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Sharma S, Rastogi A. Genetic Signature for the Causation of Charcot Neuro-osteoarthropathy of Foot in Diabetes: A Systematic Review. INT J LOW EXTR WOUND 2024:15347346241252549. [PMID: 38711285 DOI: 10.1177/15347346241252549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Charcot neuro-osteoarthropathy (CNO) is a complication of diabetes occurring in people with diabetic neuropathy with a prevalence of 0.5% to 1% that may culminate to foot deformity, amputation, and early mortality. However, it is not known why only certain patients with diabetic neuropathy develop CNO. Hence, early recognition of risk factors, timely diagnosis, and appropriate intervention of CNO is pertinent. Recent understanding of the pathophysiology of CNO has expanded to suggest the involvement of RANKL-OPG pathways. But pharmaco-therapeutic interventions targeting bone metabolism predominantly inhibiting RANKL were not found to be useful. Moreover, there are not enough markers to help identify patients with diabetes who are at a higher risk of developing CNO. Hence, we explored the literature in the present systematic review of mainly case-control studies to identify genetic factors that could help in understanding the pathophysiology and risk factors for the development of CNO. We could identify 7 relevant studies identifying single nucleotide polymorphism of OPG and RANK genes. There is an isolated study identifying alterations of micro RNA associated with RANKL-OPG pathway. Another study found epigenetic alterations by performing whole methylome sequencing in people with CNO compared to control. These genetic factors can be used as a diagnostic marker and their functional counterparts as targets for future therapeutic interventions. However, we found that literature is sparse on the genetic risk factors for CNO in people with diabetic neuropathy and there is still a lot of scope for future studies towards finding the molecular and genetic markers for CNO.
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Affiliation(s)
- Sonali Sharma
- Department of Endocrinology and Metabolism, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashu Rastogi
- Department of Endocrinology and Metabolism, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Rastogi A, Kulkarni SA, Agarwal S, Akhtar M, Arsule S, Bhamre S, Bhosle D, Desai S, Deshmukh M, Giriraja KV, Jagannath J, Kashiva RY, Kesavan R, Khandelwal D, Kolte S, Kongara S, Darivemula AK, Madhusudan C, Pyare Saheb Qureshi MAH, Ramu M, Rathod G, Yalamanchi SR, Shakya S, Shetty P, Singh S, Deshpande SK, Viswanathan V, Unnikrishnan AG. Topical Esmolol Hydrochloride as a Novel Treatment Modality for Diabetic Foot Ulcers: A Phase 3 Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2311509. [PMID: 37184839 DOI: 10.1001/jamanetworkopen.2023.11509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Importance Preclinical and phase 1/2 studies with esmolol hydrochloride suggest its potential role in treatment of diabetic foot ulcers (DFUs). Objective To study the efficacy of topical esmolol for healing of uninfected DFUs. Design, Setting, and Participants A randomized, double-blind, multicenter, phase 3 clinical trial was conducted from December 26, 2018, to August 19, 2020, at 27 referral centers across India. Participants included adults with DFUs. Interventions Participants were randomized after a run-in phase (1 week) to receive esmolol, 14%, gel with standard of care (SoC), SoC only, or vehicle with SoC (3:3:1 proportion) for 12 weeks (treatment phase) and followed up subsequently until week 24. Main Outcomes and Measures The primary outcome was the proportion of wound closure within the 12-week treatment phase in the esmolol with SoC and SoC only groups. Analysis was conducted using an intention-to-treat safety evaluable population, full analysis set or efficacy-evaluable population, and per-protocol population comparing the esmolol plus SoC and SoC only treatment groups. Results In the study, 176 participants (122 men [69.3%]; mean [SD] age, 56.4 [9.0] years; mean [SD] hemoglobin A1c level, 8.6% [1.6%]) with DFUs classified as University of Texas Diabetic Wound Classification system grade IA and IC (mean [SD] ulcer area, 4.7 [2.9] cm2) were randomized to the 3 groups. A total of 140 participants were analyzed for efficacy. The proportion of participants in the esmolol with SoC group who achieved target ulcer closure within 12 weeks was 41 of 68 (60.3%) compared with 30 of 72 (41.7%) participants in the SoC only group (odds ratio [OR], 2.13; 95% CI, 1.08-4.17; P = .03). A total of 120 participants completed the end of study visit which were analyzed. Target ulcer closure by the end of the study (week 24) was achieved in 44 of 57 (77.2%) participants in the esmolol with SoC group and 35 of 63 (55.6%) participants in the SoC only group (OR, 2.71; 95% CI, 1.22-5.99; P = .01). The median time for ulcer closure was 85 days for the esmolol with SoC group and was not estimable for SoC only group. Significant benefits of Esmolol with SoC were seen in patients with factors that impede the healing of DFU. Treatment-emergent adverse events were noted in 18.8% of the participants, but most (87.3%) of these events were not attributable to the study drug. Conclusions and Relevance In this multicenter, randomized, double-blind clinical trial, the addition of esmolol to SoC was shown to significantly improve the healing of DFUs. With these results, topical esmolol may be an appropriate addition to SoC for treating DFUs. Trial Registration ClinicalTrials.gov Identifier: NCT03998436; Clinical Trial Registry, India CRI Number: CTRI/2018/11/016295.
