This prospective study was performed to compare calcaneal and lumbar bone mineral density (BMD) in individuals with and without diabetes mellitus. We compared bone density with the time from onset of Charcot’s neuroarthropathy (CN) in patients with unilateral, nonoperative, reconstructive-stage CN. The final purpose was to investigate the role that sex, age, and serum vitamin D level may have in osseous recovery.
Thirty-three individuals were divided into three groups: controls and patients with diabetes mellitus with and without CN. Peripheral instantaneous x-ray imaging and dual-energy x-ray absorptiometry were performed.
The calcaneal BMD of patients with diabetes mellitus and CN was lower than that of the control group (P < .01) but was not significantly lower than that of patients with diabetes mellitus alone. There was no statistically significant difference in lumbar T-scores between groups. Women demonstrated lower BMD than did men (P = .02), but patients 60 years and older did not demonstrate significantly lower BMD than did patients younger than 60 years (P = .135). A negative linear relationship was demonstrated between time and BMD in patients with CN.
The results of this study suggest that lumbar BMD does not reflect peripheral BMD in patients with diabetes mellitus and reconstructive-stage CN. This study has clinical implications when reconstructive osseous surgery is planned in patients with CN. (J Am Podiatr Med Assoc 102(3): 213–222, 2012)
Background: To compare pathogens involved in skin and soft-tissue infections (SSTIs) and pedal osteomyelitis (OM) in patients with and without diabetes with puncture wounds to the foot.
Methods: We evaluated 113 consecutive patients between June 1, 2011, and March 31, 2019, with foot infection (SSTIs and OM) from a puncture injury sustained to the foot. Eighty-three patients had diabetes and 30 did not. We evaluated the bacterial pathogens in patients with SSTIs and pedal OM.
Results: Polymicrobial infections were more common in patients with diabetes mellitus (83.1% versus 53.3%; P = .001). The most common pathogen for SSTIs and OM in patients with diabetes was Staphylococcus aureus (SSTIs, 50.7%; OM, 32.3%), whereas in patients without diabetes it was Pseudomonas (25%) for SSTIs. Anaerobes (9.4%) and fungal infection (3.1%) were uncommon. Pseudomonas aeruginosa was identified in only 5.8% of people with diabetes.
Conclusions: The most common bacterial pathogen in both SSTIs and pedal OM was S aureus in patients with diabetes. Pseudomonas species was the most common pathogen in people without diabetes with SSTIs.
Objective: To investigate the predictive value of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in persons with and without diabetes with osteomyelitis (OM).
Methods: We evaluated 455 patients in a retrospective cohort study of patients admitted to the hospital with diabetic foot OM (n = 177), diabetic foot soft-tissue infections (STIs) (n = 176), nondiabetic OM (n = 51), and nondiabetic STIs (n = 51). Infection diagnosis was determined through bone culture, histopathologic examination for OM, and/or imaging (magnetic resonance imaging/single-photon emission computed tomography) for STI. The optimal cutoff values of ESR and CRP in predicting OM were determined by receiver operating characteristic curve analysis. Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were determined through contingency tables.
Results: In persons without diabetes with STI or OM, the mean ESR and CRP differences were 10.0 mm/h and 2.6 mg/dL, respectively. In contrast, persons with diabetes had higher levels of each: 24.8 mm/h and 6.8 mg/dL, respectively. As a result, ESR and CRP predicted OM better in patients with diabetes. However, when patients were stratified by neuropathy status, ESR remained predictive of OM in diabetic patients with neuropathy (75% sensitivity, 58% specificity) but not in diabetic patients without neuropathy (50% sensitivity, 44% specificity). Also, CRP remained predictive irrespective of neuropathy status. A similar trend was observed in patients without diabetes.
Conclusions: Previous studies have reported that ESR and CRP are predictive of OM. However, this study suggests that neuropathy influences the predictive value of inflammatory biomarkers. The underlying mechanisms require further study.
Background: The aim of this study was to evaluate the incidence and recovery of acute kidney injury (AKI) in patients admitted to the hospital with and without diabetes mellitus (DM) with foot infections.
