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Background. Charcot osteoarthropathy of the foot (COA) can currently only be treated using prolonged periods of immobilization of the affected extremity. Therefore, the hypothesis is that COA leads to altered body composition and increased sarcopenia. Objective. To investigate the changes over several years in sarcopenia, body composition, and fat distribution in diabetes patients with previous COA compared to diabetes patients without previous COA. Methods. Prospective observational clinical study. Twenty-one subjects were included and had two DXA scans done with mean 8.6-year intervals to compare changes in lean mass and fat distribution. The lean mass of limbs was used as an estimate of appendicular lean mass (aLM). Fat mass and aLM were then used to detect sarcopenic individuals using different methods. Results and Conclusions. As compared to baseline, both groups had significant loss of lean mass, and diabetics without COA had significant gain of total fat percentage. No statistically different prevalence of sarcopenia between the groups could be established. Likewise, no difference was found in total lean and fat mass changes. None of the groups had statistically significant changes of android fat distribution. As compared with published data on sarcopenia, people with diabetes might be more prone to sarcopenia than healthy individuals.

INTRODUCTION. Hyperglycaemia during hospitalisation is associated with a longer and more complicated admission and with increased mortality. Therefore, guidelines suggest that blood glucose should be less than 10 mmol/l. In this audit, we aimed to describe the prevalence of diabetes patients at four orthopaedic departments in the Capital Region of Denmark and to measure the quality of in-hospital diabetes management. METHODS. We conducted audits of medical records in the electronic health record system for two months in 2019. All patients admitted were included in the audit. We gathered information on diabetes status, orthopaedic diagnosis, glycosylated haemoglobin and diabetes management. RESULTS. Among 2,463 included patients, 10% had diabetes. The three most frequent diagnosis groups were infection, fracture of lower extremity and hospitalised for alloplastic surgery. The number of blood glucose measurements during 24-hour perioperative care was 6.5. Among patients analysed, 10-20% did not have their blood glucose measured in the days following surgery. Among patients, 64% received insulin 1-50% of the required times. CONCLUSION. We demonstrated that 10% of hospitalised patients suffer from diabetes. The audit also showed that blood glucose is generally measured according to guidelines, whereas the treatment of an elevated blood glucose is far from being given according to guidelines. This may potentially delay recovery and prolong hospitalisation. FUNDING. none. TRIAL REGISTRATION. not relevant.

OBJECTIVE: Charcot foot is a serious complication of diabetes, with degeneration of the bones and joints in the foot and ankle. It is unknown whether patients with diabetes with a Charcot foot have an increased risk of osteoporosis and fractures. The aim of this study was to investigate whether patients with diabetes with a Charcot foot have an increased risk of fracture and/or osteoporosis compared with patients with diabetes without Charcot foot. RESEARCH DESIGN AND METHODS: A Danish register-based, nationwide population-based matched cohort study was conducted. During 1995-2018, we identified 1,602 patients with diabetes with Charcot foot and matched them on sex and date of diagnosis of diabetes with 16,296 patients with diabetes without Charcot foot. We used logistic regression to estimate odds ratios (ORs) with 95% CIs for fracture and osteoporosis. Information about exposure, outcome, and comorbidities was retrieved from the Danish National Patient Register. RESULTS: Diabetes patients with Charcot foot had higher risk of fractures compared with those without Charcot foot (i.e., ORs for any fracture, lower-leg fracture, foot fracture, and osteoporotic fracture were 1.8 [95% CI 1.6-2.0], 2.4 [2.0-2.8], 2.9 [2.6-3.3], and 1.3 [1.1-1.4], respectively). Furthermore, patients with diabetes with Charcot foot had higher risk of osteoporosis compared with the patients without Charcot foot, with an OR of 1.3 (95% CI 1.1-1.5). CONCLUSIONS: Patients with diabetes with a Charcot foot have an increased risk of fractures and osteoporosis compared with patients with diabetes without a Charcot foot.