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Affiliation(s)
- Ashu Rastogi
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Sanjay Agarwal
- Grant Medical Foundation, Ruby Hall Clinic, Department of Diabetology, Cardiac OPD Medical Foundation, Pune, India
| | - Murtaza Akhtar
- N.K.P Salve Institute of Medical Sciences & Research Centre and Lata Mangeshkar Hospital, Digdoh Hills, Nagpur, India
| | - Sachin Arsule
- Sujata Birla Hospital & Medical Research Center, Opposite Bytco College, Nashik, India
| | - Sudhir Bhamre
- Dr Vasantrao Pawar Medical College, Hospital & Research Centre Vasantdada Nagar, Adgaon Nashik, India
| | - Deepak Bhosle
- Clinical Research Unit, Department of Clinical Pharmacology & Therapeutics, Mahatma Gandhi Mission Medical College & Hospital, Aurangabad, India
| | - Sanjay Desai
- M.S. Ramaiah Hospital, Department of Vascular and Endovascular Surgery, M.S. Ramaiah Nagar, Karnataka, India
| | - Manisha Deshmukh
- Deenanath Mangeshkar Hospital & Research Center, Wound Healing Center, Pune, India
| | - K V Giriraja
- Rajalakshmi Hospital, Department of Clinical Research, Bangalore, India
| | - Jagannath Jagannath
- Department of Surgery, Sri Siddhartha Medical College and Research Centre, Tumkur, India
| | - Reema Yuvraj Kashiva
- Noble Hospital Private Limited Hadapsar, Maharashtra, India, Hadapsar, Pune, India
| | | | - Deepak Khandelwal
- Maharaja Agrasen Hospital, Department of Endocrinology, West Punjab Bagh, New Delhi, India
| | - Sanjay Kolte
- Sahyadri Hospital, Department of Surgery, Erandawane, Pune, India
| | | | | | - C Madhusudan
- Sapthagiri Institute of Medical Sciences and Research Centre Department of General Medicine, Bangalore, India
| | | | - Muthu Ramu
- Madras Diabetic Research Centre, Department of Diabetology, Chennai, India
| | - Gunvant Rathod
- B.J. Medical College and Civil Hospital, Ahmedabad, India
| | | | - Shobhit Shakya
- Dr Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | | | - Sudagar Singh
- Sri Ramachandra Hospital, Department of General Medicine, Chennai, India
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Gooday C, Hardeman W, Poland F, Woodburn J, Dhatariya K. Controversies in the management of active Charcot neuroarthropathy. Ther Adv Endocrinol Metab 2023; 14:20420188231160406. [PMID: 37101723 PMCID: PMC10123890 DOI: 10.1177/20420188231160406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 02/11/2023] [Indexed: 04/28/2023] Open
Abstract
Charcot neuroarthropathy (CN) was first described over 150 years ago. Despite this there remains uncertanity around the factors that contribute to its development, and progression. This article will discuss the current controversies around the pathogenesis, epidemiology, diagnosis, assessment and management of the condition. The exact pathogenesis of CN is not fully understood, and it is likely to be multifactorial, with perhaps currently unknown mechanisms contributing to its development. Further studies are needed to examine opportunities to help screen for and diagnose CN. As a result of many of these factors, the true prevalence of CN is still largely unknown. Almost all of the recommendations for the assessment and treatment of CN are based on low-quality level III and IV evidence. Despite recommendations to offer people with CN nonremovable devices, currently only 40-50% people are treated with this type of device. Evidence is also lacking about the optimal duration of treatment; reported outcomes range from 3 months to more than a year. The reason for this variation is not entirely clear. A lack of standardised definitions for diagnosis, remission and relapse, heterogeneity of populations, different management approaches, monitoring techniques with unknown diagnostic precision and variation in follow-up times prevent meaningful comparison of outcome data. If people can be better supported to manage the emotional and physical consequences of CN, then this could improve people's quality of life and well-being. Finally, we highlight the need for an internationally coordinated approach to research in CN.
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Affiliation(s)
| | - Wendy Hardeman
- Behavioural and Implementation Science Group, School of Health Sciences, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Fiona Poland
- Institute for Volunteering Research, Faculty of Medicine and Health Science, University of East Anglia, Norwich, UK
| | - Jim Woodburn
- School of Health Sciences and Social Work, Griffith University, Southport, QLD, Australia
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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Rastogi A, Saini U, Jude E. Ankle Charcot Mimics: Tubercular Rheumatism to Complex Regional Pain Syndrome. J Am Podiatr Med Assoc 2022; 112:21-122. [PMID: 36525329 DOI: 10.7547/21-122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Charcot Foot is often misdiagnosed because of its varied presentation that mimics other common disorders including tubercular rheumatism, complex regional pain syndrome or gout. We present a case of ankle swelling and discuss the differential diagnosis, radiological findings, and management. We also discuss the approach to diagnosis and provide differences in clinical presentations, magnetic resonance imaging,and bone scan findings for various differentials considered for Charcot foot.
