The aim of this longitudinal study was to report on the clinical characteristics and treatment course of acute Charcot's arthropathy at a tertiary care diabetic foot clinic. Fifty-five diabetic subjects, with a mean age of 58.6 +/- 8.5 years, were studied. All patients were treated with serial total contact casting until quiescence. Following casting and before transfer to prescription footwear, patients were eased into unprotected weightbearing via a removable cast walker. This cohort was followed for their entire treatment course and for a mean 92.6 +/- 33.7 weeks following return to shoes. Pain was the most frequent presenting complaint in these otherwise insensate patients (76%). The mean duration of casting was 18.5 +/- 10.6 weeks. Patients returned to footwear in a mean 28.3 +/- 14.5 weeks. Nine per cent of the population had bilateral arthropathy. These subjects were casted significantly longer than the unilateral group (p < 0.02). Surgery was performed on 25% of patients, with approximately two-thirds of these procedures involving plantar exostectomies and one-third fusions of affected joints. Patients receiving surgery remained casted significantly longer than non-surgical patients (p < 0.05). Additionally, men were casted longer than women (p < 0.008). Acute Charcot's arthropathy requires prompt, uncompromising reduction in weightbearing stress. Our data show that the ambulatory total contact cast is very effective for this. Regardless of the specific treatment method instituted, it is imperative that appropriate and aggressive treatment be undertaken immediately following diagnosis to help prevent progression to a profoundly debilitating, limb-threatening deformity.

This work is concerned with the role of insulin-like growth factor binding protein (IGFBP)-2 and -4 in the regulation of IGF bioactivity in bovine follicles during the development of dominance. We measured the expression of IGFBP-2 and -4 messenger RNA (mRNA) in small (1-4 mm) gonadotropin-sensitive follicles and medium (4-8 mm) and large (>8 mm) gonadotropin-dependent follicles using in situ hybridization. In healthy nonatretic bovine follicles, IGFBP-2 and -4 mRNA expression was confined to granulosa and theca tissue, respectively. Moreover, during the development of follicular atresia, there were distinct changes in the temporal and spatial expression of these genes. IGFBP-2 immunoactivity was localized in granulosa tissue and the basement membrane of healthy preantral follicles, whereas IGFBP-4 immunoactivity was localized in both theca and granulosa tissue. Of particular interest was the lack of IGFBP-2 mRNA expression in large (>8 mm) gonadotropin-dependent follicles, an observation that was confirmed by the lack of immunoreactive IGFBP-2 in these follicles. The regulation of IGFBP-2 and -4 mRNA expression in granulosa and theca cells was analyzed using a serum-free cell culture system. FSH inhibited the expression of IGFBP-2 mRNA in granulosa cells, whereas LH stimulated IGFBP-4 mRNA expression in theca cells. Our results provide evidence for the existence of different roles for IGFBP-2 and -4 in the developing follicle.

IGFs regulate gonadotrophin-stimulated proliferation and differentiation of granulosa and theca cells in vitro.

This retrospective study reviewed the culture results of 112 admissions to a multidisciplinary diabetic foot care team with a primary diagnosis of infected diabetic pedal ulceration. An average of 1.5 +/- 0.9 species per patient (P < 0.0001) were isolated. Eighty-nine percent of wounds cultured grew two or fewer organisms. Anaerobic species were isolated in only 5% of all cultures. Of these isolates, the distinction between anaerobic colonization and true anaerobic infection is made. Results suggest that aggressive early hospitalization, coupled with aggressive intraoperative debridement, may yield less microbiologically complex infections that may be controlled with less expensive narrow spectrum antibiotic therapy. Diagnosis of the infected pedal ulceration of a patient with diabetes is a clinical one. If this diagnosis is combined with appropriate surgical intervention, microbiologic correlation, and antimicrobial therapy, the result may be a less complex hospital course and improved outcome.

We reviewed the hospital course of 77 diabetic and 69 nondiabetic subjects who had incision, drainage, and exploration of infected puncture wounds of the foot. Diabetics were 5 times more likely to have multiple operations and 46 times more likely to have a lower extremity amputation than nondiabetics. The interval from injury to surgery was significantly longer in diabetics than nondiabetics. Total lymphocyte count and hemoglobin, hematocrit, and albumin values were significantly lower in diabetics than in nondiabetics. Diabetic amputees had higher prevalences of nonpalpable pulses, nephropathy, neuropathy, and osteomyelitia as compared with diabetic nonamputees. The neuropathic diabetic foot is not protected by pain. When combined with other comorbid factors, this may increase morbidity associated with puncture wounds of the foot.