Study protocol for a multicentre comparative diagnostic accuracy study of tools to establish the presence and severity of peripheral arterial disease in people with diabetes mellitus: the DM PAD study.

INTRODUCTION: Peripheral arterial disease (PAD) is a key risk factor for cardiovascular disease, foot ulceration and lower limb amputation in people with diabetes. Early diagnosis of PAD can enable optimisation of therapies to manage these risks. Its diagnosis is fundamental, though challenging in the context of diabetes. Although a variety of diagnostic bedside tests are available, there is no agreement as to which is the most accurate in routine clinical practice.The aim of this study is to determine the diagnostic performance of a variety of tests (audible waveform assessment, visual waveform assessment, ankle brachial pressure index (ABPI), exercise ABPI and toe brachial pressure index (TBPI)) for the diagnosis of PAD in people with diabetes as determined by a reference test (CT angiography (CTA) or magnetic resonance angiography (MRA)). In selected centres, we also aim to evaluate the performance of a new point-of-care duplex ultrasound scan (PAD-scan). METHODS AND ANALYSIS: A prospective multicentre diagnostic accuracy study (ClinicalTrials.gov Identifier NCT05009602). We aim to recruit 730 people with diabetes from 18 centres across the UK, covering primary and secondary healthcare. Consenting participants will undergo the tests under investigation. Reference tests (CTA or MRA) will be performed within 6 weeks of the index tests. Imaging will be reported by blinded consultant radiologists at a core imaging lab, using a validated scoring system, which will also be used to categorise PAD severity. The presence of one or more arterial lesions of ≥50% stenosis, or tandem lesions with a combined value of ≥50%, will be used as the threshold for the diagnosis of PAD. The primary outcome measure of diagnostic performance will be test sensitivity. ETHICS AND DISSEMINATION: The study has received approval from the National Research Ethics Service (NRES) (REC reference 21/PR/1221). Results will be disseminated through research presentations and papers. TRIAL REGISTRATION NUMBER: NCT05009602.

Aerial strategies advance volcanic gas measurements at inaccessible, strongly degassing volcanoes.

Volcanic emissions are a critical pathway in Earth's carbon cycle. Here, we show that aerial measurements of volcanic gases using unoccupied aerial systems (UAS) transform our ability to measure and monitor plumes remotely and to constrain global volatile fluxes from volcanoes. Combining multi-scale measurements from ground-based remote sensing, long-range aerial sampling, and satellites, we present comprehensive gas fluxes-3760 ± [600, 310] tons day-1 CO2 and 5150 ± [730, 340] tons day-1 SO2-for a strong yet previously uncharacterized volcanic emitter: Manam, Papua New Guinea. The CO2/ST ratio of 1.07 ± 0.06 suggests a modest slab sediment contribution to the sub-arc mantle. We find that aerial strategies reduce uncertainties associated with ground-based remote sensing of SO2 flux and enable near-real-time measurements of plume chemistry and carbon isotope composition. Our data emphasize the need to account for time averaging of temporal variability in volcanic gas emissions in global flux estimates.

Developing a foot ulcer risk model: what is needed to do this in a real-world primary care setting?

