revealed that 80% of the strains were able to form biofilm. A comparable level of biofilm production was found with both MDRO and not-MDRO with no significant differences between groups. All the methicillin-resistant Staphylococcus aureus (MRSA) and 80% of Pseudomonas aeruginosa MDR strains were found as moderate/high biofilm producers. Conversely, less than 17% of Klebsiella pneumoniae extended-spectrum beta-lactamase (ESBL), Escherichia coli-ESBL and Acinetobacter baumannii were moderate/high biofilm producers. Notably, those strains classified as non-biofilm producers, were always associated with biofilm producer bacteria in polymicrobial colonization. This study shows that biofilm producers were present in all chronic skin ulcers, suggesting that biofilm represents a key virulence determinant in promoting bacterial persistence and chronicity of ulcerative lesions independently from the MDRO phenotype

Exploring Methods to Improve Pressure Ulcer Detection: Spectroscopic Assessment of the Blanch Response

Pressure damage in intact skin is difficult to detect, particularly in individuals with dark skin, because color changes and tissue blanching are masked by the skin's pigmentation. Tissue reflectance spectroscopy (TRS) may be able to detect the blanch response regardless of skin color by measuring the change in total hemoglobin (delta tHb) that occurs when pressure is applied to the skin. The objective of this dissertation was to examine the ability of TRS to detect the blanch response at sites at risk for pressure ulcer development in individuals with various levels of skin pigmentation. Three studies were conducted to address this objective. In Study 1, delta tHb was assessed at the heel and sacrum of light and dark-skinned healthy participants using a portable TRS system. Study 1 showed that a significant decrease (p less than 0.001) in tHb could be measured in both light and dark skinned-participants with good intra-rater reliability (ICC greater than or equal to 0.80) at the heel, but not at the sacrum. Study 2 was conducted to identify a reliable method of skin color description for use in subsequent studies of the spectroscopic blanch response. Two examiners (B and C) performed three skin color assessments at the volar forearm of ten healthy participants using Munsell color tile matching and colorimetry. Intra and inter-rater reliability was excellent for colorimetry (ICCs typically greater than or equal to 0.90). Reliability for Munsell color tile matching was highest for Munsell value within Examiner B (93% agreement, kappa 0.87-1.00), which was determined to be sufficiently high for use in subsequent studies. In Study 3, delta tHb was assessed at the heels of light, moderate, and dark-skinned elderly nursing home residents at risk for pressure ulcers. As in the pilot study, a significant decrease in tHb was observed in all skin color groups (p less than 0.05). Intra-rater reliability for delta tHb was moderate or greater (ICC greater than or equal to 0.61). In combination, the results of Study 1 and Study 3 demonstrated that a significant spectroscopic blanch response could be detected with moderate or greater intra-rater reliability at the heel regardless of age or pressure ulcer risk status

Evaluating The Utility Of Spect/ct Imaging Of Angiosome Perfusion In Diabetic Patients With Critical Limb Ischemia