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Affiliation(s)
- Ashu Rastogi
- *Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Uttam Saini
- *Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Edward Jude
- †Tameside and Glossop Integrated Care NHS Foundation Trust, University of Manchester, United Kingdom
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Yammine K, Boulos K, Assi C, Hayek F. Amputation and mortality frequencies associated with diabetic Charcot foot arthropathy: a meta-analysis. Foot Ankle Surg 2022; 28:1170-1176. [PMID: 36028441 DOI: 10.1016/j.fas.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 07/12/2022] [Accepted: 08/09/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Five-year mortality and amputation frequencies after new-onset diabetic ulceration have been reported up to 55% and 74%, respectively. for patients with lower-extremity amputation. Following Charcot arthropathy, these frequencies were reported with wide variations. The aim of this meta-analysis is to provide a quantitative evaluation of amputation and mortality frequencies in a diabetic patient with a Charcot foot arthropathy. METHODS Electronic search strategy was applied on Medline, Web of Science, Cochrane Library and Google Scholar since inception to December 2021. Extracted data included study design, sample and patients characteristics, diabetes type and duration, lab results, ulcers at diagnosis, co-morbidities and follow up period. Meta-analysis reporting random-effects values was used to generate the weights results. RESULTS A total of 16 studies were included in the quantitative meta-analysis with a pooled sample of 2250 patients with 2272 Charcot feet. Two studies including 255 patients yielded a 1-year mortality frequency of 4% (95% CI = 0.018-0.065). Seven studies including 1706 patients reported a 5-year mortality frequency of 24.5% (95% CI = 0.172-0.326, I² = 88.5%). Four studies including 277 patients yielded a seven plus year mortality frequency of 16% (95% CI = 0.065-0.289, I² = 84.3%). Ten studies including 871 foot yielded an amputation frequency of 15% (95% CI = 0.067-0.258, I² = 93.6%) where 9% where major amputations (95% CI = 0.062-0.127, I² = 60%) and 5% were minor amputations (95% CI = 0.004-0.126, I² = 94.7%) CONCLUSION: Diabetic Charcot arthropathy yields marked risk of amputation and mortality. However, mortality frequencies were unexpectedly lesser compared to those related to the published frequencies associated with diabetic foot ulcers.
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Affiliation(s)
- Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Diabetic Foot Clinic, Lebanese American University Medical Center-Rizk Hospital, Beirut, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research.
| | - Karl Boulos
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
| | - Chahine Assi
- Department of Orthopedic Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon; Center for Evidence-Based Anatomy, Sport & Orthopedics Research
| | - Fady Hayek
- Division of Vascular Surgery, Lebanese American University Medical Center-Rizk Hospital, Lebanese American University, School of Medicine, Lebanon
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Cerqueira MMBDF, Maia HMSF, Mercês MCD, Santos da Natividade M, Almeida ODS, Santana EF, Oliveira BAM, Araújo M. Complications related to diabetic foot ulcer and associated social vulnerability factors at a referral centre in Brazil. J Wound Care 2022; 31:946-960. [DOI: 10.12968/jowc.2022.31.11.946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: To analyse the prevalence and associated social vulnerability factors of complications related to diabetic foot ulcer (DFU) among individuals followed up in a public care centre in Brazil. Method: This is a cross-sectional study carried out with individuals followed up at the diabetic foot service of the State Referral Center for Diabetes and Endocrinology Assistance (CEDEBA) between December 2019 and October 2020, during the COVID-19 pandemic. Descriptive analysis and comparison of the prevalence of complications related to DFU were carried out. The factors associated with the outcome variables were verified by hierarchical logistic regression analysis. Results: Among the 253 participants in this study, 30.4% had an active ulcer, 57.1% had a previous ulcer and 45.1% had an amputation. Lower limb ulcers were positively associated with male sex (prevalence ratio (PR): 1.22 (1.04–1.43)) and negatively associated with age >60 years (PR: 0.71 (0.61–0.83)), screening for diabetic foot (PR: 0.79 (0.67–0.92)) and the use of public transport to access CEDEBA (PR: 0.82 (0.71–0.96)). On the other hand, amputations were positively associated with male sex (PR: 1.61 (1.23–2.11)) and not working (PR: 3.83 (1.48–9.95)) and negatively associated with age >60 years (PR: 0.57 (0.45–0.74)) and the use of public transport to access CEDEBA (PR: 0.63 (0.49–0.81)). Conclusion: The prevalence of complications was higher than in previous studies, and associated with sociodemographic and clinical characteristics. Further research should be encouraged to investigate the role that determinants of health play in the course of the disease, contributing to the construction of strategies that incorporate formulations developed in the social and economic spheres to broaden the impact of health actions on the prevention of major diabetic foot complications.
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Swoboda L, Held J. Impaired wound healing in diabetes. J Wound Care 2022; 31:882-885. [DOI: 10.12968/jowc.2022.31.10.882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Impaired wound healing for patients with diabetes is due to a constellation of structural, biochemical, cellular and microbial factors. Hyperglycaemia and its associated inflammation contribute to immune dysfunction, vascular damage, neuropathy, cellular senescence, impaired transition beyond the inflammatory stage, microbiome disruptions, failed extracellular matrix formation, growth factor and cytokine imbalance, limited re-epithelialisation, and alterations in fibroblast migration and proliferation. Optimising glycaemic control remains the primary intervention to prevent continual dysfunction and comorbid disease progression.