AIM: To determine how routinely collected data can inform a risk model to predict de novo foot ulcer presentation in the primary care setting. METHODS: Data were available on 15 727 individuals without foot ulcers and 1125 individuals with new foot ulcers over a 12-year follow-up in UK primary care. We examined known risk factors and added putative risk factors in our logistic model. RESULTS: People with foot ulcers were 4.2 years older (95% CI 3.1-5.2) than those without, and had higher HbA1c % (mean 7.9 ± 1.9 vs 7.5 ± 1.7) / HbA1c mmol/mol (63 ± 21 vs 59 ± 19) (p<0.0001) concentration [+0.45 (95% CI 0.33-0.56), creatinine level [+6.9 µmol/L (95% CI 4.1-9.8)] and Townsend score [+0.055 (95% CI 0.033-0.077)]. Absence of monofilament sensation was more common in people with foot ulcers (28% vs 21%; P<0.0001), as was absence of foot pulses (6.4% vs 4.8%; P=0.017). There was no difference between people with or without foot ulcers in smoking status, gender, history of stroke or foot deformity, although foot deformity was extremely rare (0.4% in people with foot ulcers, 0.6% in people without foot ulcers). Combining risk factors in a single logistic regression model gave modest predictive power, with an area under the receiver-operating characteristic curve of 0.65 (95% CI 0.62-0.67). The prevalence of ulceration in the bottom decile of risk was 1.8% and in the top decile it was 13.4% (compared with an overall prevalence of 6.5%); thus, the presence of all six risk factors gave a relative risk of 7.4 for development of a foot ulcer over 12 years. CONCLUSION: We have made some progress towards defining a variable set that can be used to create a foot ulcer prediction model. More accurate determination of foot deformity/pedal circulation in primary care may improve the predictive value of such a future risk model, as will identification of additional risk variables.

Novel Semiquantitative Bone Marrow Oedema Score and Fracture Score for the Magnetic Resonance Imaging Assessment of the Active Charcot Foot in Diabetes.

There are no accepted methods to grade bone marrow oedema (BMO) and fracture on magnetic resonance imaging (MRI) scans in Charcot osteoarthropathy. The aim was to devise semiquantitative BMO and fracture scores on foot and ankle MRI scans in diabetic patients with active osteoarthropathy and to assess the agreement in using these scores. Three radiologists assessed 45 scans (Siemens Avanto 1.5T, dedicated foot and ankle coil) and scored independently twenty-two bones (proximal phalanges, medial and lateral sesamoids, metatarsals, tarsals, distal tibial plafond, and medial and lateral malleoli) for BMO (0-no oedema, 1-oedema < 50% of bone volume, and 2-oedema > 50% of bone volume) and fracture (0-no fracture, 1-fracture, and 2-collapse/fragmentation). Interobserver agreement and intraobserver agreement were measured using multilevel modelling and intraclass correlation (ICC). The interobserver agreement for the total BMO and fracture scores was very good (ICC = 0.83, 95% confidence intervals (CI) 0.76, 0.91) and good (ICC = 0.62; 95% CI 0.48, 0.76), respectively. The intraobserver agreement for the total BMO and fracture scores was good (ICC = 0.78, 95% CI 0.6, 0.95) and fair to moderate (ICC = 0.44; 95% CI 0.14, 0.74), respectively. The proposed BMO and fracture scores are reliable and can be used to grade the extent of bone damage in the active Charcot foot.

Acute Charcot neuro-osteoarthropathy.

Charcot neuro-osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Charcot foot when the X ray is still negative (stage 0 or incipient Charcot foot). Recent advances in imaging modalities have enabled the detection of initial signs of inflammation and underlying bone damage before overt bone and joint destruction has occurred. Casting therapy remains the mainstay of medical therapy of acute CN. If timely instituted, offloading can arrest disease activity and prevent foot deformity. In cases with severe deformity, modern surgical techniques can correct the unstable deformity for improved functional outcome and limb survival. Emerging new studies into the cellular mechanisms of severe bone destruction have furthered our understanding of the mechanisms of pathological bone and joint destruction in CN. It is hoped that these studies may provide a scientific basis for new interventions with biological agents.

Growth promoting hormonal implant pellets coated with a polymeric, porous film promote weight gain by grazing beef heifers and steers for up to 200 days.

