Amputations and foot-related hospitalisations disproportionately affect dialysis patients.

Patients with diabetes have increased risk for foot ulcers, amputations and hospitalisations. We evaluated a closed cohort of patients with diabetes and established risk factors in two high risk groups: (i) dialysis patients and (ii) patients with previous foot ulceration. We used claims data for diabetes (ICD-9 250.X), ulceration (ICD-9 707·10, 707·14 and 707·15) and dialysis (CPT 90935-90937) from the Scott and White Health Plan to identify 150 consecutive patients with diabetes on dialysis (dialysis group) and 150 patients with a history of foot ulceration (ulcer history group). We verified these diagnoses by manually reviewing corresponding electronic medical records. Each patient was provided 30 months follow-up period. The incidence of foot ulcers was the same in dialysis patients and patients with an ulcer history (210 per 1000 person-years). The amputation incidence rate was higher in dialysis patients (58·0 versus 13·3, P < 0·001). Hospital admission was common in both study groups. The incidence of hospitalisation was higher in the ulcer history group (477·3 versus 381·3, P < 0·001); however, there were more foot-related hospital admissions in the dialysis group (32·9% versus 14·0%, P < 0·001) during the 30-month evaluation period. The incidence of ulcers, amputations and all-cause hospitalisations is high in persons with diabetes and a history of foot ulceration or on dialysis treatment; however, those on dialysis treatment have disproportionately higher rates of foot-related hospitalisations. Intervention strategies to reduce the burden of diabetic foot disease must target dialysis patients as a high-risk group.

RANKL-OPG and RAGE modulation in vascular calcification and diabetes: novel targets for therapy.

Type 2 diabetes is associated with increased cardiovascular morbidity and mortality and early vascular ageing. This takes the form of atherosclerosis, with progressive vascular calcification being a major complication in the pathogenesis of this disease. Current research and drug targets in diabetes have hitherto focused on atherosclerosis, but vascular calcification is now recognised as an independent predictor of cardiovascular morbidity and mortality. An emerging regulatory pathway for vascular calcification in diabetes involves the receptor activator for nuclear factor κB (RANK), RANK ligand (RANKL) and osteoprotegerin (OPG). Important novel biomarkers of calcification are related to levels of glycation and inflammation in diabetes. Several therapeutic strategies could have advantageous effects on the vasculature in patients with diabetes, including targeting the RANKL and receptor for AGE (RAGE) signalling pathways, since there has been little success-at least in macrovascular outcomes-with conventional glucose-lowering therapy. There is substantial and relevant clinical and basic science evidence to suggest that modulating RANKL-RANK-OPG signalling, RAGE signalling and the associated proinflammatory milieu alters the natural course of cardiovascular complications and outcomes in people with diabetes. However, further research is critically needed to understand the precise mechanisms underpinning these pathways, in order to translate the anti-calcification strategies into patient benefit.

Functional availability of medical oxygen for the management of hypoxaemia in Cameroon: A nationwide facility-based cross-sectional survey.

Background: Medical oxygen is essential for managing hypoxaemia, which has a multifactorial origin, including acute and chronic lung diseases such as pneumonia, asthma, and severe malaria. The coronavirus disease 2019 (COVID-19) revealed substantial gaps in the availability and accessibility of safe medical oxygen, especially in low- and middle-income countries (LMICs). This study aimed to assess the availability and sources, as well as the barriers to the availability of functional medical oxygen in hospitals in Cameroon. Methods: This was a nationwide cross-sectional descriptive study conducted from 26 March to 1 June 2021. Using a convenient sampling technique, we sampled accredited public and private COVID-19 treatment centres in all ten regions in Cameroon. Representatives from the selected hospitals were provided with a pre-designed questionnaire assessing the availability, type, and state of medical oxygen in their facilities. All analyses were performed using R. Results: In total, 114 hospitals were included in this study, with functional medical oxygen available in 65% (74/114) of the hospitals. About 85% (23/27) of the reference hospitals and only 59% (51/87) of the district hospitals had available functional medical oxygen. Compared to district hospitals, reference hospitals were more likely to have central oxygen units (reference vs. district: 10 vs. 0%), oxygen cylinders (74 vs. 42%), and oxygen concentrators (79 vs. 51%). The most common barriers to the availability of medical oxygen were inadequate oxygen supply to meet needs (district vs. reference hospitals: 55 vs. 30%), long delays in oxygen bottle refills (51 vs. 49%), and long distances from oxygen suppliers (57 vs. 49%). Conclusions: The availability of medical oxygen in hospitals in Cameroon is suboptimal and more limited in districts compared to reference hospitals. The cost of medical oxygen, delays related to refills and supplies, and long distances from medical sources were the most common barriers to availability in Cameroon.

