Rheumatological manifestations in diabetes mellitus

Podiatrist intervention could reduce the incidence of foot ulcers in patients with diabetes: a hospital survey in China

OBJECTIVE

This study aimed to evaluate the effectiveness of podiatrists in preventing diabetic foot ulcers (DFUs) in China.

METHOD

The study was a prospective investigation. A total of 300 patients were enrolled from May 2016 to May 2018 in Handan Central Hospital, China. All patients who participated in this study had been diagnosed with type 2 diabetes, according to the International Classification of Diseases (ICD-10). All participants underwent our survey, which included basic patient data and information about DFUs. The patients were followed for one year, during which time they received appropriate intervention from podiatrists, including lifestyle guidance, callus resection, tinea grinding and ingrown nail correction. At the end of the year all the patients were surveyed again. The data before and after the year were statistically compared.

RESULTS

The results showed that the incidence of DFUs in patients with diabetes was significantly decreased after one year of intervention from podiatrists (20.7% versus 6.7%, p<0.001). Additionally, there was a negative correlation between the number of intervention visits and the number of DFU occurrences (Spearman correlation coefficient: -0.496, p<0.001). Furthermore, we found that 68 patients with a history of DFUs or amputation had an obviously reduced incidence of DFUs after intervention by a podiatrist (89.7% versus 27.9%, p<0.001). We also investigated other foot risk factors in all participants, such as limb neuropathy (76.3%), lower extremity vascular disease (65.7%) and foot paralysis (43.7%).

CONCLUSION

The results of this study help in understanding the situation of patients with diabetes in China and to prove that standardised podiatrist intervention has an important role in inhibiting the occurrence and development of DFUs.

Mucopolysaccharidosis: What Pediatric Rheumatologists and Orthopedics Need to Know

Mucopolysaccharidosis (MPS) is a group of disorders caused by the reduced or absent activity of enzymes involved in the glycosaminoglycans (GAGs) degradation; the consequence is the progressive accumulation of the substrate (dermatan, heparan, keratan or chondroitin sulfate) in the lysosomes of cells belonging to several tissues. The rarity, the broad spectrum of manifestations, the lack of strict genotype-phenotype association, and the progressive nature of MPS make diagnosing this group of conditions challenging. Musculoskeletal involvement represents a common and prominent feature of MPS. Joint and bone abnormalities might be the main clue for diagnosing MPS, especially in attenuated phenotypes; therefore, it is essential to increase the awareness of these conditions among the pediatric rheumatology and orthopedic communities since early diagnosis and treatment are crucial to reduce the disease burden of these patients. Nowadays, enzyme replacement therapy (ERT) and hematopoietic stem cell transplantation (HSCT) are available for some MPS types. We describe the musculoskeletal characteristics of MPS patients through a literature review of MPS cases misdiagnosed as having rheumatologic or orthopedic conditions.

Diabetes: a silent player in musculoskeletal interventional radiology response

Diabetes has an important role in the development of several musculoskeletal disorders, such as adhesive capsulitis of the shoulder (ACs) and stenosing flexor tenosynovitis of the finger (SfTf). The etiopathophysiology of ACs and SfTf in diabetic patients is associated with both chronic hyperglycemia, increased amounts of visceral adiposity and chronic inflammation. Chronic hyperglycemia stimulates the creation of cross-links between collagen molecules, impairing degradation and resulting in the build-up of excessive collagen deposits in the cartilage, ligaments, tendon sheaths and tendons. Increased adipocytes in diabetic patients secrete proteins and cytocines such as TNF-α, IL-6 and IL-13 which result in overproduction of pro-inflammatory factors, destruction of normal tissue architecture and fibrosis. Both hyperglycemia and adipocytes inhibit efferocytosis, limiting natural resolution. Recently, multiple image-guided interventional radiology musculoskeletal treatment options have been developed, such as ultrasound-guided glenohumeral capsule hydrodistension for ACs and ultrasound-guided percutaneous pulley release for trigger finger. Diabetes can negatively influence outcomes in patients with ACs and SfTf and may impact the decision of which specific procedure technique should be employed. Further studies are necessary to define how diabetes influences response to interventional radiology treatments of these disorders, as well as the extent to which control of blood sugar levels can contribute towards the personalization and optimization of patient follow up.