Two studies evaluated growth promoting effects of implant pellets (IP), each containing 3.5 mg estradiol benzoate (EB) and 25 mg trenbolone acetate (TBA), to which a polymeric, porous coating was applied. Trial 1 evaluated performance of heifers (n = 70/treatment, initial BW = 188 ± 2.2 kg) and steers (n = 70/treatment, initial BW = 194 ± 2.2 kg) implanted subcutaneously in the ear with 0 (SC), 2 (2IP), 4 (4IP), or 6 (6IP) pellets that delivered EB/TBA (mg/mg) doses of 0/0, 7/50, 14/100, and 21/150, respectively, over grazing periods of 202 d (heifers) or 203 d (steers). Animals received experimental treatments on d 0 and over the grazing period were managed as single groups by sex in a rotational grazing system. When pasture forage availability became limited, cattle were supplemented with preserved forage but not concentrate supplements. Weight gains by heifers treated with 2IP, 4IP, and 6IP were greater (P < 0.05) than SC heifers but not different from each other. Weight gains by steers treated with 2IP, 4IP, and 6IP were greater than SC steers (P < 0.05), and ADG by steers treated with 6IP was greater (P < 0.05) than steers given 2IP or 4IP. Trial 2 was a multisite grazing study performed with heifers and steers to compare ADG after treatment with one 6-pellet, coated implant delivering 21 mg EB and 150 mg TBA (6IP) to sham treated negative controls (SC) over a grazing period of at least 200 d. A completely random design was used at each site, with the goal to treat 70 cattle per site, treatment, and sex; data were pooled across sites. Heifers (n = 558, initial BW = 229 ± 16 kg) and steers (n = 555, initial BW = 235 ± 20 kg) grazed in rotational programs consistent with regional practices for an average of 202 d. When necessary, cattle were supplemented with preserved forage, but no concentrate supplements were fed. Over 202 d, ADG by heifers treated with 6IP was 11.3% greater (P = 0.0035) than SC heifers (0.64 ± 0.06 kg/d), and ADG by steers treated with 6IP was 17.2% greater (P = 0.0054) than SC steers (0.66 ± 0.08 kg/d). In neither study was there evidence that concurrent therapeutic treatments or abnormal health observations were influenced by experimental treatments. These studies demonstrated that a 6-pellet implant with a polymeric, porous coating that delivers 21 mg EB and 150 mg TBA improved ADG by grazing heifers and steers for at least 200 d compared to sham-implanted negative controls.

Outcome of one-stage correction of deformities of the ankle and hindfoot and fusion in Charcot neuroarthropathy using a retrograde intramedullary hindfoot arthrodesis nail.

We report the outcomes of 20 patients (12 men, 8 women, 21 feet) with Charcot neuro-arthropathy who underwent correction of deformities of the ankle and hindfoot using retrograde intramedullary nail arthrodesis. The mean age of the patients was 62.6 years (46 to 83); their mean BMI was 32.7 (15 to 47) and their median American Society of Anaesthetists score was 3 (2 to 4). All presented with severe deformities and 15 had chronic ulceration. All were treated with reconstructive surgery and seven underwent simultaneous midfoot fusion using a bolt, locking plate or a combination of both. At a mean follow-up of 26 months (8 to 54), limb salvage was achieved in all patients and 12 patients (80%) with ulceration achieved healing and all but one patient regained independent mobilisation. There was failure of fixation with a broken nail requiring revision surgery in one patient. Migration of distal locking screws occurred only when standard screws had been used but not with hydroxyapatite-coated screws. The mean American Academy of Orthopaedic Surgeons Foot and Ankle (AAOS-FAO) score improved from 50.7 (17 to 88) to 65.2 (22 to 88), (p = 0.015). The mean Short Form (SF)-36 Health Survey Physical Component Score improved from 25.2 (16.4 to 42.8) to 29.8 (17.7 to 44.2), (p = 0.003) and the mean Euroqol EQ­5D­5L score improved from 0.63 (0.51 to 0.78) to 0.67 (0.57 to 0.84), (p = 0.012). Single-stage correction of deformity using an intramedullary hindfoot arthrodesis nail is a good form of treatment for patients with severe Charcot hindfoot deformity, ulceration and instability provided a multidisciplinary care plan is delivered.

Inflammatory and bone turnover markers in a cross-sectional and prospective study of acute Charcot osteoarthropathy.