Comparing knowledge, attitudes and practices regarding COVID-19 amongst Cameroonians living in urban versus rural areas.

INTRODUCTION: adherence to preventive measures to curb the spread of COVID-19 depends on the people´s knowledge, attitudes and practices (KAP) towards COVID-19. Living in rural areas may be associated with poor KAP towards COVID-19. This study compares the KAP regarding COVID-19 of people living in rural and urban areas in Cameroon. METHODS: this was a comparative cross-sectional study, using data obtained through an online survey of 1,345 Cameroonians amongst which were 828 urban and 517 rural dwellers. The survey questionnaire consisted of; demographic characteristics, 10 questions on Knowledge, 4 on attitudes and 3 on practices. Data was analyzed using SPSS version 25. RESULTS: overall, about two-thirds of participants had correct knowledge of COVID-19. The mean knowledge score for urban dwellers was about twice that of rural dwellers (15.77 ± 5.25 vs 8.86 ± 7.24 respectively, p < 0.001). Furthermore, when compared to people who live in urban areas, rural inhabitants are less optimistic about COVID-19 pandemic in Cameroon (OR = 3.43, P<0.001), less likely to accept a trial vaccine for COVID-19 (OR = 1.14, P<0.05), less likely to avoid going to crowded places (OR = 7.42, P<0.01), less likely to wear face mask outdoor (OR = 11.84, P<0,001), and less likely to practice hand hygiene (OR = 1.13, P<0.05). CONCLUSION: our findings suggest a big gap in COVID-19 related knowledge, attitudes, and practices between rural and urban inhabitants in Cameroon. This highlights the need for increase sensitization of Cameroonians, especially rural dwellers on COVID-19 related knowledge, attitudes and appropriate practices.

Diabetic foot disease in people with advanced nephropathy and those on renal dialysis.

Among the spectrum of risk for diabetic foot disease conferred by chronic kidney disease (CKD), end-stage renal disease (ESRD) has emerged as a novel independent risk factor. Apart from the classical triad of neuropathy, infection, and peripheral arterial disease that operate in these individuals, the risk is further compounded by inadequate foot self-care by patients and by dialysis centers not providing onsite foot care, as medical priorities are diverted to the dialysis itself. Consequently, the burden of diabetic foot disease has increased in the CKD and ESRD population as exemplified by high ulceration, amputation, and foot-related mortality rates. Current guidelines on foot care in diabetes should recognize advanced CKD and ESRD/dialysis as a separate risk factor for foot disease to alert professionals and highlight the opportunity for prevention. Recent studies have demonstrated improved foot outcomes when chiropody programs are instituted within dialysis units.

Developing the agenda for European Union collaboration on non-communicable diseases research in Sub-Saharan Africa.