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature

BACKGROUND

Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot.

OBJECTIVES

The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers.

METHODOLOGY

An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications.

RESULTS

Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed.

CONCLUSION

Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

Tendinopathy in diabetes mellitus patients-Epidemiology, pathogenesis, and management

Chronic tendinopathy is a frequent and disabling musculo-skeletal problem affecting the athletic and general populations. The affected tendon is presented with local tenderness, swelling, and pain which restrict the activity of the individual. Tendon degeneration reduces the mechanical strength and predisposes it to rupture. The pathogenic mechanisms of chronic tendinopathy are not fully understood and several major non-mutually exclusive hypotheses including activation of the hypoxia-apoptosis-pro-inflammatory cytokines cascade, neurovascular ingrowth, increased production of neuromediators, and erroneous stem cell differentiation have been proposed. Many intrinsic and extrinsic risk/causative factors can predispose to the development of tendinopathy. Among them, diabetes mellitus is an important risk/causative factor. This review aims to appraise the current literature on the epidemiology and pathology of tendinopathy in diabetic patients. Systematic reviews were done to summarize the literature on (a) the association between diabetes mellitus and tendinopathy/tendon tears, (b) the pathological changes in tendon under diabetic or hyperglycemic conditions, and (c) the effects of diabetes mellitus or hyperglycemia on the outcomes of tendon healing. The potential mechanisms of diabetes mellitus in causing and exacerbating tendinopathy with reference to the major non-mutually exclusive hypotheses of the pathogenic mechanisms of chronic tendinopathy as reported in the literature are also discussed. Potential strategies for the management of tendinopathy in diabetic patients are presented.

Cardiovascular Comorbidities Relate More than Others with Disease Activity in Rheumatoid Arthritis

Objectives

To explore the influence of comorbidities on clinical outcomes and disease activity in rheumatoid arthritis (RA).

Methods

In patients included in the cross-sectional observational multicenter international study COMORA, demographics, disease characteristics and comorbidities (hypertension, diabetes, hyperlipidemia, renal failure, ischemic heart disease, stroke, cancer, gastro-intestinal ulcers, hepatitis, depression, chronic pulmonary disease, obesity) were collected. Multivariable linear regression models explored the relationship between each comorbidity and disease activity measures: 28-swollen joint count (SJC), 28-tender joint count (TJC), erythrocyte sedimentation rate (ESR), patient’s and physician’s global assessment (PtGA, PhGA), patient reported fatigue and 28-Disease Activity Score (DAS28). Results are expressed as mean difference (MD) adjusted for the main confounders (age, gender, disease characteristics and treatment).

Results

A total of 3,920 patients were included: age (mean ±SD) 56.27 ±13.03 yrs, female 81.65%, disease duration median 7.08 yrs (IQR 2.97–13.27), DAS28 (mean ±SD) 3.74 ± 1.55. Patients with diabetes had more swollen and tender joints and worse PtGA and PhGA (MD +1.06, +0.93, +0.53 and +0.54, respectively). Patients with hyperlipidemia had a lower number of swollen and tender joints, lower ESR and better PtGA and PhGA (MD -0.77, -0.56, -3.56, -0.31 and -0.35, respectively). Patients with history of ischemic heart disease and obese patients had more tender joints (MD +1.27 and +1.07) and higher ESR levels (MD +5.64 and +5.20). DAS28 is influenced exclusively by cardiovascular comorbidities, in particular diabetes, hyperlipidemia, ischemic heart disease and obesity.

Conclusions

Cardiovascular comorbidities relate more than others with disease activity in RA. Diabetes and hyperlipidemia in particular seem associated with higher and lower disease activity respectively influencing almost all considered outcomes, suggesting a special importance of this pattern of comorbidities in disease activity assessment and clinical management.

Effect of non-surgical periodontal treatment on glycemic control of patients with diabetes: a meta-analysis of randomized controlled trials

Objective

The present study aimed at investigating whether non-surgical periodontal treatment can reduce the Haemoglobin A1c (HbA1c) % level in type 2 diabetic patients.

Methods

A search of the literature on English publications was performed in Cochrane Central, Medline, ISI Web of Knowledge and EMBASE (until 06 February 2014). An RCT was selected if the subject was type 2 diabetic patients diagnosed with chronic periodontitis, and compared HbA1c% change after non-surgical periodontal treatment alone for at least three months of the study duration. Weighted mean difference for pooled data and large sample size strata were calculated. Heterogeneity and publication bias were explored.

