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Charcot disease

Amyotrophic lateral sclerosis (ALS, sometimes called Lou Gehrig's disease) is a progressive, invariably fatal motor neurone disease. In ALS, both the upper motor neurons and the lower motor neurons degenerate or die, ceasing to send messages to muscles. Unable to function, the muscles gradually weaken, waste away (atrophy), and twitch (fasciculations). Eventually, the ability of the brain to start and control voluntary movement is lost. more...

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ALS causes weakness with a wide range of disabilities. Eventually, all muscles under voluntary control are affected, and patients lose their strength and the ability to move their arms, legs, and body. When muscles in the diaphragm and chest wall fail, patients lose the ability to breathe without help from mechanical ventilation. Most people with ALS die from respiratory failure, usually within 3 to 5 years from the onset of symptoms. However, about 10 % of ALS patients survive for 10 or more years.

Epidemiology

As many as 20,000 Americans have ALS, and an estimated 5,000 people in the United States are diagnosed with the disease each year. ALS is one of the most common neuromuscular diseases worldwide, and people of all races and ethnic backgrounds are affected. ALS most commonly strikes people between 40 and 60 years of age, but younger and older people also can develop the disease. Men are affected more often than women.

In 90 to 95 % of all ALS cases, the disease occurs apparently at random with no clearly associated risk factors. Patients do not have a family history of the disease, and their family members are not considered to be at increased risk for developing ALS.

About 5 to 10 % of all ALS cases are inherited. The familial form of ALS usually results from a pattern of inheritance that requires only one parent to carry the gene responsible for the disease. About 20 % of all familial cases result from a specific genetic defect that leads to mutation of the enzyme known as superoxide dismutase 1 (SOD1). Research on this mutation is providing clues about the possible causes of motor neuron death in ALS. Not all familial ALS cases are due to the SOD1 mutation, therefore other unidentified genetic causes clearly exist.

Symptoms

The onset of ALS may be so subtle that the symptoms are frequently overlooked. The earliest symptoms may include twitching, cramping, or stiffness of muscles; muscle weakness affecting an arm or a leg; slurred and nasal speech; or difficulty chewing or swallowing. These general complaints then develop into more obvious weakness or atrophy that may cause a physician to suspect ALS.

The parts of the body affected by early symptoms of ALS depend on which muscles in the body are damaged first. In some cases, symptoms initially affect one of the legs, and patients experience awkwardness when walking or running or they notice that they are tripping or stumbling more often. Some patients first see the effects of the disease on a hand or arm as they experience difficulty with simple tasks requiring manual dexterity such as buttoning a shirt, writing, or turning a key in a lock. Other patients notice speech problems.

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How much do we know about Charcot foot?
From Diabetic Foot, The, 3/22/05 by Geraint Jones

The answer to the question 'How much do we know about Charcot foot?', in brief, is 'Not a lot'. We do not know the cause. We have no specific treatment. The diagnosis is primarily clinical and we do not know how to tell when the disease is entering its quiescent phase.

[ILLUSTRATION OMITTED]

We know that it occurs in people with neuropathy (and other microvascular complications of diabetes); vascular calcification is common on plain X-ray. We know what an acute Charcot foot looks like (see Figure 1), but have no specific diagnostic test. We know that the bones of the foot may or may not be thin before the process starts, but that they become progressively osteoporotic as it develops. We know that the mainstay of management is immobilisation and weight-sparing, but we also know that it can take a long time before the inflammatory process settles down and patients can get back to walking.

There is no specific treatment, and, although bisphosphonates may help, no data have been published on long-term outcomes. The foot often ends up deformed, sometimes grossly, and secondary ulceration (with the risk of infection) is quite common. Gross deformity and osteomyelitis may result in loss of the leg and one centre has reported a surprisingly high mortality, although this is not the general experience.

[FIGURE 1 OMITTED]

On the other hand, we do not know what causes the condition, and we do not know why it is so rare--affecting only about 1-2% of all people with neuropathy. We cannot predict who will get it. We are also not always sure if we can manage to distinguish Charcot from osteomyelitis (especially in the forefoot). We do not know how long it will take any one person to get better. We do not know how to tell if the process is finally settling and the bones are entering the coalescent phase, and when it is safe to allow a patient to go back to normal walking. We do not know who will get Charcot on the other foot, and when.

A possible answer

It is for reasons such as the ones outlined above that the new collaborative network Charcot in Diabetes UK (CDUK), has been formed (see page 8 for details). The aim is to collate the experience of as many clinicians as we can, and to see if we can get a more comprehensive picture of this rare, but fascinating, disorder. At the same time, there are great advances being made in the field of biochemistry of both bone and blood vessels, and these are giving new insight into the processes which may be involved in the cause of the Charcot foot. This, in turn, could lead to possible new treatments and if--through CDUK--we have been able to establish a thriving network of interested professionals, we should then be able to pool our resources in order to do the necessary prospective studies to prove that the new treatments work.

Geraint Jones is Chairman of the Management Group of Charcot in Diabetes UK

CDUK Management Group

COPYRIGHT 2005 S.B. Communications
COPYRIGHT 2005 Gale Group

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