AIMS: To assess markers of inflammation and bone turnover at presentation and at resolution of Charcot osteoarthropathy. METHODS: We measured serum inflammatory and bone turnover markers in a cross-sectional study of 35 people with Charcot osteoarthropathy, together with 34 people with diabetes and 12 people without diabetes. In addition, a prospective study of the subjects with Charcot osteoarthropathy was conducted until clinical resolution. RESULTS: At presentation, C-reactive protein (P = 0.007), tumour necrosis factor-α (P = 0.010) and interleukin-6 (P = 0.002), but not interleukin-1ß, (P = 0.254) were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. Serum C-terminal telopeptide (P = 0.004), bone alkaline phosphatase (P = 0.006) and osteoprotegerin (P < 0.001), but not tartrate-resistant acid phosphatase (P = 0.126) and soluble receptor activator of nuclear factor-κß ligand (P = 0.915), were significantly higher in people with Charcot osteoarthropathy than in people with and without diabetes. At follow-up it was found that tumour necrosis factor-α (P = 0.012) and interleukin-6 (P = 0.003), but not C-reactive protein (P = 0.101), interleukin-1ß (P = 0.457), C-terminal telopeptide (P = 0.743), bone alkaline phosphatase (P = 0.193), tartrate-resistant acid phosphatase (P = 0.856), osteoprotegerin (P = 0.372) or soluble receptor activator of nuclear factor-kß ligand (P = 0.889), had significantly decreased between presentation and the 3 months of casting therapy time point, and all analytes remained unchanged from 3 months of casting therapy until resolution. In people with Charcot osteoarthropathy, there was a positive correlation between interleukin-6 and C-terminal telopeptide (P = 0.028) and tumour necrosis factor-α and C-terminal telopeptide (P = 0.013) only at presentation. CONCLUSIONS: At the onset of acute Charcot foot, serum concentrations of tumour necrosis factor-α and interleukin-6 were elevated; however, there was a significant reduction in these markers at resolution and these markers may be useful in the assessment of disease activity.

Facts that every vascular surgeon needs to know about the diabetic foot.

This paper describes important aspects of the diabetic foot which the vascular surgeon needs to understand to efficiently manage the diabetic foot. Firstly, it emphasises the three main pathologies which come together in the diabetic foot, namely neuropathy, ischemia and immunopathy, the latter predisposing to infection. As a result of neuropathy, the signs and symptoms of tissue breakdown, infection and ischemia may be minimal. Nevertheless the pathology emanating from such clinical events proceeds rapidly without the body being aware of it and the end stage of tissue death and necrosis is quickly reached. It is important to have a prompt system of evaluation and intervention to prevent the rapid progression to necrosis. Thus, secondly, the paper describes a simple rapid assessment of the diabetic foot, which comprises inspection, palpation and sensory testing and leads on to a modern classification and staging of the diabetic foot. This classifies six subdivisions of the diabetic foot: foot with neuropathic ulceration, Charcot foot, neuroischemic foot, critically ischemic foot, acutely ischemic foot and renal ischemic foot and six stages in the natural history of each of these subdivisions: normal foot, high risk foot, ulcerated foot, infected foot, necrotic foot and unsalvageable foot. Thirdly, it describes modern management of the diabetic foot, emphazising wound care and revascularization within the context of a multidisciplinary care team that provides integrated care focused in a diabetic foot clinic, to which patients with diabetes should have easy and rapid access. Members of the team include podiatrist, nurse, orthotist, physician, radiologist and surgeons.

Effects of estradiol benzoate and trenbolone acetate, alone or in combination at dose levels present in Synovex Choice, on performance by feedlot heifers.