Results

After the study selection process, only 9 RCTs were suitable. Compared to the control group, the pooled analysis (n=1082) showed −0.27 % (95 % CI:-0.46 % to −0.07 %, p= 0.007) absolute difference in HbA1c % with treatment while studies with sufficient sample size had HbA1c % change of −0.014 % (95 % CI:-0.18 % to 0.16 %, p= 0.87). Publication bias was marginally significant with Egger’s teat (p=0.045) but not with Begg’s test (p=0.72).

Conclusion

The moderate reduction in HbA1c after the non-surgical therapy in patients with type 2 diabetes is consistent with previous systematic reviews. However, more large scale and high-quality RCTs are necessitated to confirm these results.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-015-0810-2) contains supplementary material, which is available to authorized users.

The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer

AIMS

Evaluation of how ankle joint mobility (AJM) can be useful in the identification of patients with diabetes at risk of foot ulcer (FU).

METHODS

Plantar and dorsal flexion of foot were evaluated using an inclinometer in 87 patients (54 type 2 and 33 type 1), and 35 healthy sex- and age-matched control subjects. Patients with diabetes were followed up for diagnosis of FU over the next 8 years and subsequently, patients were subdivided into: those without a history of FU (18 type 1 and 33 type 2), those who had a history of FU detected before baseline evaluation (14 type 2) and those who had history of first ulceration detected by the 8th year of the evaluation period (7 type 2).

RESULTS

Aging and diabetes caused a significant reduction in mobility of each of the movements investigated (p<0.001), whereas after adjusting for the confounding effect of age, diabetes specifically reduced plantar flexion (p<0.0001). AJM was significantly lower in those with history of previous FU compared to all the other groups (p<0.001). The first ulceration was detected in the same foot presenting lower AJM in 17 of the 22 subjects with diabetes with history of ulcer (77.27%).

CONCLUSIONS

Diabetes and aging reduce AJM although diabetes seems to reduce plantar flexion to a more specific extent. Reduced AJM is mostly associated with a previous history of FU. The evaluation of AJM is a valid and reliable ulcer risk scale that indicates which foot is at higher ulcer risk.

PPARγ is involved in the hyperglycemia-induced inflammatory responses and collagen degradation in human chondrocytes and diabetic mouse cartilages

Diabetic hyperglycemia has been suggested to play a role in osteoarthritis. Peroxisome proliferator-activated receptor-γ (PPARγ) was implicated in several pathological conditions including diabetes and inflammation. The detailed effects and mechanisms of hyperglycemia on cartilage damage still need to be clarified. Here, we investigated the role of PPARγ in hyperglycemia-triggered chondrocyte/cartilage damages using a human chondrocyte culture model and a diabetic mouse model. Human chondrocytes were cultured and treated with high concentration of glucose (30 mM) to mimic hyperglycemia in the presence or absence of pioglitazone, a PPARγ agonist. Streptozotocin (STZ) was used to induce mouse diabetes. Our data showed that high glucose induced the protein expressions of cyclooxygenase-2 (COX-2) and production of prostaglandin-E2 (PGE2 ), interleukin-6 (IL-6), and metalloproteinase-13 (MMP-13), but decreased the protein expression of collagen II and PPARγ in human chondrocytes. These alterations in high glucose-treated human chondrocytes could be reversed by pioglitazone in a dose-dependent manner. Moreover, pioglitazone administration could also significantly reverse the hyperglycemia, formation of AGEs, productions of IL-6 and MMP-13, and cartilage damage in STZ-induced diabetic mice. Taken together, these findings suggest that hyperglycemia down-regulates PPARγ expression and induces inflammatory and catabolic responses in human chondrocytes and diabetic mouse cartilages.