INTRODUCTION: There are beneficial effects of advanced carbohydrate counting with an automatic bolus calculator (ABC) and intermittently scanned continuous glucose monitoring (isCGM) in persons with type 1 diabetes. We aim to compare the effects of isCGM, training in carbohydrate counting with ABC and the combination of the two concepts with standard care.METHODS AND ANALYSIS: A multi-centre randomised controlled trial with inclusion criteria: ≥18 years, type 1 diabetes ≥1 year, injection therapy, HbA1c >53 mmol/mol, whereas daily use of carbohydrate counting and/or CGM/isCGM wear are exclusion criteria. Inclusion was initiated in October 2018 and is ongoing. Eligible persons are randomised into four groups: standard care, ABC, isCGM or ABC+isCGM. Devices used are FreeStyle Libre Flash and smart phone diabetes application mySugr. Participants attend group courses according to treatment allocation with different educational contents. Participants are followed for 26 weeks with clinical visits and telephone consultations. At baseline and at study end, participants wear blinded CGM, have blood samples performed and fill in questionnaires on person-related outcomes, and at baseline also on personality traits and hypoglycaemia awareness. The primary outcome is the difference in time spent in normoglycaemia (4-10 mmol/L) at study end versus baseline between the isCGM group and the standard care group. Secondary outcomes will also be analysed. Results are expected in 2020.ETHICS AND DISSEMINATION: Regional Scientific Ethics Committee approval (H-17040573). Results will be sought disseminated at conferences and in high impact journals.Trial registration numberClinicalTrial.gov registry (NCT03682237).

Aim. To describe differences in healing time of diabetic foot ulcers for patients treated at the Copenhagen Wound Healing Center, Bispebjerg Hospital, between the years 1999/2000 and 2011/2012. The Center is highly specialized and receives diabetes patients with hard-to-heal foot ulcers. A further aim is to attempt to find predictors of healing time of diabetic foot ulcers. Methods. A retrospective descriptive study of records from patients with diabetic foot ulcer treated at the Copenhagen Wound Healing Center in 1999, 2000, 2011, or 2012. Follow-up data was collected until the 3rd of August 2018. Results. Median time (range) to healing was 6 (61.3) months in 1999/2000 and 6.6 (67.8) in 2011/2012 (p=0.2). About 33% of ulcers were healed, 17% were minor or major amputated, and 1.5% were dead within one year in 1999/2000, whereas 30% of ulcers were healed (p=0.6), 14% were amputated (p=0.2), and 12.8% were dead within one year in 2011/2012 (p<0.001). The single factor found significantly associated with longer ulcer duration was infection. Related to shorter ulcer duration were toe localization of the ulcer and good glycemic control. Conclusion. The median time to healing of a diabetic foot ulcer was long, around 6 months and with a high recurrence rate in 1999/2000 as well as in 2011/2012. Some factors were found to be significantly related to healing time, and intervention addressing these may improve the time to heal, although such interpretations must be taken with precaution from the present study and should be proven in randomized prospective intervention trials.

Objective: Due to the localized nature of Charcot foot, systemically altered levels of inflammation markers can be difficult to measure. The aim of this study was to investigate whether it is possible to detect an arteriovenous (A-V) flux in any locally produced inflammatory biomarkers from an acute Charcot foot by comparing local and systemic measurements.Methods: We included patients with acute diabetic Charcot foot. Blood was sampled from the vena saphena magna on the distal part of the crus bilaterally as well as from the arteria radialis. To minimize the A-V shunting effect, the feet were externally cooled with ice water prior to resampling.Results: Both before and after cooling, the A-V flux of interleukin-6 (IL-6) between the Charcot feet and the arterial level was significantly higher than the flux between the healthy feet and the arterial level (Δvaluebefore: 7.25 versus 0.41 pg/mL, resp., p = 0.008; Δvalueafter: 10.04 versus 1.68 pg/mL, resp., p = 0.032). There were no differences in the fluxes for other markers of inflammation.Conclusion: We have found an increased A-V flux of IL-6 in the acute diabetic Charcot foot compared to the healthy foot in the same patients.

BACKGROUND AND AIMS: Charcot foot is a rare but severe complication to diabetes and peripheral neuropathy. It is still unclear if an acute Charcot foot has long-term effects on the bone metabolism. To investigate this, we conducted a follow-up study to examine if a previously acute Charcot foot has any long-term effects on bone mineral density (BMD) or local or systemic bone metabolism.METHODS: An 8.5-year follow-up case-control study of 44 individuals with diabetes mellitus, 24 of whom also had acute or chronic Charcot foot at the baseline visit in 2005-2007, who were followed up in 2015 with DXA scans and blood samples.RESULTS: 21 of the 44 baseline participants participated in the follow-up. There were no difference in the change in total hip BMD from baseline to follow-up in either the Charcot or the control group (p = 0.402 and 0.517), and no increased risk of osteoporosis in the previous Charcot feet either. From baseline to follow-up, there was a significant difference in the change in levels of fsRANK-L in the Charcot group, but not in the control group (p = 0.002 and 0.232, respectively). At follow-up, there were no differences in fsRANK-L between the groups. The fsRANK-L/OPG ratio also significantly decreased from baseline to follow-up in the Charcot group (3.4 versus 0.5) (p = 0.009), but not in the control group (1.3 versus 1.1) (p = 0.302).CONCLUSION: We found that diabetes patients with an acute Charcot foot have an elevated fsRANK-L/OPG ratio, and that the level decreased from baseline to follow-up to be comparable to the level in diabetes patients without previous or current Charcot foot. We found no permanent effect of an acute Charcot foot on hip or foot BMD.