Trials were conducted with beef heifers at 4 sites to evaluate feedlot performance and carcass characteristics in response to implants containing 14 mg estradiol benzoate and 100 mg trenbolone acetate (EB/TBA; Synovex Choice, Zoetis LLC, New York, NY), 14 mg estradiol benzoate (EB), 100 mg trenbolone acetate (TBA), or a sham-implanted control (SC). The study design at each site was a randomized complete block with 12 blocks and 4 treatments. Blocks of cattle at each site were harvested in commercial abattoirs when masked personnel estimated at least 60% of animals would yield carcasses with USDA quality grades of Choice or Prime. Data were pooled across sites for statistical analysis. Initial BW averaged 374 kg, and days on feed ranged from 98 to 126 d (mean 112 d). Heifers implanted with EB/TBA, EB, and TBA had greater ADG and G:F (P < 0.05) than SC; ADG and G:F were greater for EB/TBA than EB or TBA (P < 0.05). Heifers treated with TBA had greater G:F than EB (P < 0.05). Feed intake was not affected by treatments. Mean HCW and LM area for EB/TBA were greater than for other treatments (P < 0.05). Mean HCW for TBA was greater than SC (P < 0.05) but not different from EB. Mean LM area for EB and TBA were greater than SC (P < 0.05) but not different from each other. There were no treatment differences (P > 0.05) for KPH, 12th-rib fat thickness, or yield grade. Dressing percent was greater for EB/TBA than SC (P < 0.05) but not different from EB or TBA. Marbling score was decreased by EB/TBA (P < 0.05) compared with other treatments, but no other differences were noted. Despite the effect of EB/TBA on marbling scores, there were no significant (P > 0.05) treatment differences on proportions of carcasses with quality grades ≥ Choice vs. < Choice. With respect to ADG and G:F, implants containing EB, TBA, or EB/TBA produced improved responses over SC. Furthermore, EB/TBA induced greater ADG and G:F responses than EB and TBA. Results confirmed that EB and TBA have additive effects, as evidenced by the observation that calves implanted with EB/TBA had significantly greater ADG and G:F than heifers implanted with either EB or TBA alone or compared with SC heifers.

Synovex Plus implants coated with a polymeric, porous film improve performance of beef steers and heifers fed in confinement for up to 200 days.

Synovex Plus (SP) is a product that delivers 28 mg of estradiol benzoate (EB) and 200 mg of trenbolone acetate (TBA). We studied the impact of a polymeric, porous coating on SP implants (CSP) to prolong release of EB and TBA, and stimulate feedlot performance of feedlot cattle for an extended period. In an explant study, 30 steers were implanted with SP in one ear and CSP in the contralateral ear. Cattle (n = 6/d) were necropsied 40, 81, 120, 160, and 200 d after treatment, and remaining EB and TBA were quantified. Linear regression of EB and TBA remaining as a function of time for each treatment were computed. Rates of EB and TBA depletion from SP were -0.1980 (r(2) = 0.9994) and -1.7073 mg/d (r(2) = 0.9644), respectively, and for CSP rates of EB and TBA depletion were -0.1049 (r(2) = 0.9123) and -0.9466 mg/d (r(2) = 0.9297), respectively. The effect of treatment on depletion rates of each analyte were significant (P < 0.05). Data also showed EB and TBA were delivered from CSP at least 200 d but were delivered from SP about 120 d. Multisite trials with beef-type steers (4 sites) and heifers (4 sites) evaluated feedlot performance and carcass characteristics in response to a CSP implant or when sham implanted (SC). A randomized complete block design with 9 blocks and 2 treatments was used per site within animal gender. Across sites, steers (n = 342, BW = 297 kg) were fed finishing rations for 190 to 202 d (mean 198 d) and heifers (n = 342, BW = 289 kg) were fed finishing rations for 191 to 201 d (mean 198 d). Cattle were harvested and carcasses evaluated. Data were pooled across sites within gender for statistical analysis. Steers and heifers treated with CSP yielded greater (P ≤ 0.003) ADG, DMI, and G:F than SC steers and heifers. Mean BW differences between CSP and SC continued to increase throughout the study, indicating CSP stimulated growth of steers and heifers for 198 d. Mean carcass weights of CSP steers (P = 0.005) and heifers (P = 0.004) were greater than those of SP steers and heifers by 26.2 and 20.6 kg, respectively. The LM area was larger (P < 0.001) in CSP steers and heifers than SC cattle. Marbling decreased with CSP treatment (P ≤ 0.031), which caused reductions (P ≤ 0.006) in proportions of carcasses grading Prime or Choice. Evidence from these studies showed that a single administration of CSP increased feedlot cattle performance for at least 198 d, compared with SC, and may reduce the need to reimplant cattle.