Mucopolysaccharidoses

The mucopolysaccharidoses (MPSs) are a group of rare genetic disorders of glycosaminoglycan catabolism, caused by a deficiency of lysosomal enzymes required for GAG degradation. Incomplete breakdown of glycosaminoglycans leads to progressive accumulation of these substances in many tissues throughout the body. Different residual enzymatic activity can result in different phenotypes of the same MPS disorder, from severe to attenuated. Musculoskeletal manifestations are common across all forms of MPS. Skeletal and joint abnormalities are prominent features of many MPS disorders, particularly attenuated phenotypes. However, diagnostic delays occur frequently for patients with an MPS, especially those with more attenuated forms of disease. In the absence of appropriate treatment, these conditions are chronic, progressive and often debilitating, but treatment for many types of MPS is now available. Therefore, increasing awareness of MPS among rheumatologists is extremely important.

Anti-inflammatory mechanism of metformin and its effects in intestinal inflammation and colitis-associated colon cancer

BACKGROUND AND AIM

The aim of this study is to evaluate the effect of metformin on intestinal inflammation.

METHODS

COLO205 cells were pretreated with metformin and stimulated with tumor necrosis factor (TNF)-α. Expression of interleukin (IL)-8 was determined by luciferase assay and real-time PCR. Inhibitor of kappaB (IκB) phosphorylation/degradation and adenosine monohosphate-activated protein kinase (AMPK) activity were evaluated by Western blotting. DNA-binding activity of transcription factor nuclear factor-kappaB (NF-κB) was assessed by electrophoretic mobility shift assay. In an acute colitis model, mice were given 4% dextran sulfate sodium (DSS) for 5 days. IL-10−/− mice were used to evaluate the effect of metformin on chronic colitis. In an inflamation-associated tumor model, mice were given a single intraperitoneal injection of azoxymethane followed by three cycles of 2% DSS for 5 days and 2 weeks of free water consumption.

RESULTS

Metformin significantly inhibited IL-8 induction in COLO 205 cells stimulated with TNF-α. Metformin attenuated IκBα phosphorylation and NF-κB DNA-binding activity. Administration of metformin significantly reduced the severity of DSS-induced colitis. In addition, DSS-induced IκB kinase (IKK) activation was significantly reduced in mice treated with metformin. Metformin significantly attenuated the severity of colitis in IL-10−/− mice, induced AMPK activity in intestinal epithelial cells, and inhibited the development of colitic cancer in mice.

CONCLUSIONS

These results indicate that metformin suppresses NF-κB activation in intestinal epithelial cells and ameliorates murine colitis and colitis-associated tumorigenesis in mice, suggesting that metformin could be a potential therapeutic agent for the treatment of inflammatory bowel disease.

Diabetic foot and exercise therapy: step by step the role of rigid posture and biomechanics treatment

Lower extremity ulcers represent a serious and costly complication of diabetes mellitus. Many factors contribute to the development of diabetic foot. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute in turn to the growth of additional risk factors such as limited joint mobility, muscular alterations and foot deformities. Moreover, a deficit of balance, posture and biomechanics can be present, in particular in patients at high risk for ulceration. The result of this process may be the development of a vicious cycle which leads to abnormal distribution of the foot's plantar pressures in static and dynamic postural conditions. This review shows that some of these risk factors significantly improve after a few weeks of exercise therapy (ET) intervention. Accordingly it has been suggested that ET can be an important weapon in the prevention of foot ulcer. The aim of ET can relate to one or more alterations typically found in diabetic patients, although greater attention should be paid to the evaluation and possible correction of body balance, rigid posture and biomechanics. Some of the most important limitations of ET are difficult access to therapy, patient compliance and the transitoriness of the results if the training stops. Many proposals have been made to overcome such limitations. In particular, it is important that specialized centers offer the opportunity to participate in ET and during the treatment the team should work to change the patient's lifestyle by improving the execution of appropriate daily physical activity.

Expression and function of K(ATP) channels in normal and osteoarthritic human chondrocytes: possible role in glucose sensing

