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A threatening major amputation represents a fateful turning point for diabetics. This occurs in 50% of cases of amputations in diabetics. This increases the demand for another therapeutic route not only because of the limitations in quality of life but also due to substantially higher mortality. Even if an osteomyelitic ischemic situation is often present specialized centers have succeeded in substantially reducing the rate of major amputations in such patients. The term "minor amputation" commonly used in vascular surgery is not uniformly understood. Following the "vascular surgery working model" developed by Rümenapf, the significance of "minor amputations" for retention of extremities and the associated controversies have been shown. "Minor amputations" therefore represent a maxi-task if patients undergoing such a procedure are to be timely and competently treated. The necessary interdisciplinary cooperation with other specialists should in the future also include orthopedic surgeons.

The repeatedly expressed doubts about the value of an effective therapy for diabetic neuropathies are no longer acceptable. Today a number of excellent longitudinal and cross-sectional studies, i.e. DCCT, Steno 2, DCCT/EDIC, European Diabetes Prospective Complications Study, are available. The attending physician should make every effort to diagnose diabetic neuropathies as soon as possible with all their multivarious manifestations. Treatment must be promptly, aggressively and multifactorially as described in evidence-based guidelines. In principle, the same risk factors apply to neuropathy in type 1 and type 2 diabetes as for macro-angiopathy and microangiopathy. Therapy focuses on establishing near-normal diabetes and blood pressure control, lipid management, intensive patient education, avoidance of exogenous noxae such as alcohol and nicotine and if necessary, an effective therapy of neuropathic pain. The objective of all diagnostic and preventive efforts must be always to avoid the development of the diabetic neuropathic foot syndrome, which is the most important end stage of somatic and autonomic diabetic neuropathy.

Diabetes-associated sequelae lead to a considerable reduction in the quality of life and conspicuous increase in mortality. Subsequent damage becomes manifest in terms of macroangiopathy as coronary heart disease, peripheral arterial occlusive disease, and cerebrovascular insufficiency. Moreover, there is high risk of diabetic nephropathy, neuropathy, and retinopathy entailing the danger of developing chronic renal failure, loss of vision, or diabetic foot syndrome. Although chronic hyperglycemia constitutes a separate risk factor for macro- and microangiopathic complications, associated disorders such as arterial hypertension and hypercholesterinemia increase the mortality risk to a significant extent. Hence, in the past few years, new concepts have been developed for improving the diagnosis, therapy, and long-term care of people with diabetes to include diligent treatment of concomitant risk factors in addition to maintaining near-normal blood glucose levels. This optimized medical care can improve the quality of life and prognosis of patients with diabetes mellitus.

The amputation rate in patients with diabetic foot syndrome (DFS) in Germany is still as high as 28,000 per year. Ischemia and osteomyelitis often complicate the DFS. Impaired wound healing frequently requires further surgery with a higher amputation level. The results of treating patients with DFS in our specialized foot care center were evaluated in order to assess our interdisciplinary strategy. Advanced diabetic foot wounds in patients with ischemia and osteomyelitis first require diagnostics concerning polyneuropathy, osteomyelitis, and blood supply. If peripheral arterial vessel disease is present, surgical revascularization by distal bypass grafting is the first and crucially important element of the interdisciplinary approach. Minor amputation or elective resection of the infected bone improves wound healing. Post-interventional care for wounds with secondary healing and prevention of new ulcers are provided in a foot care clinic specialized in diabetes. The clinical and radiological results of 77 patients who underwent this treatment algorithm including bypass surgery and bone resection within 1 year were collected using a standardized questionnaire. Those results were subjected to a historical comparison. Only three patients needed further intervention because of persisting ulcers and osteomyelitis. The frequency of major amputations in all patients with DFS and ischemia combined with osteomyelitis was low (10.3%). This interdisciplinary concept of treatment guarantees a high healing rate in patients even with osteomyelitis and ischemia and allows the reduction of the rate of major amputations. The data obtained allow a fact-based design for future studies.

Background and Method: In a study carried out in the years 2000 and 2002, 40 patients with diabetic polyneuropathy were treated with a daily dose of 2 x 2 capsules of the pyrimidine nucleotide preparation, Keltican N for a period of three months. The structured neurological findings in accordance with the Neuropathy Disability Score (NDS), the conduction velocity of the peroneal and sural nerves, and pain sensation on the basis of a visual analog scale., Results: All parameters showed a trend towards improvement. The difference in the sensory conduction velocity of the sural nerve and in the subjective pain score was significant.