Body of knowledge around the diabetic foot and limb salvage.

Body of knowledge around the There has been considerable progress in the care of the diabetic foot over the last three decades. The development of multidisciplinary diabetic foot care has provided specialist management of the neuropathic foot and the neuroischemic foot. Significant progress has been made in the treatment of both of these entities. The crucial aspects of therapy are the treatment of infection, relief of ischemia and promotion of wound healing. The multidisciplinary, hospital-based diabetic foot clinic has proved to be a successful way of reducing amputations and improving outcomes. This review summarises the major advances in the care of the diabetic neuroischaemic foot. These have greatly improved the outlook and prognosis for diabetic patients with ischemic foot problems.

Osteoprotegerin gene polymorphism in diabetic Charcot neuroarthropathy.

AIMS: Recently, an association between two polymorphisms (1181G>C and 245T>G) of the osteoprotegerin (OPG) gene and diabetic Charcot neuroarthropathy was suggested on the basis of studies of a limited number of samples derived from subjects from one geographical region (Italy). The aim of this study was to assess the presence of various osteoprotegerin gene polymorphisms in patients with diabetes and Charcot neuroarthropathy compared with subjects with diabetic neuropathy but no Charcot foot and healthy controls from another geographical region (Poland). METHODS: DNA was isolated from 54 patients with Charcot neuroarthropathy, 35 subjects with diabetic neuropathy but no Charcot foot, and 95 healthy controls to evaluate OPG gene polymorphisms and their possible contribution to the development of Charcot neuroarthropathy. RESULTS: Statistically significant differences between the group of subjects with neuropathy but no Charcot neuroarthropathy and the control group were found for 1217C>T, 950T>C and 245T>G polymorphisms, between the group of patients with Charcot neuroarthropathy and the control group for 1181G>C and 950T>C polymorphisms, and between the group of subjects with neuropathy but no Charcot neuroarthropathy and the group of patients with Charcot neuroarthropathy for 1217C>T and 245T>G polymorphisms. CONCLUSION: We suggest that genetic factors, particularly OPG gene polymorphisms, may play a role in the development of diabetic Charcot neuroarthropathy.

Audit of acute Charcot's disease in the UK: the CDUK study.

AIMS/HYPOTHESIS: We studied factors associated with the development and resolution of acute Charcot foot using a web-based observational study. METHODS: Clinicians managing cases of acute Charcot foot in the UK and Ireland between June 2005 and February 2007 were invited to register anonymised details on a secure website. RESULTS: A total of 288 cases (age 57.0 ± 11.3 years [mean ± SD]; 71.2% male) were registered from 76 centres. Of these, 36% of patients recalled an episode of relevant trauma in the preceding 6 months, while 12% had had surgery to the affected foot. In 101 (35%) cases, ulceration was present at registration and 20% of these had osteomyelitis. Non-removable off-loading devices were used at presentation in 35.4% of cases, with removable off-loading used in 50%. Data on resolution were available for 219 patients. The median time to resolution was 9 months in patients whose initial management included the use of non-removable off-loading, compared with 12 months in the remainder (p = 0.001). Bisphosphonates were administered intravenously in 25.4% and orally in 19.4% of cases. The median time to resolution in patients who received bisphosphonates was 12 months and was longer than in those who did not (10 months, p = 0.005). CONCLUSIONS/INTERPRETATION: The median time to resolution was longer than in earlier series. Although limited by being observational and non-randomised, these data suggest that the use of non-removable off-loading at presentation may shorten the time to resolution. They provide no evidence to indicate that the use of bisphosphonates is beneficial.

Five-year follow-up of a cohort of people with their first diabetic foot ulcer: the persistent effect of depression on mortality.