Methods: We retrospectively reviewed 294 patients with DM and 88 without DM admitted to the hospital with foot infections. The Kidney Disease: Improving Global Outcomes guidelines were used to define AKI. Recovery was divided into three categories: full, partial, and no recovery within 90 days of the index AKI.
Results: The AKI incidence was 3.0 times higher in patients with DM (DM 48.5% versus no DM 23.9%; 95% confidence interval [CI], 1.74–5.19; P < .01). Acute kidney injury incidence was similar at each stage in people with and without DM (stage 1, DM 58.1% versus no DM 47.6%; stage 2, DM 23.3% versus no DM 33.3%, and stage 3, DM 18.6% versus no DM 19.1%). Twenty-nine patients with diabetes had a second AKI event and four had a third event. In patients without DM, one patient had a second AKI. Cumulative AKI incidence was 4.7 times higher in people with DM (DM 60.9% versus no DM 25.0%; 95% CI, 2.72–8.03; P < .01). Patients with diabetes progressed to chronic kidney disease or in chronic kidney disease stage 39.4% of the time. Patients without diabetes progressed 16.7% of the time, but this trend was not significant (P = .07). Complete recovery was 3.8 times more likely in patients without diabetes (95% CI, 1.26–11.16; P = .02).
Conclusions: Acute kidney injury incidence is higher in patients with diabetes, and complete recovery after an AKI is less likely compared to patients without diabetes.
Background: To evaluate clinicians' compliance to follow national guidelines for tetanus vaccination prophylaxis in high-risk foot patients. Methods: We retrospectively evaluated 114 consecutive patients between June 2011 and March 2019 who presented with a foot infection resulting from a puncture injury through the emergency department. Eighty-three patients had diabetes mellitus and 31 patients did not have diabetes mellitus. Electronic medical records were used to collect a broad range of study data on patient demographics, previous medical history, previous tetanus immunization history and tetanus status upon presentation to the emergency department (ED), peripheral arterial disease, sensory neuropathy, laboratory values, and clinical / surgical outcomes. Results: 46.5% of the patients who presented to the ED with a puncture wound did not have up-to-date tetanus immunization. Of those patients, 79.2% received a tetanus-containing vaccine booster, 3.8% received intramuscular tetanus immunoglobulins (TIG), 3.8% received both tetanus-containing vaccine booster and TIG, and 20.8% received no form of tetanus prophylaxis. When comparing data between patients with and without diabetes, there were no statistical significant differences in tetanus prophylaxis. Conclusion: Guidelines for tetanus prophylaxis amongst high-risk foot patients in this study center are not followed in all patients. Patients with DM are at high risks of exposure to tetanus, we recommend physicians to take a detailed tetanus immunization history and vaccinate them if tetanus history is unclear.
Diabetic foot ulcers (DFUs) are a major burden to patients and to the health-care systems of many countries. To prevent or treat ulcers more effectively, predictive biomarkers are needed. We examined temperature as a biomarker and as a causative factor in ulcer development.
Thirty-seven individuals with diabetes were enrolled in this observational case-control study: nine with diabetic neuropathy and ulcer history (DFU), 14 with diabetic neuropathy (DN), and 14 nonneuropathic control participants (DC). Resting barefoot plantar temperatures were recorded using an infrared thermal camera. Mean temperatures were determined in four anatomical regions—hallux and medial, central, and lateral forefoot—and separate linear models with specified contrasts among the DFU, DN, and DC groups were set to reveal mean differences for each foot region while controlling for group characteristics.
The mean temperature reading in each foot region was higher than 30.0°C in the DFU and DN groups and lower than 30.0°C in the DC group. Mean differences were greatest between the DFU and DC groups, ranging from 3.2°C in the medial forefoot to 4.9°C in the hallux.
Increased plantar temperatures in individuals with a history of ulcers may include acute temperature increases from plantar stresses, chronic inflammation from prolonged stresses, and impairment in temperature regulation from autonomic neuropathy. Diabetic foot temperatures, particularly in patients with previous ulcers, may easily reach hazard thresholds indicated by previous pressure ulcer studies. The results necessitate further exploration of temperature in the diabetic foot and how it may contribute to ulceration.
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity. (J Am Podiatr Med Assoc 101(5): 437–446, 2011)