Prevention and the correct treatment of the diabetic foot have important social and economic consequences. Risk stratification is essential for choosing the appropriate treatment strategy. History and careful clinical examination identify the risk in each individual patient with diabetes. Peripheral neuropathy (PNP), foot deformation, peripheral arterial disease (PAD) and a history of previous ulcer or amputation are the most important risk factors. PAD must be diagnosed and treated by percutan transluminal angioplasty or bypass surgery where necessary. Primary foot deformation or secondary due to PNP require shoe modifications. Good metabolic control of diabetes and treatment of other cardiovascular risk factors (dyslipidemia, hypertension) delay or prevent the development of PNP and PAD. Therefore an early multidisciplinary approach is essential for each patient with diabetes and foot problems. In the presence of a foot ulcer, it's important to diagnose osteomyelitis by clinical or radiological examination. The choice and duration of antibiotic treatment and surgical intervention depends on the localisation and extension of infection around the ulcer and the presence of osteomyelitis. In case of limb threatening infection, the patient should be referred to a specialized treatment facility immediately.

Neuropathy is a serious complication in diabetes mellitus. It presents in a variety of clinical manifestations and is an essential precondition for the development of the diabetic foot syndrome. While the common distal symmetrical sensorimotor form of diabetic neuropathy cannot be clinically differentiated from neuropathies of other etiologies, the less common focal forms of diabetic neuropathy require the differential diagnosis from other localized disorders. In most patients diabetic neuropathies can be diagnosed on clinical grounds. Early recognition is important, and intensive glycemic control is paramount in all therapeutic efforts.

Along with angiopathy, neuropathy and osteoarthropathy are the most important effects of diabetes mellitus with regard to the foot. Because diagnosis in cases of these two consequences are very frequently wrong and too late, the diagnostic procedure and differential diagnosis will be discussed first. The goal of surgical and conservative treatment is a functioning foot and not amputation and provision of a prosthesis. The five types of osteoarthropathy together with the operative procedure for each are introduced: at the forefoot, resection of from one to all metatarsal radii whilst sparing the toes; at the metatarsus, the removal of projecting fragments; at the dorsal foot, resectioning arthroplasty. The operative procedures usual in traumatology cannot simply be transferred to osteoarthropathy. Arthrodeses and spongiosa grafting are doomed to failure in the neuropathic area, or at least carry the onus of a much longer period of convalescence. Resectioning arthroplasty for constructing a stiff pseudarthrosis is an alternative. The results are, however, only lasting if perfect orthopedic care and regular care and checking of the feet are guaranteed thereafter.

Diabetic patients are exposed to higher risk of morbidity and mortality. However, it is difficult to define this in advance and to predict the degree of inability for work. The risk is depending on type of diabetes, age of manifestation, age of the patient course and duration of the disease and mainly from glycemic control. Educational programs may markedly ameliorate the overall situation and decrease of risk of late complications which may threat kidney, eyes, nerves and the cardiovascular system. However, it is an erroneus notion that most diabetics may be crippled by complications of their disease which may result in unwarranted bias against them in both work and leisure activities. Most diabetics may undertake any occupation or hobby, of course with some exceptions when hypoglycemia due to insulin or hypoglycemic agents represents risk for themselves and other persons. Those patients may not serve as pilots and cannot hold public service vehicle driving licences. They should not take over the supervision in power-stations etc. Ordinary driving licences can be held by diabetic patients if on insulin or not, provided that they are otherwise physically fit and do not suffer from blackouts. From many studies it is known that the rate of accidents is not higher with respect to diabetic patients than in the normal population. Life assurance premiums are often raised by amounts which depend on the result of a medical examination but it is very important that the judgement is not made on the basis of a single checkup at a given time. To get information about the presence or development of late complications which have a very broad spectrum it is necessary to have insight into the course of the metabolic disorder and the tendency of worsening or amelioration.

From June 1992 to October 1995, 224 patients were operated on carpal tunnel syndrome. We treated 71 male and 153 female patients. During our investigations, we found that one third of the patients suffered from a double crush syndrome. 84% of the patients suffered from one or more predisposing accompanying diseases. In most of them (42%) we found rheumatic diseases, 19% diabetes mellitus, 8% hyperuricaemia, and 6% hypothyreosis. In 33%, we observed a very short history and a bilateral carpal tunnel syndrome. According to the preoperative tests, four different groups of patients regarding electrophysiological parameters and the graduation of thenar atrophy were differentiated. The fourth group was composed of patients with double crush syndrome, who continued to complain of considerable pain despite surgery, the operated hand remaining both weak and awkward in its movements. Inspired by the prospective study by Dellon (1992) and our results, we will perform a retrospective analysis of the longterm effect of carpal tunnel release in diabetic neuropathy.