BACKGROUND: Health research is increasing in Africa, but most resources are currently chanelled towards infectious diseases and health system development. While infectious diseases remain a heavy burden for some African countries, non-communicable diseases (NCDs) account for more than half of all deaths globally and WHO predicts 27% increase in NCDs in Africa over the next decade. We present findings of a European-Africa consultation on the research agenda for NCDs. METHODS: A workshop was held in Yaoundé, Cameroon, organized by the Network for the Coordination and Advancement of Sub-Saharan Africa-European Union Science and Technology Cooperation (CAAST-Net). Drawing on initial presentations, a small expert group from academic, clinical, public-health and administrative positions considered research needs in Africa for cardiovascular disease, cancer and diabetes. RESULTS: Research in Africa can draw from different environmental and genetic characteristics to understand the causes of the disease, while economic and social factors are important in developing relevant strategies for prevention and treatment. The suggested research needs include better methods for description and recording, clinical studies, understanding cultural impacts, prevention strategies, and the integrated organisation of care. Specific fields proposed for research are listed. CONCLUSIONS: Our paper contributes to transparency in the process of priority-setting for health research in Africa. Although the European Union Seventh Framework Research Programme prioritises biomedical and clinical research, research for Africa should also address broader social and cultural research and intervention research for greatest impact. Research policy leaders in Africa must engage national governments and international agencies as well as service providers and research communities. None can act effectively alone. Bringing together the different stakeholders, and feeding the results through to the European Union research programme is a valuable contribution of CAAST-Net.

Emerging evidence for neuroischemic diabetic foot ulcers: model of care and how to adapt practice.

Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.

The Diabetic Foot in 2008: an update from the 12th Malvern Diabetic Foot Meeting.

Every 2 years, Great Malvern, a small town in the county of Worcestershire, England, is home to the oldest international meeting on the diabetic foot that started about a quarter of a century ago. The 12th Malvern Diabetic Foot meeting, held from May 14 to 16, 2008, was attended by delegates and speakers from 5 continents and more than 25 countries. Strategic clinical specialties involved in diabetic foot management were prominently represented. Virtually every aspect of diabetic foot care was covered during this 3-day meeting through invited plenary lectures, practical interactive workshops, and scientific oral presentations. The evidence base underpinning current foot care was critically appraised, and topical issues on the diabetic foot were revisited. This review puts together key messages emanating from the meeting. All effort has been made to highlight clearly where consensus exists as well as outline areas where controversy persists.

Calcium supplementation and cardiovascular risk: A rising concern.

Over the past decade, the number of individuals taking calcium supplementation worldwide has been on the rise, especially with the emergence of new pharmaceutical companies specialized in the marketing of dietary supplements; with calcium supplementation being their main business axis. This is mostly because of the established role of calcium in the prevention and treatment of osteoporosis and, to a lesser extent, its role in the prevention of fractures. Recently, a rising body of evidence on the adverse effect of calcium supplementation on nonskeletal, especially cardiovascular, health has been a cause for concern. In fact, a significant number of studies have reported an association between calcium supplementation and adverse cardiovascular events, even though high dietary calcium intake was shown to have a protective effect. The mechanism by which calcium supplementation could cause a cardiovascular event was still unclear until a recent study published in the Journal of the American Heart Association. Combining this recent finding with available data associating calcium supplementation with cardiovascular mortality and all-cause mortality, we call on the need for an evidence-based approach to calcium supplementation, while stressing on the safety of dietary calcium intake over the former on cardiovascular health.

Applying 21st century imaging technology to wound healing: an Avant-Gardist approach.

A significant arising complication in the care of patients with diabetes is increased susceptibility to chronic wounds, including diabetic foot ulcers and pressure sores. This is driven by, e.g., neuropathy and peripheral arterial disease. It is well recognized that best practice in wound care requires wound assessment, including measurement, on presentation and regularly throughout the treatment program. Proper assessment is necessary to ensure that the most appropriate and cost-effective therapy is used at all times, with quantitative measurement necessary to track the efficacy of the chosen approach. A documented assessment can also assist patient-clinician dialog and discussion within the multidisciplinary team. Remote evaluation and assessment of the wound is also of increasing importance and practicality through the use of a telemedicine approach. There has been considerable progress in the space of imaging for wounds, including systems that include three-dimensional measurement and telemedicine features. This literature review examines the available options and reviews the clinical evidence for measurement accuracy, scope for remote assessment, and published user feedback on the systems.

Neuropathic diabetic foot ulcers - evidence-to-practice.