EVALUATING THE UTILITY OF SPECT/CT IMAGING OF ANGIOSOME PERFUSION IN DIABETIC PATIENTS WITH CRITICAL LIMB ISCHEMIA. Jessica L. Buckley, Albert J. Sinusas, Mitchel R. Stacy. Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT. Impaired lower extremity perfusion is a hallmark of peripheral arterial disease (PAD) and is particularly problematic in diabetic patients, who suffer from high rates of PAD, ulceration, and lower extremity amputation. The ability to non-invasively detect deficits in microvascular perfusion within vascular territories, or angiosomes, of the feet may provide information related to tissue viability and guide therapeutic interventions. In this study, we sought to apply single photon emission computed tomography (SPECT)/CT imaging to quantify volumetric microvascular perfusion within specific angiosomes containing non-healing foot ulcers in diabetic patients with critical limb ischemia (CLI). Additionally, we sought to assess the value of SPECT/CT perfusion imaging for predicting limb salvage in CLI patients undergoing lower extremity endovascular revascularization. Forty-one diabetic patients (mean age, 66±12 yrs) with non-healing ulcers and nine healthy control subjects (mean age, 50±10 yrs) underwent SPECT/CT imaging of the feet following a resting injection of technetium-99m (99mTc)-tetrofosmin (dose, 550.6 ± 37 Mbq). CT images of diabetic feet were segmented into five angiosomes and used for quantifying relative radiotracer uptake, expressed as standardized uptake values (SUVs). SUVs were assessed for each CLI patient in the angiosome containing the non-healing ulcers, while average whole foot perfusion was assessed for healthy control subjects. Percent change in SPECT SUVs of ulcerated angiosomes was quantified following endovascular revascularization in patients, and 3-, 6-, and 12-month limb salvage outcomes were assessed. SPECT/CT imaging allowed for visualization of perfusion deficits under resting conditions. 99mTc-tetrofosmin SPECT/CT imaging of angiosome foot perfusion demonstrated a significant difference in baseline perfusion values (SUVs) between diabetic patients with CLI and healthy control subjects (p = 0.02). Analysis of baseline SPECT/CT imaging and ankle-brachial index (ABI) measurements in CLI patients and healthy control subjects demonstrated a significant and positive relationship between SPECT/CT angiosome perfusion and ABI (p = 0.01; r = 0.41). Serial evaluation of relative changes in SPECT angiosome foot perfusion following revascularization revealed significant quantitative changes in perfusion after treatment, whereas ABI measurements did not demonstrate significant changes after revascularization. Changes in SPECT/CT-derived angiosome perfusion significantly differed between patients with and patients without amputation in the 3 (p = 0.01), 6 (p = 0.03), and 12 (p = 0.03) months following revascularization. SPECT/CT imaging provides a useful non-invasive tool for evaluating microvascular perfusion within specific angiosomes of the foot under resting conditions. SPECT/CT imaging also allows for serial assessment of sensitive changes in angiosome microvascular perfusion following revascularization that are undetected by ABI. Perfusion imaging with SPECT/CT offers a novel quantitative imaging approach for assessing the efficacy of revascularization strategies targeted at restoring perfusion to non-healing wounds of the foot and may assist with predicting limb salvage outcomes in CLI patients undergoing revascularization. Future application of SPECT/CT perfusion imaging may provide additional value for detection and targeting of ischemic tissue for therapeutic interventions in the PAD patient population

The Semmes Weinstein monofilament examination as a screening tool for diabetic peripheral neuropathy

ObjectiveThe purpose of this systematic review is to evaluate current evidence in the literature on the efficacy of Semmes Weinstein monofilament examination (SWME) in diagnosing diabetic peripheral neuropathy (DPN).MethodsThe PubMed database was searched through August 2008 for articles pertaining to DPN and SWME with no language or publication date restrictions. Studies with original data comparing the diagnostic value of SWME with that of one or more other modalities for DPN in patients with diabetes mellitus were analyzed. Data were extracted by two independent investigators. Diagnostic values were calculated after classifying data by reference test, SWME methodology, and diagnostic threshold.ResultsOf the 764 studies identified, 30 articles were selected, involving 8365 patients. There was great variation in both the reference test and the methodology of SWME. However, current literature suggests that nerve conduction study (NCS) is the gold standard for diagnosing DPN. Four studies were identified which directly compared SWME with NCS and encompassed 1065 patients with, and 52 patients without diabetes mellitus. SWME had a sensitivity ranging from 57% (95% confidence interval [CI], 44% to 68%) to 93% (95% CI, 77% to 99%), specificity ranging from 75% (95% CI, 64% to 84%) to 100% (95% CI, 63% to 100%), positive predictive value (PPV) ranging from 84% (95% CI, 74% to 90%) to 100% (95% CI, 87% to 100%), and negative predictive value (NPV) ranging from 36% (95% CI, 29% to 43%) to 94% (95% CI, 91% to 96%).ConclusionsThere is great variation in the current literature regarding the diagnostic value of SWME as a result of different methodologies. To maximize the diagnostic value of SWME, a three site test involving the plantar aspects of the great toe, the third metatarsal, and the fifth metatarsals should be used. Screening is vital in identifying DPN early, enabling earlier intervention and management to reduce the risk of ulceration and lower extremity amputation

Relationship between Pressure Ulcers in Elderly People and Physiological Indices of the Skin

