The role of diabetic neuropathy and high plantar pressures in the pathogenesis of foot ulceration

Diabetic foot ulceration is currently a serious medical problem and has, therefore, attracted much research attention during the last two decades. Previous foot ulceration, diabetic neuropathy, limited joint mobility, high plantar pressures, microangiopathy, macroangiopathy and diabetic nephropathy have already been identified as risk factors for future foot ulceration. Neuropathy has clearly been shown to be an essential permissive factor in the development of ulceration in the non-ischaemic foot. Moreover, the pathogenetic role of high plantar pressures is crucial in the presence of established clinical neuropathy. Nowadays, our therapeutic efforts clearly aim to prevent than treat foot ulcers. This demands specialist and team work in the setting up of a diabetic foot clinic in an attempt to identify and educate the diabetic patients at risk and, where possible to use suitable plantar pressure-reducing systems (footwear, hosiery etc.). Then only would it be reasonable to postulate that a significant reduction in amputations of diabetic aetiology could be achieved in the near future

Pretibial myxedema as the initial manifestation of Graves' disease

Pretibial myxedema (PM) is a localized thickening of the pretibial skin due to accumulation of acid mucopolysacharides (glycosaminoglycans): Its pathogenesis is still under investigation. Pretibial myxedema, exophthalmus and thyroid acropachy are the classic extrathyroidal manifestations of Graves’ disease. Almost invariably, PM follows the onset of ophthalmopathy, developing after the diagnosis and treatment of hyperthyroidism. Pretibial myxedema preceding Graves’ ophthalmopathy is rare. We report the case of a 28-year-old Greek woman, who presented with multiple, asymptomatic nodules and plaques of the lower legs in the absence of other physical findings. Histopathologic examination revealed deposition of mucopolysacharides in the lower dermis. Laboratory investigation showed elevated serum T3 and T4 and depressed TSH levels. In our patient, pretibial myxedema was the earliest manifestation, leading to the diagnosis of Graves’ disease

The diabetic foot in end stage renal disease

Diabetic foot lesions remain a major cause of morbidity in patients with renal failure, especially those on dialysis. Foot complications are encountered at a more than twofold frequency in diabetic patients with end-stage renal disease, and the rate of amputations is 6.5-10 times higher in comparison to the general diabetic population. The causal pathways of the diabetic foot in renal failure are multiple and inter-related. Three major pathologies-neuropathy, ischemia, and infection-are the main contributory factors. Increased awareness of this condition and careful clinical examination are indispensable to avoid serious complications. Appropriate management needs to address all contributory factors. Treatment options include revascularization, off-loading to relieve high-pressure areas, and aggressive control of infection. Equally important is the collaboration between health care providers in a multidisciplinary foot care setting. Moreover, patient education on the measures required to achieve both primary and secondary prevention is of great value. Certainly, technical innovations have made considerable progress possible, but there is a need for further improvement to reduce the number of amputations