Clinical Characteristics Of Diabetic Foots And Effects Of Substance P On The Helaing Of Diabetic Foot Ulcers

[Background]The incidence of diabetic mellitus increased sharply of late years, which is a threatening disease to human health and a global major public health problem. The World Health Organization forecast that:the number of persons with diabetic mellitus will increase to 366 million. The National Diabetes Epidemiology Survey (2007-2008) which is completed by China diabetes and metabolic syndrome research team showed that:the prevalence of total diabetes were 9.7% in people over the age of twenty,10.6% among men and 8.8% among women respectively. Hence we conclude that there are 92 million adults with diabetes.Diabetic foot is one of the common chronic complications of diabetic mellitus, Along with the increase of incidence of diabetes, the number of diabetes foot patients also expands gradually. Aaccording to foreign coverages, about 15 percent of diabetic patients will suffer foot ulcers at some stage in their life. DF is one of the serious complications of DM, DF is the first reason of resulting in nontraumatic amputation-in developed countries, whose most common consequence is chronic ulcer,most serious consequence is amputation even death, and DF greatly reduce patients' quality of life. Therefore, a series of clinical and social problems caused by DF are being paid more and more widely extensive and attention, and new precautions and treatments are important topics today.DF is a pathological state of a diabetic foot or leg tissue damage, which is the result of peripheral vascular disease (PVD), diabetic neuropathy (DPN) and infection jointly action. DPN plays a major role in the etiology of DF, DM patients with nerve injury may affects the function of motor nerve,sensory nerve and autonomic nerve, motor nerve injury causes muscle weakness,atrophy,mild paralysis. DM patients with motor nerve injury and sensory nerves injury will suffer from trauma which is caused by impose their own foots on inappropriate pressure without knowing. Autonomic nerve injury can lead to decreased sweating, foot skin become dry and easy to be damaged. In addition, high blood glucose, lipid metabolism, and many other factors make patients'lower extremity arterial wall prone to thickening and stenosis, then the blood supply of lower limb gradually reduce. In summary, DPN, PVD and the changes of foot structure interaction may increased foot pressure and cause tissue ulceration, ultimately leading to the occurrence of ulcer.DPN is widely recognized as a common risk factor which leading the occurrence of DF, therefore, early screening of DPN is important for preventing the occurrence of foot ulcers. The commonly used methods of DPN diagnose and research are for large fiber neuropathy, neglecting the value of small fiber nerves which accounted for 70% of peripheral nerves, especially autonomic nervous system in the prevention of foot ulcers. Researches suggested that small fiber neuropathy may occur before large fiber neuropathy, severe autonomic neuropathy can also promote the occurrence of foot ulcers. Therefore, our study will analysis the effect of various neuropathy on the occurrence of foot ulcers, including touch, pain and other large nerve fibers or small nerve fibers. Diabetic foot ulcers can be prevented, foreign research found that about 86% lower limb amputation of DM patients were due to small foot skin lesions induced by vascular disease or neuropathay, such as skin trauma when work or movement, abrasiondamage when barefoot or shoes do not fit well shoes, scissor wound when clip the nails ineptly, scald when improper heating or high water temperature, these incentives can be completely avoided, especially scald,wearing inappropriate footwear and scissor wound when clip the nails ineptly. But there are also research found that a clear incentive was not essential to the occurrence of foot ulcer. At present, researches on the clinical characteristics of DF patients without specific incentives for foot ulcers are rare.The underlying etiologies of diabetic foot ulcers are vascular disease or neuropathay, and infection aggravate the disease. In general, the healing situation of neuropathic foot ulcers is better than vascular foot ulcers. Peripheral vascular disease is an important factor of affecting the healing situation of wound and amputation, severe lower limb ischemia disease and infection are the main reasons for the increase of amputation rate. Foot ulcers which penetrating to the bone indicated poor healing, and which generally were WagnerⅢgrade ulcers with deep abscesses or osteomyelitis and WagnerⅣ-Ⅴgrade ulcers with gangrene. Thus it can be seen that types of foot ulcers,Wagner classification and infection are three important factors of affecting the healing situation of foot ulcers, and they are also mutual influence.Diabetes patients suffer from stubborn refractory foot ulcers, which is one of clinical important issues to be solved urgently. In recent years, researches on the mechanism of diabetic refractory wound are proceeding apace, which mainiy focus on signaling pathway,angiogenesis,neuropeptide,advanced glycation end products,apoptosis and matrix metalloproteinases, etc. Diabetic wound is characterized by disorder of wound healing, especially in inflammatory stage and proliferative stage, which is characterized by lower inflammatory reaction in early stage of wound healing,cell division decreased in proliferative stage,lower expression and the barrier of utilization of growth