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Affiliation(s)
- Laura Swoboda
- Froedtert & the Medical College of Wisconsin, Community Hospital Division, US
| | - Jessica Held
- Froedtert & the Medical College of Wisconsin, Community Hospital Division, US
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Hjelm LR. Diabetes Mellitus: An Overview in Relationship to Charcot Neuroarthropathy. Clin Podiatr Med Surg 2022; 39:535-542. [PMID: 36180186 DOI: 10.1016/j.cpm.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Diabetes mellitus with the lack of glycemic control increases risks for developing comorbidities affecting organ systems responsible for critical function. The development of diabetic neuropathy predisposes patients to the onset of Charcot neuroarthropathy (CN). There is significant complexity with treatment of diabetic-induced CN, which can have an often delayed or missed diagnosis. Supervision and treatment from trained specialists are required to provide care for this multifaceted disease process. It is essential for patients to partner with glucose control, comorbidity prevention and care, as well as lower extremity management. Ultimately, CN can result in significant lower extremity deformity placing patients at risk of limb and life.
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Affiliation(s)
- Lindsey R Hjelm
- Department of Podiatry and Foot & Ankle Surgery, Virginia Mason Franciscan Health, 16233 Sylvester Road SW G-10, Burien, WA 98166, USA.
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Diabetic Foot Ulcer Infections and Pseudomonas aeruginosa Biofilm Production During the COVID-19 Pandemic. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2022. [DOI: 10.22207/jpam.16.1.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
During the different waves of the coronavirus (COVID-19) pandemic, there has been an increased incidence of diabetes mellitus and diabetic foot infections. Among gram-negative bacteria, Pseudomonas aeruginosa is the predominant causative agent for diabetic foot ulcer infections in low-resource countries. P. aeruginosa possesses a variety of virulence factors, including biofilm formation. Biofilm formation is an important benchmark characteristic in the pathophysiology of diabetic foot ulceration. The main objective of the current study was to identify the most commonly isolated organisms and their antibiotic susceptibility patterns in diabetic foot patients during the COVID-19 pandemic. We also determined the genes associated with bacterial persistence and biofilm formation in the predominantly isolated organism. Accordingly, 100 wound swab samples were collected from diabetic foot patients from different hospitals in Alexandria, Egypt. Through phenotypic detection of biofilm formation, 93% (40) of the 43 P. aeruginosa isolates examined were categorized as biofilm producers. Molecular detection of the biofilm-encoding genes among the 43 P. aeruginosa isolates was as follows: algD (100%), pelF (88%) and pslD (49.7%), and this highlights a need for biofilm formation inhibitors to prevent the persistence of bacterial pathogens, and thus achieve better clinical outcomes in diabetic foot ulcer infections.
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Long-term foot outcomes following differential abatement of inflammation and osteoclastogenesis for active Charcot neuroarthropathy in diabetes mellitus. PLoS One 2021; 16:e0259224. [PMID: 34748565 PMCID: PMC8575293 DOI: 10.1371/journal.pone.0259224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/18/2021] [Indexed: 11/19/2022] Open
Abstract
AIMS Inflammatory osteolysis is sine-qua-non of active Charcot neuroarthropathy (CN) causing decreased foot bone mineral density (BMD) and fractures. We aimed to explore the effect of anti-inflammatory or anti-resorptive agents for effect on foot bone mineral content (BMC) and consequent long-term outcomes of foot deformities, fractures and amputation. METHODS Forty-three patients with active CN (temperature difference >2°C from normal foot) were evaluated. Patients were off-loaded with total contact cast and randomized to receive either methylprednisolone (1gm) (group A), zoledronate (5mg) (group B) or placebo (100ml normal saline) (group C) once monthly infusion for three consecutive months. Change in foot BMC was assessed at 6 months or at remission and followed subsequently up to 4 years for the incidence of new-onset fracture, deformities, or CN recurrence. RESULTS Thirty-six participants (24 male, 12 female) were randomized (11 in group A, 12 group B, 13 group C). The mean age was 57.7± 9.9 years, duration of diabetes 12.3± 5.8 years and symptom duration 6.5± 2.8 weeks. BMC increased by 36% with zoledronate (p = 0.02) but reduced by 13% with methylprednisolone (p = 0.03) and 9% (p = 0.09) with placebo at remission. There were no incident foot fractures, however, two patients sustained ulcers, and 3 had new-onset or worsening deformities and none required amputation during 3.36 ± 0.89 years of follow-up. CONCLUSION Bisphosphonate for active CN is associated with an increase in foot bone mineral content as compared to decrease with steroids or total contact cast but long-term outcomes of foot deformities, ulceration and amputation are similar. TRIAL REGISTRATION ClinicalTrials.gov: NCT03289338.