ATP-sensitive potassium [K(ATP)] channels sense intracellular ATP/ADP levels, being essential components of a glucose-sensing apparatus in various cells that couples glucose metabolism, intracellular ATP/ADP levels and membrane potential. These channels are present in human chondrocytes, but their subunit composition and functions are unknown. This study aimed at elucidating the subunit composition of K(ATP) channels expressed in human chondrocytes and determining whether they play a role in regulating the abundance of major glucose transporters, GLUT-1 and GLUT-3, and glucose transport capacity. The results obtained show that human chondrocytes express the pore forming subunits, Kir6.1 and Kir6.2, at the mRNA and protein levels and the regulatory sulfonylurea receptor (SUR) subunits, SUR2A and SUR2B, but not SUR1. The expression of these subunits was no affected by culture under hyperglycemia-like conditions. Functional impairment of the channel activity, using a SUR blocker (glibenclamide 10 or 20 nM), reduced the protein levels of GLUT-1 and GLUT-3 by approximately 30% in normal chondrocytes, while in cells from cartilage with increasing osteoarthritic (OA) grade no changes were observed. Glucose transport capacity, however, was not affected in normal or OA chondrocytes. These results show that K(ATP) channel activity regulates the abundance of GLUT-1 and GLUT-3, although other mechanisms are involved in regulating the overall glucose transport capacity of human chondrocytes. Therefore, K(ATP) channels are potential components of a broad glucose sensing apparatus that modulates glucose transporters and allows human chondrocytes to adjust to varying extracellular glucose concentrations. This function of K(ATP) channels seems to be impaired in OA chondrocytes.

Association of hand or knee osteoarthritis with diabetes mellitus in a population of Hispanics from Puerto Rico

BACKGROUND

Although a higher prevalence of osteoarthritis (OA) has been reported among diabetes mellitus (DM) patients, inconsistencies and limitations of observational studies have precluded a conclusive association.

OBJECTIVE

The objective of this study was to evaluate the association of hand or knee OA with DM in a population of Hispanics from Puerto Rico.

METHODS

A cross-sectional study was performed in 202 subjects (100 adult DM patients as per the National Diabetes Data Group Classification and 102 nondiabetic subjects). Osteoarthritis of hand and knee was ascertained using the American College of Rheumatology classification criteria. Sociodemographic characteristics, health-related behaviors, comorbidities, pharmacotherapy, and DM clinical manifestations were determined. Multivariable logistic regression was used to evaluate the association of DM with hand or knee OA and to evaluate factors associated with hand or knee OA among DM patients.

RESULTS

The mean (SD) age for DM patients was 51.6 (13.1) years; 64.0% were females. The mean (SD) DM duration was 11.0 (10.4) years. The prevalence of OA in patients with DM and nondiabetic subjects was 49.0% and 26.5%, respectively (P < 0.01). In the multivariable analysis, patients with DM had 2.18 the odds of having OA when compared with nondiabetic subjects (95% confidence interval [CI], 1.12-4.24). In a subanalysis among DM patients, female patients were more likely to have hand or knee OA (odds ratio [95% CI], 5.06 [1.66-15.66]), whereas patients who did not use insulin alone for DM therapy were more likely to have OA (odds ratio [95% CI], 4.44 [1.22-16.12]).

CONCLUSIONS

In this population of Hispanics from Puerto Rico, DM patients were more likely to have OA of hands or knees than were nondiabetic subjects. This association was retained in multivariable models accounting for established risk factors for OA. Among DM patients, females were at greater risk for OA, whereas the use of insulin was negatively associated.

Upper limb musculoskeletal abnormalities in type 2 diabetic patients in low socioeconomic strata in Pakistan

BACKGROUND

Musculoskeletal manifestations of diabetes in the upper limb are well recognized. No data has been available in this regard from Pakistan. Our aim was to find out the frequency of upper limb musculoskeletal abnormalities in diabetic patients.

METHODS

This was an observational study in which type 2 diabetes patients attending our diabetic clinic were enrolled along with age and gender matched controls. Data was analyzed on SPSS 16.

RESULTS

In total, 210 Type 2 diabetics (male 34.3%, female 65.7%) and 203 controls (male 35%, female 65%) were recruited. The mean age was 50.7± 10.2 years in diabetic group as compared to 49.5±10.6 years in the control group. The frequencies of hand region abnormalities were significantly higher in the diabetic subjects as compared to the controls (20.4%, p-value <0.001). Limited joint mobility (9.5% vs 2.5%), carpal tunnel syndrome (9% vs 2%), trigger finger (3.8% vs 0.5%), and dupuytren's contracture (1% vs 0%) were found more frequent as compared to controls (all p-values <0.05). In the shoulder region of diabetic subjects, adhesive capsulitis and tendonitis was found in 10.9% and 9.5% respectively as compared to 2.5% and 2% in control group [p- value <0.001]. A weak but positive relationship was observed between age and duration of diabetes with these upper limb abnormalities. However, no correlation was found between the frequencies of these abnormalities with control of diabetes.