Objective: To assess the relationship between rate-corrected QT interval (QTc interval) and cardiac reflex tests in order to determine the value of QTc interval measurements in the diagnosis of diabetic cardiac autonomic neuropathy., Investigations: The QTc interval was measured in the resting ECG of 97 type 1 diabetics (58 women, 39 men; mean age 35 +/- 12 years; duration of diabetes 18 +/- 10 years; HbA1c 7.8 +/- 1.8%). Age-related results were compared with five cardiac function tests (heart rate variation at rest and on forced breathing; 30/15 ratio of heart rate; Valsalva manoeuvre; orthostasis)., Results: The QTc interval was not prolonged ( < or = 440 ms) in 68 patients (70%), while in 29 (30%) it was prolonged ( > 440 ms). No significant differences regarding QTc interval were found between patients with autonomic cardiac neuropathy ( > or = 2 abnormal function tests) and those without ( < 2 abnormal function tests) (QTc interval 436 +/- 25 vs 426 +/- 19 ms). QTc intervals correlated with the coefficients of variation for heart rate variation at rest and on forced breathing and the 30/15 ratio of heart rate (p = 0.001; p = 0.001; p = 0.03), but not with the results of the Valsalva manoeuvre and the orthostasis test., Conclusion: Prolongation of the QTc interval in longstanding type 1 diabetes does not provide a reliable indication of cardiac autonomic neuropathy and this measure cannot replace conventional reflex tests for its diagnosis.

Foot disease in patients with diabetes mellitus is multifactorial and results from a combination of peripheral neuropathy, vascular compromise and superimposed infection. Foot complications in diabetic patients are common and account for more hospital days than any other aspects of their disease. Therefore, familiarity with the spectrum of findings in the different imaging modalities appears essential. Radiographically, significant changes include Charcot joints of the tarsus (destructive type) and bone absorption of the forefoot (mutilating type). In diabetic foot problems, magnetic resonance imaging and leukocyte scintigraphy appear to be the most effective tools for detection of osteomyelitis, and a negative study makes osteomyelitis unlikely. However, the findings of both techniques in active, noninfected neuropathic osteoarthropathy may be indistinguishable from those of osteomyelitis.

For 3 years a 75-year-old man with type II diabetes had been suffering from paroxysmal pruritus in a circumscribed area of brown discoloration of the skin over the left should blade. This condition, also known as notalgia paraesthetica, is a rare, but perhaps underdiagnosed, neurocutaneous entity, a largely sensory neuropathy due to a muscular compression phenomenon. In this case histological examination of a biopsy specimen showed focal acanthosis, obvious basal hyperpigmentation and discrete perivascular lymphocytic infiltration with numerous melanophages. At first, glucocorticoids were administered unsuccessfully against the distressing pruritus. Purely symptomatic local capsaicin treatment decreased the pruritus temporarily. Endocrinological diagnosis failed to demonstrate multiple endocrine neoplasia (MEN) syndrome 2A, which has been frequently described in association with notalgia paraesthetica.

A 26-year-old female with severe complications from type I diabetes mellitus of 17 years' duration (proliferative retinopathy, nephropathy with renal failure and nephrotic syndrome) developed rapid deterioration of vision in the right eye to 6/60 over a period of several weeks. There were no other neurological signs. Ophthalmological examination showed no worsening of the diabetic retinopathy, but the presence of bilateral optic atrophy, confirmed by visual evoked potentials. CT scan did not reveal any retrobulbar process, and MR scans of both the optic nerves and the visual pathways were unremarkable. The clinical features and the investigations pointed towards ischaemic optic atrophy. Detailed platelet studies showed intravascular platelet activation and an ADP-inducible increase in aggregation, although thromboxane formation was almost absent because of cyclooxygenase inhibition by acetylsalicylic acid. These findings suggest that the ischaemia was due to microcirculatory disturbances secondary to diabetic microangiopathy and platelet hyperreactivity.

Study Design: In an open, multicentric observational study involving 234 doctors in private practice, the evolution of symptoms and the tolerability of a vitamin B preparation (Neurotrat forte) used as treatment in 1,149 patients with polyneuropathy, neuralgia, radiculopathy and neuritis associated with pain and paresthesias, were observed. The form of administration (ampoules, dragées), dosage and duration of treatment were left to the individual care-providing physician. The target symptoms evaluated were intensity of pain, muscle weakness affecting the legs, and paresthesia., Results: Under treatment, there was a clear improvement in these symptoms. At a second examination approximately three weeks after initiation of treatment, a positive effect on pain in particular was observed in 69% of the cases. Similar observations were also made for paresthesias and muscular weakness in the legs.