Foot ulcers and their attendant complications are disquietingly high in people with diabetes, a majority of whom have underlying neuropathy. This review examines the evidence base underpinning the prevention and management of neuropathic diabetic foot ulcers in order to inform best clinical practice. Since it may be impractical to ask patients not to weight-bear at all, relief of pressure through the use of offloading casting devices remains the mainstay for management of neuropathic ulcers, whilst provision of appropriate footwear is essential in ulcer prevention. Simple non-surgical debridement and application of hydrogels are both effective in preparing the wound bed for healthy granulation and therefore enhancing healing. Initial empirical antibiotic therapy for infected ulcers should cover the most common bacterial flora. There is limited evidence supporting the use of adjunctive therapies such as hyperbaric oxygen and cytokines or growth factors. In selected cases, recombinant human platelet-derived growth factor has been shown to enhance healing; however, its widespread use cannot be advised due to the availability of more cost-effective approaches. While patient education may be beneficial, the evidence base remains thin and conflicting. In conclusion, best management of foot ulcers is achieved by what is taken out of the foot (pressure, callus, infection, and slough) rather than what is put on the foot (adjuvant treatment).

The RANKL/RANK/OPG signaling pathway mediates medial arterial calcification in diabetic Charcot neuroarthropathy.

OBJECTIVE: The receptor activator of nuclear factor-κB (RANK), RANK ligand (RANKL), and osteoprotegerin (OPG) signaling pathway (RANKL/RANK/OPG signaling) is implicated in the osteolysis associated with diabetic Charcot neuroarthropathy (CN); however, the links with medial arterial calcification (MAC) seen in people with CN are unclear. This study aimed to investigate the role of RANKL/OPG in MAC in patients with CN. RESEARCH DESIGN AND METHODS: Enzyme-linked immunosorbent assay and Bio-plex multiarray technology were used to quantify a range of cytokines, including RANKL and OPG in sera from 10 patients with diabetes, 12 patients with CN, and 5 healthy volunteers. Human tibial artery segments were immunohistochemically stained with Alizarin red and human RANKL antibody. Human vascular smooth muscle cells (VSMCs) were also explanted from arterial segments for in vitro studies. RESULTS: We demonstrate colocalization and upregulation of RANKL expression in areas displaying MAC. Systemic levels of RANKL, OPG, and inflammatory cytokines (interleukin-8, granulocyte colony-stimulating factor) were elevated in those with CN compared with diabetic patients and healthy control subjects. Human VSMCs cultured in CN serum showed accelerated osteoblastic differentiation (alkaline phosphatase activity) and mineralization (alizarin red staining) compared with cells treated with diabetic or control serum (P < 0.05). Coincubation with OPG, the decoy receptor for RANKL, attenuated osteogenic differentiation of VSMCs and was independent of a high calcium-phosphate milieu. The accelerated mineralization induced by RANKL and CN serum correlated with nuclear translocation of nuclear factor-κB, a process abrogated by OPG. CONCLUSIONS: Our data provide direct evidence that RANKL/RANK/OPG signaling is modulated in patients with CN and plays a role in vascular calcification. This study highlights this pathway as a potential target for intervention.

Impact of chronic kidney disease on survival after amputation in individuals with diabetes.

OBJECTIVE: To identify factors that influence survival after diabetes-related amputations. RESEARCH DESIGN AND METHODS: We abstracted medical records of 1,043 hospitalized subjects with diabetes and a lower-extremity amputation from 1 January to 31 December 1993 in six metropolitan statistical areas in south Texas. We identified mortality in the 10-year period after amputation from death certificate data. Diabetes was verified using World Health Organization criteria. Amputations were identified by ICD-9-CM codes 84.11-84.18 and categorized as foot, below-knee amputation, and above-knee amputation and verified by reviewing medical records. We evaluated three levels of renal function: chronic kidney disease (CKD), hemodialysis, and no renal disease. We defined CKD based on a glomerular filtration rate<60 ml/min and hemodialysis from Current Procedural Terminology (CPT) codes (90921, 90925, 90935, and 90937). We used χ2 for trend and Cox regression analysis to evaluate risk factors for survival after amputation. RESULTS: Patients with CKD and dialysis had more below-knee amputations and above-knee amputations than patients with no renal disease (P<0.01). Survival was significantly higher in patients with no renal impairment (P<0.01). The Cox regression indicated a 290% increase in hazard for death for dialysis treatment (hazard ratio [HR] 3.9, 95% CI 3.07-5.0) and a 46% increase for CKD (HR 1.46, 95% CI 1.21-1.77). Subjects with an above-knee amputation had a 167% increase in hazard (HR 2.67, 95% CI 2.14-3.34), and below-knee amputation patients had a 67% increase in hazard for death. CONCLUSIONS: Survival after amputation is lower in diabetic patients with CKD, dialysis, and high-level amputations.