This study examined the relationship between skin physiological indices and pressure ulcers in elderly people. The subjects were 55 bedridden elderly Japanese patients with a median age of 85 years. The following parame-ters were measured using non-invasive devices: skin surface temperature, moisture content in the stratum corneum, moisture content in the dermis, transepidermal water loss as an index of skin barrier function, skin erythema and skin elasticity. The sacral and 2 heel areas were observed as sites predisposed to pressure ulcers. Within one month after measuring the skin physiological indices, we confirmed pressure ulcers of National Pressure Ulcer Advisory Panel classification Stage II or worse based on medical records. Among the 55 patients, 4 (7.3%) prospectively developed a total of 5 pressure ulcers within 16 days. Only the skin erythema score was significantly higher with than without pressure ulcers (p < 0.001). We performed a binary logistic regression analysis and confirmed a significant relationship between pressure-ulcer development and the level of erythema (odds ratio = 1.026; 95% confidence interval: 1.011-1.042). Skin erythema increased before the development of pressure ulcers. Taken together, our results show that the high skin erythema score can be a predictive indicator of pressure ulcers

DETECTION OF GRANULATION TISSUE FOR HEALING ASSESSMENT OF CHRONIC ULCERS

Wounds that fail to heal within an expected period develop into ulcers that cause severe pain and expose patients to limb amputation. Ulcer appearance changes gradually as ulcer tissues evolve throughout the healing process. Dermatologists assess the progression of ulcer healing based on visual inspection of ulcer tissues, which is inconsistent and subjective. The ability to measure objectively early stages of ulcer healing is important to improve clinical decisions and enhance the effectiveness of the treatment. Ulcer healing is indicated by the growth of granulation tissue that contains pigment haemoglobin that causes the red colour of the tissue. An approach based on utilising haemoglobin content as an image marker to detect regions of granulation tissue on ulcers surface using colour images of chronic ulcers is investigated in this study. The approach is utilised to develop a system that is able to detect regions of granulation tissue on ulcers surface using colour images of chronic ulcers

Classification of forefoot plantar pressure distribution in persons with diabetes : a novel perspective for the mechanical management of diabetic foot?

Background: The aim of this study was to identify groups of subjects with similar patterns of forefoot loading and verify if specific groups of patients with diabetes could be isolated from non-diabetics. Methodology/Principal Findings: Ninety-seven patients with diabetes and 33 control participants between 45 and 70 years were prospectively recruited in two Belgian Diabetic Foot Clinics. Barefoot plantar pressure measurements were recorded and subsequently analysed using a semi-automatic total mapping technique. Kmeans cluster analysis was applied on relative regional impulses of six forefoot segments in order to pursue a classification for the control group separately, the diabetic group separately and both groups together. Cluster analysis led to identification of three distinct groups when considering only the control group. For the diabetic group, and the computation considering both groups together, four distinct groups were isolated. Compared to the cluster analysis of the control group an additional forefoot loading pattern was identified. This group comprised diabetic feet only. The relevance of the reported clusters was supported by ANOVA statistics indicating significant differences between different regions of interest and different clusters. Conclusion/s Significance: There seems to emerge a new era in diabetic foot medicine which embraces the classification of diabetic patients according to their biomechanical profile. Classification of the plantar pressure distribution has the potential to provide a means to determine mechanical interventions for the prevention and/or treatment of the diabetic foot

Upper gastrointestinal bleeding risk scores: who, when and why?

Upper gastrointestinal bleeding (UGIB) remains a significant cause of hospital admission. In order to stratify patients according to the risk of the complications, such as rebleeding or death, and to predict the need of clinical intervention, several risk scores have been proposed and their use consistently recommended by international guidelines. The use of risk scoring systems in early assessment of patients suffering from UGIB may be useful to distinguish high-risks patients, who may need clinical intervention and hospitalization, from low risk patients with a lower chance of developing complications, in which management as outpatients can be considered. Although several scores have been published and validated for predicting different outcomes, the most frequently cited ones are the Rockall score and the Glasgow Blatchford score (GBS). While Rockall score, which incorporates clinical and endoscopic variables, has been validated to predict mortality, the GBS, which is based on clinical and laboratorial parameters, has been studied to predict the need of clinical intervention. Despite the advantages previously reported, their use in clinical decisions is still limited. This review describes the different risk scores used in the UGIB setting, highlights the most important research, explains why and when their use may be helpful, reflects on the problems that remain unresolved and guides future research with practical impact.info:eu-repo/semantics/publishedVersio