Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom.

AIMS: The presence of diabetic foot ulcers is strongly associated with an increased risk of death. In this study, we investigate whether the effects of diabetes-associated complications can explain the apparent relationship between diabetic foot ulcers and death. METHODS: We analysed data from 414 523 people with diabetes enrolled in practices associated with The Health Improvement Network in the United Kingdom. Our methods were designed to control for potential confounders in order to isolate the relationship between diabetic foot ulcers and death. Using proportional hazards models and the area under the receiver operator curve, we evaluated the effects of diabetic foot ulcers and the covariates on death. RESULTS: Among the patients, 20 737 developed diabetic foot ulcers; 5.0% of people with new ulcers died within 12 months of their first foot ulcer visit and 42.2% of people with foot ulcers died within 5 years. After controlling for major known complications of diabetes that might influence mortality, the correlation between diabetic foot ulcers and death remained strong with a fully adjusted hazard ratio of 2.48 (95% confidence interval: 2.43, 2.54). Geographic variance existed but was not spatially associated. CONCLUSIONS: Diabetic foot ulcers are linked to an increased risk of death. This cannot be explained by other common risk factors. These results suggest that either there are major unknown risk factors associated with both diabetic foot ulcers and death, or that diabetic foot ulceration itself is a serious threat, which seems unlikely. A diabetic foot ulcer should be seen as a major warning sign for mortality, necessitating closer medical follow-up.

Major cost savings associated with biologic dose reduction in patients with inflammatory arthritis.

The purpose of this study was to explore whether patients with Inflammatory Arthritis (IA) (Rheumatoid Arthritis (RA), Psoriatic Arthritis (PsA) or Ankylosing Spondylitis (AS)) would remain in remission following a reduction in biologic dosing frequency and to calculate the cost savings associated with dose reduction. This prospective non-blinded non-randomised study commenced in 2010. Patients with Inflammatory Arthritis being treated with a biologic agent were screened for disease activity. A cohort of those in remission according to standardized disease activity indices (DAS28 < 2.6, BASDAI < 4) was offered a reduction in dosing frequency of two commonly used biologic therapies (etanercept 50 mg once per fortnight instead of weekly, adalimumab 40 mg once per month instead of fortnightly). Patients were assessed for disease activity at 3, 6, 12, 18 and 24 months following reduction in dosing frequency. Cost saving was calculated. 79 patients with inflammatory arthritis in remission were recruited. 57% had rheumatoid arthritis (n = 45), 13% psoriatic arthritis (n = 10) and 30% ankylosing spondylitis (n = 24). 57% (n = 45) were taking etanercept and 43% (n = 34) adalimumab. The percentage of patients in remission at 24 months was 56% (n = 44). This resulted in an actual saving to the state of approximately 600,000 euro over two years. This study demonstrates the reduction in biologic dosing frequency is feasible in Inflammatory Arthritis. There was a considerable cost saving at two years. The potential for major cost savings in biologic usage should be pursued further.

A CMP-based method for tunable, cell-mediated gene delivery from collagen scaffolds.

The use of collagen-based biomaterials in regenerative medicine has rapidly increased over the past decade. The unique structural and biochemical properties of collagen make it a particularly promising material for delivering both protein and DNA-based therapeutics. Although many collagen modification techniques have been developed, the majority of them require multi-step chemical treatments that can modify the natural favourable properties of collagen. We have developed a promising biomimetic modification technique employing collagen-mimetic peptides (CMP)s to control the retention and delivery of DNA polyplexes from collagen structures, including both monomeric 2-D collagen films and fibrous, 3-D gels. Variations in the concentration of CMPs displayed on polyplexes enabled tuning of polyplex retention vs. release over periods of at least 2 weeks on films and a month on gels. Retention of CMP-modified polyplexes (20 days) was substantially improved compared to non-modified polyplexes, which were retained for only 2 days. The activity of bound polyplex in collagen gels was shown, through a series of transfection studies, to be maintained in the presence of serum for a minimum of 2 weeks. Only matrix metalloproteinase (MMP)-stimulated cells exhibited significant levels of transfection suggesting that cell mobility within the gel was vital and that collagen remodelling played a role in stimulating gene release and expression. To our knowledge, this study is the first to deliver genes with CMP-modified polyplexes and to examine the effects of CMP display on DNA release. The results suggest that this technique may be used more broadly to create tuneable, collagen-based delivery systems.