On the basis of own experiences with the care of diabetes in the northern highland of Ethiopia the particularities of the tropical diabetes mellitus are described. In the light of the control score according to Noviks and co-workers the quality of the metabolic management of 100 patients is estimated as above all unsatisfactory, from which the conclusion is to be deduced more than up to now to include the diabetes mellitus into the health care system of Ethiopia and to improve thoroughly the conditions for the diagnostics, the therapy, education and dispensary care.

Neuropathy, arterial obstruction and infection are involved to varying degrees in the development of the 'diabetic foot'. A careful diagnosis is necessary in order to comprehend the various noxa and to introduce the adequate therapy. In case of the predominantly neuropathic foot with malum perforans, one must essentially proceed in a conservative way; only cornea callosities and osteomyelitic parts must be removed. In case of the predominantly angiopathic foot, revascularizing measures are most important. After improving the blood flow, the necrotic parts of the foot are sparingly resected. As prevention of a possible relapse, two things are necessary: accurately fitted shoes in order to prevent pressure points, and extremely careful foot care in order to prevent infections.

Chronic diseases (diabetes mellitus, end stage renal failure on hemodialysis, post-hepatitic liver cirrhosis) caused autonomic neuropathy in 34 of 65 cases. The frequency of autonomic neuropathy was 14 of 30 diabetics (typ I and typ II), twelve of 19 patients on dialysis, and eight of 16 non-alcoholic liver cirrhotics. We did not find a correlation between the tests of the cardiovascular and of the gastrointestinal system. The distribution of the neuropathic changes was undependent of the underlying disorder. Using appropriate tests, alterations of the autonomic functions can be discovered frequently even in asymptomatic patients. At least two pathological test results are necessary to reach a significant difference between patients and healthy controls. This indicates that the diagnosis of autonomic neuropathy should rely on two or more pathological test results. The evidence of autonomic neuropathy identifies a population of high risk patients.

Cardiac autonomic neuropathy is not a rare complication of diabetes. In a selected diabetic population, the prevalence of this complication indicated by abnormal response in beat-to-beat variation during forced respiration was 26%. Patients with cardiac autonomic neuropathy had a two- to threefold higher frequency of diabetic retinopathy. The mortality rate during a 5 year period was increased in diabetics with cardiac autonomic neuropathy.

By investigation of the carbohydrate metabolism in 357 patients with polyneuropathy observed in hospital in recent years, and by statistical comparison with a control group in the literature, an attempt was made to find out whether subclinical diabetes can cause diabetic polyneuropathy to a greater extent. In spite of the more frequent occurrence in the total number of patients, a more significant etiological role for this type of metabolic disorder in polyneuropathy cannot be concluded from the results. Whether a more unspecific, general polyneuropathy-promoting influence is to be ascribed to it must remain open.

Average endoneurial area was correlated with measurements of myelinated fiber density in sural nerves from diabetics and controls. Although, in general, myelinated fiber density decreased with increasing endoneurial area, this relationship was not significant for diabetic nerves. The increase in endoneurial area was attributed to expansion of the endoneurial space as a result of endoneurial edema. A possible role for such edema in the pathogenesis of diabetic neuropathy is considered.

The diabetic osteoarthropathy is an important diabetic complication. There is an obligatory connexion of the diabetic osteoarthropathy with the diabetic neuropathy. It seems to be essential for the diagnosis and treatment to separate the neuropathic and arthropathic lesions from angiopathic changes. It should be paid more attention to the diabetic osteoarthropathy in the treatment and training of diabetic patients suffering from diabetic neuropathy.

Decrease in gall-bladder surface area, as obtained by ultrasound, was measured in 52 patients with insulin-dependent diabetes (27 with and 25 without autonomic neuropathy) 60 minutes after administration of the bile stimulant Biloptin. The post-stimulation area was 33 +/- 6% of initial value in patients with autonomic neuropathy, and 67 +/- 8% (P less than 0.0005) in those without autonomic neuropathy. Comparison with insulin-dependent chronic diabetics matched for sex, age and duration of illness, demonstrated that heart-rate variability in cholelithiasis was less than in the control subjects (P less than 0.05). It is concluded that autonomic neuropathy, measured by the occurrence of spontaneous vagotomy, in insulin-dependent diabetics is an important risk factor in the overall pathogenesis of cholelithiasis.