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Prevalent vascular complications in people with diabetes: a multicentre observational cohort study. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-01010-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Rossboth S, Rossboth B, Schoenherr H, Lechleitner M, Oberaigner W. Risk factors for diabetic foot complications among patients with type 2 diabetes in Austria-A registry-based retrospective cohort study. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00286. [PMID: 34505418 PMCID: PMC8502226 DOI: 10.1002/edm2.286] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/23/2021] [Accepted: 06/26/2021] [Indexed: 12/29/2022]
Abstract
Aims Diabetic foot complications, a serious consequence of diabetes mellitus, are associated with a tremendous burden on both individual patients and health care systems. Since prevention strategies may reduce the incidence of this complication, identification of risk factors in large longitudinal studies is essential to optimize early detection and personalized screening of patients at increased risk. Materials and methods We conducted a registry‐based retrospective cohort study using data from 10,688 patients with type 2 diabetes mellitus aged ≥18 years. Cox regression models were used to identify risk factors for foot complications while adjusting for potential confounders. Results We observed 140 diabetic foot complications in our patient cohort. The multivariate Cox regression model revealed neuropathy, peripheral arterial disease and male gender as being positively associated with foot complications. The same effect was detected for nephropathy in the time >10 years after T2DM diagnosis. For higher age at diagnosis and use of insulin, however, a negative association was retrieved. Conclusion Male gender and several diabetes‐related comorbidities were identified as risk factors for subsequent initial foot complications in patients with type 2 diabetes mellitus. These findings suggest that personalized early detection of patients at increased risk might be feasible by using information on demographics, medical history and comorbidities.
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Affiliation(s)
- Sophia Rossboth
- Department of Public Health, Research Unit for Diabetes Epidemiology, Health Services Research and Health Technology Assessment, Medical Informatics and Technology, UMIT-Private University for Health Sciences, Hall i.T., Austria
| | | | - Hans Schoenherr
- Department of Public Health, Research Unit for Diabetes Epidemiology, Health Services Research and Health Technology Assessment, Medical Informatics and Technology, UMIT-Private University for Health Sciences, Hall i.T., Austria.,Department of Internal Medicine, St. Vinzenz Hospital Zams, Zams, Austria
| | | | - Willi Oberaigner
- Department of Public Health, Research Unit for Diabetes Epidemiology, Health Services Research and Health Technology Assessment, Medical Informatics and Technology, UMIT-Private University for Health Sciences, Hall i.T., Austria
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Bandeira MA, Dos Santos ALG, Woo K, Gamba MA, de Gouveia Santos VLC. Incidence and Predictive Factors for Amputations Derived From Charcot's Neuroarthropathy in Persons With Diabetes. INT J LOW EXTR WOUND 2021:15347346211025893. [PMID: 34142879 DOI: 10.1177/15347346211025893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Charcot's neuroarthropathy (CN) is the progressive destruction of the bones and joints of the feet, as a consequence of severe peripheral neuropathy, which predisposes patients to amputations. The purpose of this study was to measure the cumulative incidence of amputations resulting from CN and risk factors among amputated people with diabetes mellitus (DM). This was an epidemiological, observational, and retrospective study of 114 patients with DM who had an amputation involving the lower limbs. Data were collected from 2 specialized outpatient clinics between 2015 and 2019, including socio-demographic and clinical variables (cause of amputation: CN, peripheral arterial disease [PAD], infected ulcers, fracture, osteomyelitis, and others; body mass index [BMI]; 1 or 2 DM, time since DM diagnosis, insulin treatment, glycated hemoglobin; creatinine; smoking and drinking; systemic arterial hypertension, diabetic retinopathy, diabetic kidney disease, diabetic peripheral neuropathy, acute myocardial infarction, PAD, and stroke; characteristics of amputation [level and laterality], in addition to the specific variables related to CN [time of amputation in relation to the diagnosis of CN, diagnosis of CN in the acute phase, and treatment implemented in the acute phase]). We compared socio-demographic and clinical characteristics, including types of amputation, between patients with and without CN. Statistical analyses were performed using the 2 sample t-test or Wilcoxon-Mann-Whitney test, for quantitative variables, and the Pearson's χ2 test or Fisher's exact test for categorical variables. The investigation of the possible association of predictive factors for a CN amputation was carried out through logistic regression. The amputation caused by CN was present in 27 patients with a cumulative incidence of 23.7% in 5 years. There was a statistically significant association between BMI and the occurrence of CN (odds ratio: 1.083; 95% confidence interval: 1.001-1.173; P = .048); higher values of BMI were associated with a higher occurrence of amputations secondary from CN.
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Affiliation(s)
| | | | - Kevin Woo
- 4257Queen's University, Kingston, Ontario, Canada
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Rastogi A, Bhansali A, Jude EB. Efficacy of medical treatment for Charcot neuroarthropathy: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol 2021; 58:687-696. [PMID: 33439331 DOI: 10.1007/s00592-020-01664-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/21/2020] [Indexed: 12/20/2022]
Abstract
No pharmacotherapeutic agents are yet recommended for active CN though many anti-resorptive agents have been studied. We conducted a systematic review and meta-analysis of the randomized placebo-controlled trials (RCTs) evaluating the time to remission of active CN with anti-resorptive or antiinflammatory drugs. RCTs published in PubMed, EMBASE, SCOPUS and Cochrane Library from January 1994 to December 2019 were accessed. We reviewed studies and extracted information on study design, participants' characteristics, time to remission, bone turnover markers, bone mineral content (BMC) and temperature difference between feet. Five RCTs out of 588 total identified records were included. Standardized mean differences (SMD) between groups with 95% CI are summarized. Pharmacotherapy nonsignificantly increased time to remission [SMD 0.52 weeks (- 0.71, 1.75), p = 0.402; I2 = 88.6%] as compared to TCC alone. The pooled median time to remission with the intervention was 18.5 weeks (11.2, 28.1) compared to 16.8 weeks (8.7, 27.7) with TCC. A nonsignificant increase in BMC [SMD 3.39% (- 0.78, 7.56), p = 0.109; I2 = 96.7%], a decrease in foot temperature [SMD - 0.42 °C (- 0.78, - 0.07), p = 0.020; I2 = 0%] and alkaline phosphatase [SMD = -2.51% (- 3.24, - 1.77), p < 0.001; I2 = 0%] was observed with intervention. Limited evidence from available studies does not support the role of anti-resorptive or anti-inflammatory drugs for earlier remission when added to offloading with total contact cast for active CN of the foot.