Aim To identify risk factors for early death in diabetes patients who undergo amputations below the ankle. Methods A retrospective study, where all hospital records of all diabetes patients who had undergone minimum one amputation below the ankle at the CWHC Bispebjerg Hospital, Denmark, in the period 1996-2013, were examined. The amputations were mainly trans-metatarsal amputations and partial amputations of toes. The participants were found via ICD10-codes. The included patients were followed from their first contact to the last registered contact. The statistical analysis in this article is performed on patients with a of minimum 5-year follow-up. Results The 5 year mortality was 42% for patients with type 2 diabetes, and 29% for patients with type 1 diabetes. For patients with type 2 diabetes, multivariable analysis showed that high age, peripheral arterial insufficiency and short time from first admission to amputation were independently statistically significantly associated with increased 5-years mortality. Use of statins was associated with decreased mortality. 35% died as a result of their diabetes, mostly due to cardiovascular causes. Conclusion Short time from first admission to amputation is a risk factor for early death. Arterial insufficiency and high age is also associated with increased mortality, whereas use of statin is associated with decreased mortality, in patients with type 2 diabetes.

INTRODUCTION: Charcot foot is a severe complication to diabetes mellitus and treatment involves several different clinical specialities. Our objective was to describe the current awareness, knowledge and treatment practices of Charcot foot among doctors who handle diabetic foot disorders.METHODS: This study is based on a questionnaire survey sent out to healthcare professionals, primarily doctors, working with diabetic foot ulcers and Charcot feet in the public sector of the Danish healthcare system.RESULTS: The survey obtained a 52% response rate. A temperature difference of > 2 °C between the two feet was the most used method of diagnosing Charcot foot. Along with clinical inspection, temperature difference was also the measurement used for monitoring of healing. None of the suggested formalised classification systems were used to any extent. Most responders use detachable bandages for offloading (83%). All centres use some form of a multidisciplinary team, with the most common permanent members being orthopaedic surgeons (71%), wound specialist nurses (76%), podiatrists (65%), endocrinologists (47%) and diabetes specialist nurses (41%).CONCLUSION: We conducted a survey of the diagnosis and treatment practices of acute diabetic Charcot foot at diabetes foot clinics in Denmark. The responders seem to follow the international recommendations and guidelines on management of the acute diabetic Charcot foot, despite a lack of Danish guidelines.FUNDING: none.TRIAL REGISTRATION: not relevant.

INTRODUCTION: The diabetic foot is a complicated health issue which ideally involves several different specialists to ensure the most effective treatment. The Danish Health and Medicines Authority recently published a national guideline to address the implementation of multidisciplinary teams in the treatment. The objective of this study was to describe the treatment practices at the time the guidelines were launched.METHODS: A questionnaire-based survey was conducted among Danish hospital departments working with diabetic feet. All public departments were invited by e-mail to participate and the participant answering the questionnaire was identified as knowledgeable about the department's procedures on treatment of diabetic feet. Only one questionnaire per department was allowed.RESULTS: A total of 62 questionnaires were sent out. We achieved a response rate of ~37% (n = 23). Respondents (n = 13) were mostly orthopaedic surgeons. A classification system of the diabetic foot was rarely or never used, and eight respondents (42%) reported having a multidisciplinary team in accordance with the national guidelines. 73% of the respondents performed some form of surgical intervention on diabetic feet, mainly minor procedures.CONCLUSION: The study demonstrated that several areas of treatment practices relating to the diabetic foot had potential for improvement as they did not adhere to national Danish guidelines. A follow-up survey, allowing time for local implementation, seems warranted.

Treatment of patients with perioxisome proliferator-activated receptor-¿ full agonists are associated with weight gain, heart failure, peripheral oedema, and bone loss. However, the safety of partial perioxisome proliferator-activated receptor-¿ agonists has not been established in a clinical trial. The BALaglitazone glucose Lowering Efficacy Trial aimed to establish the glucose-lowering effects and safety parameters of the perioxisome proliferator-activated receptor-¿ partial agonist balaglitazone in diabetic patients on stable insulin therapy.