factor, leading to wound healing.Plenty of domestic and foreign research shows that diabetic neuropathy is an important pathologic basis of diabetic refractory wound. With the progress of neuroimmunology, we find that neuropeptide substance P secretion by sensory nerve endings may be an important sunstance in the neural regulation of wound healing in our body. Research showed that diabetes suffer from delayed healing of chronic wounds was related to the diminished secretion of SP in injured tissue.SP is the earliest discovered neuropeptide in the world, which was discovered by Von Euler and Gaddum when they were extracting acetylcholine from horse intestine in 1931. Because people did not know its chemical properties at that time, so named it substance P. Its receptors are divided into three types, namely neurokinin-1, neurokinin 2 and neurokinin 3, SP mainly conduct its biological effects through NK-1. PCNA which expresses in the nucleus is mainly relate with cell proliferation,a positive regulator of cell growth factor, and its expression level may reflect the state of cell proliferation. Substance P is the most important neuropeptide which is released by peripheral nerve, researches on the effect of SP in the refractory wound of diabetes is still rare, selecting substance P as the research object has partial practical significance.Our research is divided into two parts, in the first part we intensively studied the clinical characteristics of relating factors on the occurrence and coalescence of diabetic foot ulcers, with the purpose of providing theoretical evidence for preventing and treating of diabetic foot ulcers. In the second part, we observed the expression characteristics of SP,NK-1 and PCNA in diabetic chronic ulcers skin tissues, and compare with non-diabetes foot chronic ulcers and normal controls, with the purpose of studying effects of substance P on the healing of diabetic foot chronic ulcers, so as to provide a theoretical evidence for preventing and treating diabetic foot.Part 1 Clinical characteristics of diabetic foots foot ulcers[Objective]Intensively study the clinical characteristics of relating factors on the occurrence and coalescence of diabetic foot ulcers, with the purpose of providing theoretical evidence for preventing and treating of diabetic foot ulcers.[Methods]1. There were 154 cases of hospitalized DM patients with diabetic foot from January 2007 to October 2010, then we recorded their datas by unified questionnaire.2. The content of questionnaire is as follows:sex, age, duration of DM, systolic blood pressure (SBP), diastolic blood pressure (DBP), blood urea nitrogen (BUN), creatinine (CR), total protein (TP), albumin (ALB), fasting plasma glucose (FPG), triglyceride ester (TG), total cholesterol (CHOL), low-density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), glycosylated hemoglobin (HbA1c), fasting C peptide (CP),24-hours urine microalbumin (UMA), ankle brachial index (ABI), peripheral neuropathay including autonomic nerve function (absolutely discoloration time of Ou Minuo diagnosis Plaster), temperature sensation, pain sensation, tactile sensation and vibration perception threshold (VPT), history of diabetic retinopathy, diabetic nephropathy history, incentives of ulcers, pathogenesis of ulcers, Wanger classification, the length and the cost of hospitalization, results of bacterial culture, results of ulcer treatment.3. On the premise of randomly selecting 300 type 2 diabetes patients without foot ulcers as controls, univariate analysis is used to analyze the risk factors of diabetic foot ulcers, logistic regression analysis is used to analyze the factors which are statistically significant in univariate analysis of diabetic foot ulcers.4. Using SPSS 13.0 as statistical analysis, measurement datas are measured by mean±standard deviation. In univariate analysis, independent sample t test is used to analyze the measurement datas,χ2 test is used to analyze the enumeration datas, logistic regression analysis is used to multivariate analyze, several independent samples of non-parametric test is used to the comparation of healing situation of foot ulcers in different group, P<0.05 is considered statistically significant.[Results]1. The average age and average DM duration of 154 DF patients are 63.9±11.9 years old and 8.9±6.3 years respectively, the incidence of diabetic foot rose with the increases of age and duration..2. Univariate analysis showed that age,duration,SBP,TP,ALB,HDL-C 24-hours urine microalbumin,peripheral neuropathay including tactile sensation,pain sensation,temperature sensation,vibration sensation,autonomic nerve function and ABI levels were related with the occurrence of foot ulcers3. Logistic multiple regression analysis exhibited that pain sensation,temperature sensation,vibration sensation,autonomic nerve function and ABI levels were closely related with the occurrence of diabetic foot.4. Most of the incentives of foot ulcers (47.6%) were paying no attention to the details in daily life, such as scratch,scissor wound,scald.40.3%of foot ulcers patients had no specific incentives, whose age and incidence of PAD were significantly higher than patients with specific incentives (P<0.05).5. The qualitative classification of 154 diabetic foots:77 cases are mixed type ulcers, accounting for 50.0 percent,73 cases are neuropathic ulcers, accounting for 47.4 percent,4 cases are vascular ulcer, accounting for 2.6 percent. The healing situation of neuropathic foot ulcer was best, next was mixed foot ulcer, and vascular foot ulcer was worst among three properties of the foot ulcers. 