CONCLUSION

A higher frequency of upper limb musculoskeletal abnormalities was observed in Type 2 diabetic patients as compared to control group.

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention

BACKGROUND

The prevalence of diabetes is increasing rapidly. Given its pro-inflammatory nature, comorbid diabetes may affect the course of Crohn's disease (CD).

AIM

To determine whether comorbid diabetes influences the natural history of CD.

METHODS

We compared a cohort with CD and comorbid diabetes to a nondiabetic control population and calculated the period prevalence of surgical intervention over a 5-year period. Unadjusted and adjusted odds-ratios were calculated regarding the need for surgical intervention using univariate and multivariate logistic regression.

RESULTS

A total of 240 patients were identified, 16 of whom were diabetics (6.7%). The period prevalence of CD-specific surgery in the diabetic cases was 75.0% and in the nondiabetic controls, 31.7%. The diabetic patients were more obese than the controls (44% vs. 10%; P < 0.0001) and older than the controls (47.4 years vs. 38.6; P < 0.01). There was no difference in the frequency of biologic therapy use, immunomodulator use, smoking, perianal disease, ileal involvement or corticosteroid use between the diabetics and controls. Univariate analysis revealed that diabetes (OR 6.46 [95% CI 2.01-20.8]), smoking (OR 2.46 [95% CI 1.24-4.90]), ileal disease (OR 2.21 [95% CI 1.15-4.24]) and obesity (OR 2.22 [95% CI 1.04-4.77]) were risk factors for needing surgery. After adjustment for covariates, the OR for surgical intervention in diabetics was 5.4 (95% CI 1.65-17.64).

CONCLUSION

Co-morbid diabetes in patients with Crohn's disease predicts a greater need for surgical intervention.

Comparison of ultrasonographic findings of the rotator cuff between diabetic and nondiabetic patients with chronic shoulder pain: a retrospective study

It is still unclear whether diabetic mellitus (DM) is associated with rotator cuff lesions. The object of this retrospective study was to compare the ultrasonographic (US) findings of rotator cuffs in diabetic patients with those of nondiabetic patients with chronic shoulder pain. In total, 419 patients (80 diabetic, 339 nondiabetic) who had chronic shoulder pain and had been referred to receive US examination between January 2005 and January 2008 in a medical center were included in this study. The US findings of rotator cuff lesions were classified into two main categories: rotator cuff tears (RCTs) and calcifying tendinopathy (CT). In total, 114 (25.2%) shoulders with CT of the rotator cuff and 160 (35.3%), 15 (3.3%) and 5 (1.1%) shoulders with supraspinatus, infraspinatus and subscapularis tears, respectively, were noted. No difference in the ratio of tears of RCTs was found on US examinations between two groups. The crude odds ratio (OR) for CT of diabetic patients was 1.85 (p = 0.014); however, the adjusted OR for CT in diabetic patients became insignificant after controlling for the other variables (OR = 1.59, p = 0.08). To our knowledge, this is the first study to explore US findings among diabetic and nondiabetic patients with chronic shoulder pain. Further study is advised to confirm our findings.

Increased Risk of Stroke After Adhesive Capsulitis

Background and Purpose— No previous study has described the association between stroke and previous adhesive capsulitis (AC). This study aims to investigate the risk of stroke after AC with a population-based database.

Method— Records for 10 935 with a principal diagnosis of AC and 32 805 randomly selected controls were collected between 2000 and 2003. The log-rank test was performed to analyze the differences in accumulated stroke-free survival rates between the 2 groups. Cox proportional hazard regressions were performed to calculate the longitudinal hazard of stroke.

Results— During the follow-up period, 575 patients from the study group (5.3%) and 1201 from the comparison group (3.7%) had strokes. The crude hazard ratio for stroke for patients with AC was 1.46-times greater than for controls (95% CI, 1.32–1.62; P <0.001), and the adjusted hazard ratio was 1.22 (95% CI, 1.06–1.40; P =0.002).

Conclusions— Our study demonstrates increased prevalence and risk of stroke after AC. Further study is needed to confirm our findings and explore underlying mechanisms.