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Affiliation(s)
- Ashu Rastogi
- Foot Care Division, Department of Endocrinology and Metabolism, PGIMER, Room 0016, Nehru Extension Block, Chandigarh, 160012, India.
| | - Anil Bhansali
- Foot Care Division, Department of Endocrinology and Metabolism, PGIMER, Room 0016, Nehru Extension Block, Chandigarh, 160012, India
| | - Edward B Jude
- Diabetes and Endocrinology Department,, Tameside and Glossop Integrated Care NHS FT, Ashton under Lyne, Lancs, OL69RW, UK
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Rastogi A, Hiteshi P, Bhansali A. A, Jude EB. Virtual triage and outcomes of diabetic foot complications during Covid-19 pandemic: A retro-prospective, observational cohort study. PLoS One 2021; 16:e0251143. [PMID: 33956847 PMCID: PMC8101747 DOI: 10.1371/journal.pone.0251143] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 04/20/2021] [Indexed: 12/23/2022] Open
Abstract
AIMS Limb and patient outcomes in people with diabetic foot complications including diabetic foot ulcer (DFU) provided virtual triage and personalized video consultations during COVID-19 pandemic are not known. METHODS Patients with foot complications attending the diabetic foot clinic prior to lockdown who sought teleconsultations during COVID-19 lockdown underwent virtual triage to include clinical history, visual inspection of feet, domiciliary wound care (community nurse assisted dressings) and offloading instructions. The subsequent ulcer, limb and mortality outcomes during the following 24 weeks of COVID-19 lockdown (April-September 2020, group 1) were assessed and compared with those who attended foot clinic during the same period in 2019 (April-September, group 2). RESULTS Group 1 included 561 participants with foot complications provided with teleconsultations, median age 57 (51 to 63) years and diabetes duration of 10 (5 to 16) years. Twelve patients with severe DFU were excluded and 549 patients [357 (65%) neuropathic foot, 104 (18.9%) ischemic foot and 88 (16%) chronic Charcot foot with deformities] were evaluated. There were 227 (41.3%) participants with active DFU at start of lockdown, 32 (5.8%) with new onset ulcer during lockdown (47.1%) and 290 patients without ulcers. Group 2 included 650 participants; active foot ulcer was present in 366 patients. Wound closed or reduced in area in 78.4% of participants of group 1 compared to 76.0% (p = 0.318) in group 2. Fourteen (5.4%) patients required amputations [3 major and 11 minor] in group 1 during the study period compared to 6.8% in group 2 (p = 0.191). Twenty-one (3.8%) and 28 (4.3%) patients died (p = 0.532) during 24 weeks of follow up in group 1 and 2, respectively. CONCLUSIONS Targeted foot-care service through virtual triage and teleconsultations during COVID-19 pandemic for people with foot complications have similar ulcer and limb outcomes compared to face-to-face foot care delivery.
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Affiliation(s)
- Ashu Rastogi
- Department of Endocrinology, PGIMER, Chandigarh, India
- * E-mail: (EBJ); (AR)
| | - Priya Hiteshi
- Department of Endocrinology, PGIMER, Chandigarh, India
| | | | - Edward B. Jude
- Tameside and Glossop Integrated Care NHS Foundation Trust, Tameside on Lyne, United Kingdom and Manchester Metropolitan University, Manchester, United Kingdom
- * E-mail: (EBJ); (AR)
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Ahluwalia R, Maffulli N, Lázaro-Martínez JL, Kirketerp-Møller K, Reichert I. Diabetic foot off loading and ulcer remission: Exploring surgical off-loading. Surgeon 2021; 19:e526-e535. [PMID: 33642205 DOI: 10.1016/j.surge.2021.01.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 12/26/2020] [Accepted: 01/06/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Diabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration. METHODS We systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations. RESULTS Five discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements. CONCLUSIONS AND IMPLICATIONS Surgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.
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Affiliation(s)
- Raju Ahluwalia
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
| | - Nicola Maffulli
- Department of Trauma and Orthopaedic Surgery, Faculty of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy; School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK; Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, 275 Bancroft Road, London, England, E1 4DG, UK.
| | - José L Lázaro-Martínez
- Diabetic Foot Unit, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Del Hospital, Clínico San Carlos (IdISSC), 28040, Madrid, Spain.
| | - Klaus Kirketerp-Møller
- Copenhagen Wound Healing Center, Department of Dermatology and Wounds, Bispebjerg Hospital, Copenhagen, Denmark; Steno Diabetes Center Copenhagen, Denmark.
| | - Ines Reichert
- Department of Trauma & Orthopaedics, Kings College Hospital, London, UK.