6. The healing situation of foot ulcer among different wagner classification was statistically significant difference (P<0.05), the healing situation of foot ulcer was getting worse with the increase of Wagner classification.7. In 94 cases of DF patients whose bacteria,fungi culture were positive,50 cases (53.2%) were pure infections,44 cases (46.8%) were mixed infection, Including 31 cases of mixed infection between bacteria,13 cases of mixed infection between bacteria and fungi. Among 28 patients of WagnerⅠ-Ⅱ,19 cases (67.9%) were pure infection,9 cases (32.1%)were mixed infection. bacterial cultures were primarily aerobic gram positive cocci. Among 66 patients of WagnerⅢ-Ⅴ,31 cases (47.0%) were pure infection,35 cases (53.0%)were mixed infection. bacterial cultures were primarily aerobic gram negative bacilli.[Conclusions]1. Strengthen the screening of diabetic neuropathy and vasculopathy for diabetic patients are of great significance to preventing the occurrence of DF.2. Strengthen the education for diabetic patients at high risk for foot ulceration are of great significance to preventing the occurrence of DF. For high-risk groups which are elderly and with severe vascular disease, the key of preventing foot ulcers is to improve the low limbs ischemia condition as soon as possible.3. Besides debridement and other basic therapies in the treatment of diabetic foot ulcers, we also should differentiate the properties and evaluate the severity of foot ulcers, then select scientific scientific treatments as soon as possible.Part 2 Analysis of the expression and significance of substance P in skins on the edge of diabetes foot chronic ulcers[Objective] To observe the expression characteristics of SP,NK-1 and PCNA in diabetic chronic ulcers skin tissues, and compare with non-diabetes foot chronic ulcers and normal controls, with the purpose of studying effects of substance P on the healing of diabetic foot chronic ulcers.[Methods]1. We selecte skins on the edge of diabetes foot chronic ulcers as subjects, skins on the edge of non-diabetes foot chronic ulcers and normal skins as controls, three groups are age and gender-matched and skins are drawn from acrotarsium.2. The age,sex of all subjects,times of ulcer formation of chronic ulcers groups and duration of DM are recorded.3. Observing their histological differences by HE staining.4. Observing their expression differences of SP,NK-1 and PCNA by immunohistochemistry.5. Using SPSS 13.0 as statistical analysis, measurement datas are measured by mean±standard deviation. Independent sample t test is used to analyze the times of ulcer formation between chronic ulcers groups, one-way ANOVA test is used to analyze the age and PCNA expression between three groups, Bonferroni test is used when meet homogeneity of variance and Dunnett's T3 test is used when not in comparison between any two groups, several independent samples of non-parametric test is used to analyze the expression of SP and NK-1, P<0.05 is considered statistically significant.[Results]1. The average ages among three groups show no significant difference (P= 0.105), times of ulcer formation between two chronic ulcers groups show no significant difference (P=0.231).2. Skins of two chronic ulcers groups show obvious histological changes, such as extension and broadening of the trochanterellus,significantly reducation and severe vacuolization of prickle cells,sparsity and inordinance of dermal collagen, focal infiltration of a large number of chronic inflammatory cells in collagen degeneration region, which are a sharp contrast with the clear-cut stratified structure of epidermis,rich,regular and compact arrangement of collagen tissue of normal skins.3. SP and its receptor NK-1 are positive or weakly positive expression in three groups, their positions of positive expression are mainly the cytoplasm of basal cells, there are also few expression in the cytoplasm of sweat gland cells, fibroblasts, vascular endothelial cells and inflammatory cells. The SP and NK-1 expression are statistically significant among three groups (P=0.000, P=0.002), and their expression among three groups show the same trends, according to the average ranks, normal controls group are highest, followed by non-diabetic chronic ulcers group, diabetic chronic ulcers group are lowest.4. PCNA is positive or strong positive expression in three groups, its positions of positive expression are mainly the nucleus of cuticular layer cells,especially basal cells,sweat gland cells,vascular endothelial cells,few fibroblasts and few inflammatory cells. The number of PCNA-positive cells is statistically significant between diabetic chronic ulcers group and normal controls group,between diabetic chronic ulcers group and non-diabetic chronic ulcers group (P=0.000, P=0.002), but it's no significant difference between non-diabetic chronic ulcers group and normal controls group (P=0.720), normal controls group are highest, followed by non-diabetic chronic ulcers group, diabetic chronic ulcers group are lowest.[Conclusions]1. Diabetic patients may have microanatomy changes before their skin is damaged and tissue integrity is destroyed, which may be an important cause for their skins are vulnerable and wounds are refractory.2. The expression of SP and NK-1 in skins of diabetic foot chronic ulcers are reduced, Which may lead to abnormal inflammatory response in diabetic wounds and impaired proliferation of repair cells, and then are an important cause for diabetic refractory wound.