Functional limitations of upper limbs in older diabetic individuals. The Italian Longitudinal Study on Aging

BACKGROUND AND AIMS

This study aimed at assessing the prevalence rate of symptoms of shoulder osteoarthritis in diabetic subjects and their possible associations, as part of the prospective study called ILSA (Italian Longitudinal Study on Aging).

METHODS

The study examined 5632 individuals aged 65-84 years, living either independently or in institutions. Of the above number, 2109 subjects were examined in the 1996 follow-up, with evaluation of the diabetic status and osteoarthritis symptoms (at least one of the following sites: hand, knee, shoulder, hip). Associations between diabetes and osteoarthritis symptoms were examined by means of the chi2 test or the non-parametric Wilcoxon rank-sum test. Relationships of diagnoses of osteoarthritis and possible risk factors were analysed by multinomial logistic regression, adjusting for significant interactions.

RESULTS

Only for shoulders did osteoarthritis symptoms reveal a significant association with diabetes (p=0.0107). Significant risk factors for shoulder osteoarthritis were gender, age, completed years of schooling, BMI and diabetes. A woman of </=76 years was 3.3 times more likely to have definite osteoarthritis and almost 2 times more likely to have possible osteoarthritis than a man of similar age. A man of over 76 years was estimated to be 3.5 times as likely to have definite osteoarthritis and almost 1.6 times more likely to have possible osteoarthritis than a younger man.

CONCLUSIONS

It was concluded that the high prevalence rates of osteoarthritis symptoms in diabetic patients should be a major concern when planning treatment, because they might lead to a reduction in physical exercise, due to joint pain. Common pathophysiological pathways should be identified, such as RANKL/OPG and inflammation markers, to explain the independent association of these disabling conditions.

Impaired glucose transporter-1 degradation and increased glucose transport and oxidative stress in response to high glucose in chondrocytes from osteoarthritic versus normal human cartilage

Introduction

Disorders that affect glucose metabolism, namely diabetes mellitus (DM), may favor the development and/or progression of osteoarthritis (OA). Thus far, little is known regarding the ability of chondrocytes to adjust to variations in the extracellular glucose concentration, resulting from hypoglycemia and hyperglycemia episodes, and so, to avoid deleterious effects resulting from deprivation or intracellular accumulation of glucose. The aim of this study was to compare the ability of normal and OA chondrocytes to regulate their glucose transport capacity in conditions of insufficient or excessive extracellular glucose and to identify the mechanisms involved and eventual deleterious consequences, namely the production of reactive oxygen species (ROS).

Methods

Chondrocytes, isolated from normal and OA human cartilage, were maintained in high-density monolayer cultures, in media without or with 10 or 30 mM glucose. Glucose transport was measured as the uptake of 2-deoxy-D-glucose (2-DG). Glucose transporter-1 (GLUT-1) mRNA and protein content were evaluated by real-time RT-PCR and western blot, respectively. ROS production was measured with 2',7'-dichlorodihydrofluorescein diacetate.

Results

Basal and IL-1β-induced 2-DG uptake, including the affinity (1.066 ± 0.284 and 1.49 ± 0.59 mM) and maximal velocity (0.27 ± 0.08 and 0.33 ± 0.08 nmol/μg protein/hour), and GLUT-1 content were identical in normal and OA chondrocytes. Glucose deprivation increased 2-DG uptake and GLUT-1 protein both in normal and OA chondrocytes. Exposure to high glucose (30 mM) for 18 or 48 hours decreased those parameters in normal but not in OA chondrocytes. GLUT-1 mRNA levels were unaffected by high glucose, either in normal or OA chondrocytes. The high glucose-induced reduction in GLUT-1 protein in normal chondrocytes was reversed by treatment with a lysosome inhibitor. High glucose induced ROS production, which lasted significantly longer in OA than in normal chondrocytes.

Conclusions

Normal human chondrocytes adjust to variations in the extracellular glucose concentration by modulating GLUT-1 synthesis and degradation which involves the lysosome pathway. Although capable of adjusting to glucose deprivation, OA chondrocytes exposed to high glucose were unable downregulate GLUT-1, accumulating more glucose and producing more ROS. Impaired GLUT-1 downregulation may constitute an important pathogenic mechanism by which conditions characterized by hyperglycemia, like DM, can promote degenerative changes in chondrocytes that can facilitate the progression of OA.