Diabetic foot prevention: a neglected opportunity in high-risk patients.

OBJECTIVE: To evaluate the frequency of foot prevention strategies among high-risk patients with diabetes. RESEARCH DESIGN AND METHODS: Electronic medical records were used to identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation with 30 months follow-up to determine the frequency with which patients received education, podiatry care, and therapeutic shoes and insoles as prevention services. RESULTS: Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or preventative podiatric care (30%). The ulcer incidence density was the same in both groups (210 per 1,000 person-years). In contrast, the amputation incidence density was higher in the dialysis group compared with the ulcer group (58.7 vs. 13.1 per 1,000 person-years, P < 0.001). Patients on dialysis were younger and more likely to be of non-Hispanic white descent (P = 0.006) than patients with a previous history of ulcer or amputation. CONCLUSIONS: Prevention services are infrequently provided to high-risk patients.

High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy.

OBJECTIVE: To evaluate the prevalence of lower-limb complications in a multiracial cohort of patients with diabetes receiving dialysis. RESEARCH DESIGN AND METHODS: This work was a cross-sectional study of lower-limb complications in dialysis-treated patients with diabetes in the U.K. and U.S. RESULTS: We studied 466 patients (139 U.K.; 327 U.S.). The prevalence of lower-limb complications was high (foot ulcers 12%, neuropathy 79%, peripheral arterial disease 57%, history of foot ulceration 34%, and prior amputation 18%), with no significant ethnic variation, except that foot ulcers were more common in whites than in patients of African descent (P = 0.013). Ninety-five percent of patients were at high risk of lower-limb complications. Prior amputation was related to foot ulcer history, peripheral arterial disease, and hemodialysis modality in multivariable analysis. Prevalent ulceration showed independent associations with foot ulcer history and peripheral arterial disease, but not with ethnicity. CONCLUSIONS: All patients with diabetes receiving dialysis are at high risk of lower-limb complications independent of ethnic background.

Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease.

OBJECTIVE: To determine whether dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and renal impairment. RESEARCH DESIGN AND METHODS: We performed a cross-sectional study of consecutive patients with diabetes and stage 4 or 5 chronic kidney disease (CKD) attending clinics in Manchester (U.K.). Patients were classified as either receiving dialysis therapy (dialysis) or not (no dialysis). Foot assessment included diabetic peripheral neuropathy (DPN), peripheral arterial disease (PAD), prior foot ulceration and amputation, and foot self-care. Risk factors for prevalent foot ulceration were assessed by logistic regression. RESULTS: We studied 326 patients with diabetes and CKD (mean age 64 years; 61% male; 78% type 2 diabetes; 11% prevalent foot ulceration). Compared with no dialysis patients, dialysis patients had a higher prevalence of DPN (79 vs. 65%), PAD (64 vs. 43%), prior amputations (15 vs. 6.4%), prior foot ulceration (32 vs. 20%), and prevalent foot ulceration (21 vs. 5%, all P < 0.05). In univariate analyses, foot ulceration was related to wearing bespoke footwear (odds ratio 5.6 [95% CI 2.5-13]) dialysis treatment (5.1 [2.3-11]), prior foot ulceration (4.8 [2.3-9.8], PAD (2.8 [1.3-6.0], and years of diabetes (1.0 [1.0-1.1], all P < 0.01). In multivariate logistic regression, only dialysis treatment (4.2 [1.7-10], P = 0.002) and prior foot ulceration (3.1 [1.3-7.1], P = 0.008) were associated with prevalent foot ulceration. CONCLUSIONS: Dialysis treatment was independently associated with foot ulceration. Guidelines should highlight dialysis as an important risk factor for foot ulceration requiring intensive foot care.