AIMS/HYPOTHESIS: Depressive disorders are associated with mortality within 18 months of presentation of diabetic foot ulcers (DFU). The main aim of this study was to determine whether depressive disorder is still associated with increased mortality in people with their first foot ulcer at 5 years. METHODS: This is a 5-year follow-up of a cohort of 253 patients presenting with their first DFU. At baseline, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) 2.1 was used to define those who met DSM-IV (Diagnostic and Statistical Manual 4th edition) criteria for depressive disorder. Cox regression analysis controlled for potential covariates: age, sex, marital status, socioeconomic status, smoking, mean HbA(1c), diabetes complications and ulcer severity. The main outcome was mortality at 5 years. RESULTS: The prevalence of DSM-IV depressive disorder at baseline was 32.2% (n = 82). There were 92 (36.4%) deaths over the 5 years of follow-up. In the Cox regression (n = 246), after adjusting for covariates, baseline DSM-IV depressive disorder was significantly associated with a twofold increased risk of mortality for any depressive episode (HR 2.09, 95% CI 1.34, 3.25), minor (HR 1.93, 95% CI 1.00, 3.74) or major depressive disorders (HR 2.18, 95% CI 1.31, 3.65), compared with patients who were not depressed. CONCLUSIONS/INTERPRETATION: Depression is associated with a persistent twofold increased risk of mortality in people with their first DFU at 5 years.

Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study.

AIMS/HYPOTHESIS: The aim of the present study was to investigate resource utilisation and associated costs in patients with diabetic foot ulcers and to analyse differences in resource utilisation between individuals with or without peripheral arterial disease (PAD) and/or infection. METHODS: Data on resource utilisation were collected prospectively in a European multicentre study. Data on 1,088 patients were available for the analysis of resource use, and data on 821 patients were included in the costing analysis. Costs were calculated for each patient by multiplying the country-specific direct and indirect unit costs by the number of resources used from inclusion into the study up to a defined endpoint. Country-specific costs were converted into purchasing power standards. RESULTS: Resource use and costs varied between outcome groups and between disease severity groups. The highest costs per patient were for hospitalisation, antibiotics, amputations and other surgery. All types of resource utilisation and costs increased with the severity of disease. The total cost per patient was more than four times higher for patients with infection and PAD at inclusion than for patients in the least severe group, who had neither. CONCLUSIONS/INTERPRETATION: Important differences in resource use and costs were found between different patient groups. The costs are highest for individuals with both peripheral arterial disease and infection, and these are mainly related to substantial costs for hospitalisation. In view of the magnitude of the costs associated with in-hospital stay, reducing the number and duration of hospital admissions seems an attractive option to decrease costs in diabetic foot disease.

The association between alcohol consumption and risk of COPD exacerbation in a veteran population.

BACKGROUND: Alcohol has been associated with COPD-related mortality but has not yet been demonstrated to be an independent risk factor for COPD exacerbation. Our objective was to evaluate the association between alcohol consumption and the subsequent risk of COPD exacerbation. METHODS: A prospective cohort study of general medicine outpatients seen at one of seven Veterans Affairs (VA) medical centers who returned health screening questionnaires. Three screening questionnaires, AUDIT-C (0 to 12 points), CAGE (0 to 4 points), and a single item about the frequency of drinking six or more drinks on an occasion (binge drinking), were used to classify alcohol consumption. The main outcome, COPD exacerbation, was based on primary VA discharge diagnosis (International Classification of Diseases, Ninth Revision) or outpatient diagnosis of COPD accompanied by prescriptions for either antibiotics or prednisone within 2 days. RESULTS: Among the 30,503 patients followed up for a median of 3.35 years, those patients with AUDIT-C scores > or = 6, CAGE scores > or = 2, or who reported binge drinking at least weekly were at an increased risk of COPD exacerbation in age-adjusted analysis. Adjusted hazard ratios were 1.4 (95% confidence interval [CI], 1.1 to 1.7) for AUDIT-C score > or = 6, 1.4 (95% CI, 1.3 to 1.5) for CAGE score > or = 2, and 1.6 (95% CI, 1.2 to 2.2) for those who reported binge drinking daily or almost daily. However, with adjustment for measures of tobacco use, the association between alcohol consumption and increased risk of COPD exacerbation was no longer evident. CONCLUSIONS: Alcohol consumption, whether quantified by AUDIT-C, CAGE score, or binge drinking, was not associated with an increased risk of COPD exacerbation independent of tobacco use.