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Dardari D. An overview of Charcot's neuroarthropathy. J Clin Transl Endocrinol 2020; 22:100239. [PMID: 33251117 PMCID: PMC7677697 DOI: 10.1016/j.jcte.2020.100239] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 10/17/2020] [Accepted: 10/20/2020] [Indexed: 12/30/2022] Open
Abstract
Charcot's neuroarthropathy is a destructive complication of the joints, which is often found in people with diabetes with peripheral neuropathy. Despite the fact that its description was published almost 130 years ago, its pathophysiology, diagnosis, and treatment remain areas that need to be described. Thanks to the use of bone remodelling, new therapeutic classes have emerged, we hope that this review will shed light on the pathology from its discovery through to the current state of knowledge on its classification, diagnosis and treatment methods.
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Affiliation(s)
- Dured Dardari
- Diabetology Department, Centre Hopitalier Sud Francilien, Corbeil Essonnes, France
- LBEPS, Univ Evry, IRBA, Université Paris Saclay, 91025 Evry, France
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Heggie R, Chappell F, Crawford F, Martin A, Gupta S, Hawkins N, Horne M, Leese GP, Lewsey J. Complication rate among people with diabetes at low risk of foot ulceration in Fife, UK: an analysis of routinely collected data. Diabet Med 2020; 37:2116-2123. [PMID: 32510602 DOI: 10.1111/dme.14339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2020] [Indexed: 11/27/2022]
Abstract
AIMS To estimate the rate at which people with diabetes and a low risk of foot ulceration change diabetic foot ulceration risk status over time, and to estimate the rate of ulceration, amputation and death among this population. METHODS We conducted an observational study of 10 421 people with diabetes attending foot screening in an outpatient setting in NHS Fife, UK, using routinely collected data from a national diabetes register, NHS SCI Diabetes. We estimated the proportion of people who changed risk status and the cumulative incidence of ulceration, amputation and death, respectively, among people with diabetes at low risk of diabetic foot ulceration at 2-year follow-up. RESULTS At 2-year follow-up, 5.1% (95% CI 4.7, 5.6) of people with diabetes classified as low risk at their first visit had progressed to moderate risk. The cumulative incidence of ulceration, amputation and death was 0.4% (95% CI 0.3, 0.6), 0.1% (95% CI 0.1, 0.2) and 3.4% (95% CI 3.1, 3.8), respectively. CONCLUSIONS At 2-year follow-up, 5% of people at low risk of diabetic foot ulceration changed clinical risk status and <1% of people experienced foot ulceration or amputation. These findings provide information which will help to inform the current debate regarding optimal foot screening intervals.
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Affiliation(s)
- R Heggie
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow
| | - F Chappell
- Usher Institute, University of Edinburgh, Edinburgh
| | - F Crawford
- School of Medicine, University of St Andrews, Fife
| | - A Martin
- NHS Fife, Queen Margaret Hospital, Dunfermline
| | - S Gupta
- NHS Fife, Queen Margaret Hospital, Dunfermline
| | - N Hawkins
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow
| | - M Horne
- Usher Institute, University of Edinburgh, Edinburgh
| | | | - J Lewsey
- Health Economics and Health Technology Assessment, Institute of Health and Wellbeing, University of Glasgow, Glasgow
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Singhai K, Swami MK, Nebhinani N, Rastogi A, Jude E. Psychological adaptive difficulties and their management during COVID-19 pandemic in people with diabetes mellitus. Diabetes Metab Syndr 2020; 14:1603-1605. [PMID: 32862099 PMCID: PMC7443210 DOI: 10.1016/j.dsx.2020.08.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS People with diabetes have multiple psychosocial issues related to diabetes and its complications and this may be exacerbated during the COVID-19 pandemic. METHODS We reviewed the psychological adaptative difficulties in people with diabetes especially during natural disasters including the prevailing COVID-19 pandemic. RESULTS There are significant concerns regarding worsening of glycemic control, unavailability of appropriate medicines, inaccessibility to health care or acquiring SARS- CoV-2 infection and subsequent poorer outcomes during the COVID-19 pandemic. Although there are some guidance documents for managing diabetes and associated complications during COVID-19 pandemic but very few address the psychological issues in people with diabetes. We discuss the psychological adaptive difficulties and an approach to address the psychosocial concerns in people with diabetes during the COVID-19 pandemic. CONCLUSIONS People with diabetes have significant diabetes distress and psychological adaptive difficulties that is aggravated by the COVID-19 pandemic. An integrated multidisciplinary approach is needed to manage the prevailing psychological issues amongst people with diabetes during the COVID-19 pandemic.
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Affiliation(s)
- Kartik Singhai
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Mukesh Kumar Swami
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Naresh Nebhinani
- Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, 342005, India
| | - Ashu Rastogi
- Department of Endocrinology and Metabolism, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Edward Jude
- Consultant Diabetologist, Diabetes and Endocrinology Department, Tameside and Glossop Integrated Care NHS FT, Ashton under Lyne, Lancs, OL69RW, UK.