Increased osteoclastic activity in acute Charcot's osteoarthropathy: the role of receptor activator of nuclear factor-kappaB ligand.

AIMS/HYPOTHESIS: Our aims were to compare osteoclastic activity between patients with acute Charcot's osteoarthropathy and diabetic and healthy controls, and to determine the effect of the receptor activator of nuclear factor-kappaB ligand (RANKL) and its decoy receptor osteoprotegerin (OPG). METHODS: Peripheral blood monocytes isolated from nine diabetic Charcot patients, eight diabetic control and eight healthy control participants were cultured in the presence of macrophage-colony stimulating factor (M-CSF) alone, M-CSF and RANKL, and also M-CSF and RANKL with excess concentrations of OPG. Osteoclast formation was assessed by expression of tartrate-resistant acid phosphatase on glass coverslips and resorption on dentine slices. RESULTS: In cultures with M-CSF, there was a significant increase in osteoclast formation in Charcot patients compared with healthy and diabetic control participants (p=0.008). A significant increase in bone resorption was also seen in the former, compared with healthy and diabetic control participants (p<0.0001). The addition of RANKL to the cultures with M-CSF led to marked increase in osteoclastic resorption in Charcot (from 0.264+/-0.06% to 41.6+/-8.1%, p<0.0001) and diabetic control (0.000+/-0.00% to 14.2+/-16.5%, p<0.0001) patients, and also in healthy control participants (0.004+/-0.01% to 10.5+/-1.9%, p<0.0001). Although the addition of OPG to cultures with M-CSF and RANKL led to a marked reduction of resorption in Charcot patients (41.6+/-8.1% to 5.9+/-2.4%, p=0.001), this suppression was not as complete as in diabetic control patients (14.2+/-16.5% to 0.45+/-0.31%, p=0.001) and in healthy control participants (from 10.5+/-1.9% to 0.00+/-0.00%, p<0.0001). CONCLUSIONS/INTERPRETATION: These results indicate that RANKL-mediated osteoclastic resorption occurs in acute Charcot's osteoarthropathy. However, the incomplete inhibition of RANKL after addition of OPG also suggests the existence of a RANKL-independent pathway.

Development of transfection and high-producer screening protocols for the CHOK1SV cell system.

To date, the FDA has approved 18 monoclonal antibody (MAb) therapeutic drugs with targets ranging from asthma and rheumatoid arthritis to leukemia. Many of these approved products are produced in Chinese hamster ovary cells (CHO) making CHO a significant and relevant host system. We studied the applicability of CHOK1SV cells as a potential host cell line for MAb production in terms of timelines, achievable titers, transfectant stability, and reproducibility. CHOK1SV, developed by Lonza Biologics, is a suspension, protein-free-adapted CHOK1-derivative utilizing the glutamine synthetase (GS) gene expression system. CHOK1SV expresses the GS enzyme endogenously; thus, positive transfectants were obtained under the dual selection of methionine sulfoximine (MSX) and glutamine-free media. We examined outgrowth efficiencies, specific productivities, and achievable batch titers of three different IgG MAbs transfected into CHOK1SV. Reducing the MSX concentration in the initial selection medium resulted in a decreased incubation time required for transfectant colonies to appear. Specific productivities of "high-producers" ranged between 11 and 49 pg/c/d with batch titers ranging from 105 to 519 mg/L. Transfectant stability and the effects of MSX also were investigated, which indicated that the addition of MSX was necessary to maintain stable MAb production. Cell growth was stable regardless of MSX concentration.