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Rastogi A, Hiteshi P, Bhansali A. Improved glycemic control amongst people with long-standing diabetes during COVID-19 lockdown: a prospective, observational, nested cohort study. Int J Diabetes Dev Ctries 2020; 40:476-481. [PMID: 33106739 PMCID: PMC7576977 DOI: 10.1007/s13410-020-00880-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023] Open
Abstract
Background and aims COVID-19 is likely to affect the lives of individuals with type 2 diabetes. However, the effect of COVID-19 lockdown on physical activity and glycemic control in such individuals is not known. We studied the physical activity and glycemic control during lockdown in comparison to pre-lockdown parameters in individuals with long-standing type 2 diabetes. Methods This prospective, observational study includes 2240 people with T2DM regularly attending diabetes clinic prior to lockdown. Glycemic record, HbA1c, and physical activity assessed with Global Physical Activity Questionnaire (GPAQ) as metabolic equivalents (MetS min/week) were obtained during lockdown (minimum duration of 3 months). Results A total of 422 out of 750 participants (nest) responded. The median (IQR) for age was 58 (52 to 64) years, duration of diabetes 11 (6 to 16) years, prevalent foot complications in 59.7%, and atherosclerotic cardiovascular disease in 21.3% of participants. There was a decrease in HbA1c from 7.8% (6.9 to 9.4) prior lockdown to 7.4% (6.6 to8.7) during lockdown [ΔHbA1c − 0.41 ± 0.27% (p = 0.005)] and postprandial blood glucose 200.0 mg/dl (152.0 to 252.0) to 158.0 (140.0 to 200.0) mg/dl (p < 0.001). The physical activity increased during lockdown from a GPAQ score 140 (0.0 to 1260) MetS to 840 (0.0 to 1680) MetS (p = 0.014). The improvement of glycemic control was observed in either gender and independent of the presence of foot complications or increase in physical activity. Conclusions There is an overall improvement of glycemic control during COVID-19 lockdown independent of increase in physical activity in people with long duration of diabetes.
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Affiliation(s)
- Ashu Rastogi
- Department of Endocrinology, Nehru Hospital, PGIMER, Chandigarh, 160012 India
| | - Priya Hiteshi
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, PGIMER, Chandigarh, India
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Rastogi A, Goyal G, Kesavan R, Bal A, Kumar H, Kamath P, Jude EB, Armstrong DG, Bhansali A. Long term outcomes after incident diabetic foot ulcer: Multicenter large cohort prospective study (EDI-FOCUS investigators) epidemiology of diabetic foot complications study: Epidemiology of diabetic foot complications study. Diabetes Res Clin Pract 2020; 162:108113. [PMID: 32165163 DOI: 10.1016/j.diabres.2020.108113] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 02/20/2020] [Accepted: 03/02/2020] [Indexed: 10/24/2022]
Abstract
AIMS This long-term prospective study evaluated limb amputation and mortality after the first neuropathic diabetic foot ulcer (DFU). METHODS A total of 2880 patients with neuropathic DFU (DFU group) and a similar number of patients of diabetes without DFU (nDFU) matched for age and diabetes duration were prospectively assessed at five referral-centers over 14 years. Pre-defined outcome was death during follow-up. Various diabetic co-morbidities and amputation were assessed as mortality predictors. RESULTS Overall, 501 (17.4%) patients in DFU group died compared to 89 (3.1%) (p < 0.01) in nDFU group during a median follow-up of 7(1-14) years. The 5- and 10-year mortality was 22% and 71% in the DFU group with a median survival of 7.72 (7.37-8.08) years compared to 3% (p < 0.01) and 5% (p < 0.01) and survival of 12.6 (10.5-12.7) years (p < 0.001) in nDFU group. 29.3% patients had limb amputations. The mortality risk was independent of glycemic control [OR 1.03 (0.80-1.32; p = 0.83)]. However, diabetes duration > 10 years [OR 1.31(1.02-1.70, p = 0.035)], nephropathy [OR 1.47 (1.04-2.09, p < 0.030)], minor 1.85 (1.40-2.44; p < 0.001) or major amputation 2.96 (2.01-4.34, p < 0.001)] predicted mortality. CONCLUSIONS Every one-in-three individual with neuropathic DFU has amputation and every sixth individual has an early demise. Prevalent nephropathy and incident amputation following DFU predicts mortality.
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Affiliation(s)
- Ashu Rastogi
- Deptt. of Endocrinology, PGIMER, Chandigarh, India.
| | - Ghanshyam Goyal
- ILS Hospital, Salt Lake, Kolkata, India; SVS Marwari Hospital, Amhesrst Street, Kolkata, India
| | | | - Arun Bal
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Harish Kumar
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Priyatham Kamath
- Deptt. of Endocrinology, Amrita Institute of Medical Sciences, Kochi, India
| | - Edward B Jude
- Tameside Hospital, NHS Foundation and Trust, Ashton under Lyne, Manchester, UK
| | - David G Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, USA
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Das L, Bhansali A, Prakash M, Jude EB, Rastogi A. Effect of Methylprednisolone or Zoledronic Acid on Resolution of Active Charcot Neuroarthropathy in Diabetes: A Randomized, Double-Blind, Placebo-Controlled Study. Diabetes Care 2019; 42:e185-e186. [PMID: 31597669 DOI: 10.2337/dc19-1659] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 09/08/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Liza Das
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Mahesh Prakash
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Edward B Jude
- Tameside Hospital NHS Foundation Trust and University of Manchester, Ashton under Lyne, U.K
| | - Ashu Rastogi
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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